What ever happened to spontaneous labor? Have you found yourself longing for the "good old days" when spontaneous labor was the norm and it was exciting to wait for the next patient who presented to the unit? If so, you've probably been practicing perinatal nursing for some time. The increase in the elective induction rate over the past decade has profoundly changed our practice. Instead of predominately caring for women who present in spontaneous active labor, many labor nurses spend a significant portion of their time titrating an oxytocin infusion and managing its side effects. Nurses often are pressured by physician colleagues to increase the oxytocin rate to "keep labor on track" and speed the labor process when labor is otherwise proceeding normally at 0.5 to 1 cm per hour and/or there is evidence of excessive uterine activity (Simpson, James, & Knox, 2006). Although nurses report that they usually resist these types of requests for safety reasons, these ongoing clinical conflicts are a source of dissatisfaction for nurses and physicians (Simpson et al., 2006). Oxytocin mismanagement has become a significant factor in perinatal liability (American College of Obstetricians and Gynecologists, 2004).

The increase in cesarean birth rate-partly the result of widespread elective labor induction of nulliparous women-is changing mother-baby units into surgical units in which nearly one-third of patients are recovering from major surgery. These shifts in obstetrical practice have affected staffing requirements, length of stay, and healthcare costs. Although the continued increase in elective labor induction seems to be a fact of life, clinical practices based on the best available evidence promote the safest care possible for mothers and babies. There is much work to be done to provide education to pregnant women so they have enough information to make an informed decision about labor induction. How often have you cared for a woman who said, "My doctor told me I have to be induced early because my baby is getting too big," only to attend her birth of a 6-pound baby who is admitted to the special care nursery with symptoms of iatrogenic prematurity or "I had no idea I was at risk for a cesarean because I was induced; I really wanted to avoid that"?

This is a complex issue that involves all participating parties: the pregnant woman, her family, her obstetrician or CNM or both, the institution, and the nurse. More data are needed to fully evaluate risks and benefits of induction and stimulation of labor. Care would be safer if all institutions adopted policies and protocols based on the American College of Obstetricians and Gynecologists' Practice Bulletin "Induction of Labor" (1999), the Association of Women's Health Obstetric and Neonatal Nurses' Practice Monograph "Cervical Ripening and Induction and Augmentation of Labor" (Simpson, 2002), and the recommendations for appropriate gestational age for elective births from the National Institute of Child Health and Human Development (2005). Documentation of indications for induction with analysis of care processes and clinical outcomes in each institution would provide valuable information about the implications of these practices. This is a significant opportunity for nursing research because nurses are providing the most bedside care during labor induction.

Safe Care Practices for Labor Induction

* No elective labor inductions before 39 completed weeks of gestation

* Cervical readiness before labor induction

* Standard oxytocin protocol, including a standard concentration and standard dosing regimen (start at

* 1 mU/min and increase by 1 to 2 mU/min at intervals no more frequent than every 30 min)

* No increase in oxytocin rate unless all three criteria are met: FHR is reassuring, labor progress is less than 0.5 to 1 cm/hr, contractions are no closer than every 2 to 3 min

* Agreed upon definition of hyperstimulation (more than five contractions in 10 min, contractions lasting 2 min or more, or contractions of normal duration occurring within 1 min of each other)

* Rare cases of uterine hyperstimulation and when it occurs, appropriate and timely interventions (treatment is not delayed until the FHR is nonreassuring)

* Minimum ratio of 1:2 nursing care

* Common understanding among members of the perinatal team regarding how labor induction will be conducted and an agreement that all team members will participate

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