1. Labor Induction Methods: Compared Outcomes
Jenifer E. Smith, SN, CLD
Cedar Crest College, Allentown, PA

2. EDUCATOR. ADVOCATE. FRIEND.
What is a Doula?
EDUCATOR. ADVOCATE. FRIEND.
A Doula provides:
Evidence-based Information
Emotional Support
Physical Comfort

3. Objectives
Describe significance of research to determine best evidence-based practice for labor induction methods.
State one aspect of the research data retrieval process and analysis.
Describe one recommendation to improve future processes.

4. PICO Question: P: Patient Population
Term to late-term nulliparous or multiparous pregnant women
I: Intervention
Transcervical Foley catheter induction
C: Comparison
Pharmacological, prostaglandin induction
O: Outcome
The number of vaginal deliveries?

5. PICO Question:
In term to late-term pregnant nulliparous or multiparous women does transcervical catheter induction compared to
pharmacological induction reduce the number of vaginal deliveries?

6. Significance
Induction rates in the US have more than doubled since 1990 – 1 in 4 births will be induced (AWHONN, 2014).
Induction and labor augmentation of labor are 1 of the top 3 perinatal liabilities with patient risk (Simpson & Knox, 2005).
Induction has a high risk of leading to a cesarean surgery, which has its own risks (AWHONN, 2014).

7. Cesarean Risks Infection
Abnormal placenta attachment in future pregnancies
Fetal stress
Respiratory illness
Interrupted bonding and breastfeeding
(AWHONN, 2014)

8. “Code of Ethics for Nurses”
Provision 3 "The nurse promotes, advocates for, and protects the rights, health, and safety of the patient." Provision 3.4 "Professional Responsibility in Promoting a Culture of Safety." Provision 3.5 "Protection of Patient Health and Safety by Acting on Questionable Practice." Provision 7 "The nurse, in all roles and settings, advances the profession through research and scholarly inquiry..." (ANA, 2015)

9. Literature Search Methods
Databases: PubMed and WorldCat
Keywords: Foley labor induction, catheter labor induction, prostaglandin labor induction, cervical ripening, and catheter, prostaglandin, induction
Inclusion criteria: peer-reviewed, published within , human trials
Exclusion criteria: induction subgroups of specific targets, early induction, simultaneous induction methods

10. Research Overview Level II/Good Quality: Cromi et al. (2012)
Randomized controlled trial – double-balloon transcervical catheter to prostaglandin vaginal insert
Small sample, 210 women
Vaginal delivery occurrence higher in the transcervical catheter group
Secondary Finding: Uterine hyperstimulation occurrence higher in the prostaglandin group

11. Research Overview Level I/High Quality: Jozwiak et al. (2012)
Randomized controlled trial – transcervical catheter to prostaglandin vaginal insert
Small sample, 226 women & meta-analysis of top rated quality comparable randomized controlled trials
Comparable vaginal and cesarean deliveries in both groups
Secondary Finding: Uterine hyperstimulation occurrence higher in the prostaglandin group

12. Research Overview
Level I/Good Quality: Vaknin, Kurzweil, & Sherman (2010)
Meta-analysis of 27 Randomized controlled trials – transcervical catheter to prostaglandin vaginal insert in term pregnancies
3,532 participants combined through all trials reviewed
Comparable vaginal and cesarean deliveries in both groups
Secondary Finding: Uterine hyperstimulation and abnormal contraction patterns occurred higher in the prostaglandin groups

13. Research Conclusions Evidence found a patient safety concern!
Uterine hyperstimulation occurrence was higher in prostaglandin groups in all research reviewed
Uterine Hyperstimulation Risks:
Late fetal heart decelerations or fetal tachycardia
Fetal stress leading to meconium aspiration risk

14. Research Recommendations
More Randomized Controlled Trials
Larger sample sizes with specific criteria: type of prostaglandin, size of catheter, balloon volumes, maximal period of cervical ripening time
Qualitative Research
Part of evidence-based practice considers patient preference
Encouragement to utilize Foley catheter induction
Given the uterine hyperstimulation risk found with prostaglandin use, Foley catheter method should be utilized more often

15. References
American Nurses Association [ANA]. (2015). Code of ethics for nurses with interpretive statements. Retrieved from
ANA new logo. (2016). Retrieved from
Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN]. (2014). Position statement discourages induction of labor without medical indications. Nursing for Women's Health, 18(6), doi: X.12168
Cesarean Birth 2. (2010). Retrieved from with-no-indicated-risk
Cook Cervical Ripening Balloon. Retrieved from
Cromi, A., Ghezzi, F., Uccella, S., Agosti, M., Serati, M., Marchitelli, G., & Bolis, P. (2012). A randomized trial of preinduction cervical ripening: Dinoprostone vaginal insert versus double-balloon catheter. American Journal of Obstetrics & Gynecology, 207(2), 125.e1-125.e7. doi: /j.ajog
Jozwiak, M., Rengerink, K. O., Eikelder, M. L., Pampus, M. G., Dijksterhuis, M. G., Graaf, I. M., … Bloemenkamp, K. W. (2013). Foley catheter or prostaglandin E2 inserts for induction of labour at term: An open-label randomized controlled trial (PROBAAT-P trial) and systematic review of literature. European Journal of Obstetrics & Gynecology and Reproductive Biology, 170, doi: /j.ejogrb
Simpson, K. R., & Knox, G. E. (2005). Essential criteria to promote safe care during labor and birth. AWHONN Lifelines, 9(6), doi: /
Tachycardia. (2014). Retreived from
Vaknin, Z., Kurzweil, Y., & Sherman, D. (2010). Foley catheter balloon vs locally applied prostaglandins for cervical ripening and labor induction: A systematic review and metaanalysis. American Journal of Obstetrics & Gynecology, 203(5), doi: /j.ajog
Walling, A. D. (2002). Uterine hyperstimulation depends on misoprostol route. American Family Physician, 65(2),

16. Questions. You can direct all questions and discussion to: Jenifer E
Questions? You can direct all questions and discussion to: Jenifer E. Smith