Student Projects
Quantitative Research Proposal

Effectiveness of Castor Oil for Labor Induction

Traci Labreck

Posted April 2010

Induction of labor is "the act of stimulating the uterus to begin labor", with the intent of bringing about the birth of a woman's baby prior to spontaneous physiologic initiation of labor. (Knoche, Selzer, & Smolley, 2008). The rate of inductions has risen from approximately 10% in 1990 to nearly 22% in 2006, despite the fact that medical indications for labor induction have remained stable. About 41% of women report having some medical intervention in order to induce labor, with 22% attempting self induction with methods such as: sexual intercourse, taking herbal or homeopathic substances and performing nipple stimulation (Knoche, Selzer, & Smolley, 2008). The increase in labor inductions is thought to be due to provider and patient desire for a convenient delivery schedule, in addition to previous lenient guidelines for appropriate indication for induction as promulgated by the American College of Obstetricians and Gynecologist (ACOG). In light of the changes in the labor induction guidelines set forth by ACOG in August 2009, there is renewed interest in herbal medicines that have been used for years in attempt to stimulate labor, such as castor oil. Castor oil is oil derived from the bean of the castor plant (Ricinus communis) that has been used as a labor induction technique dating as far back as ancient Egypt (Knoche, Selzer, & Smolley, 2008). A comprehensive literature review revealed that castor oil is the most commonly used herbal method for labor induction by midwives despite the non-standardized dosage, unknown mechanism of action and significant and near-universal side effects of nausea, abdominal cramps and diarrhea (Knoche, Selzer, & Smolley, 2008). Knowledge of the efficacy, risks and benefits of self-administered herbal induction agents is essential to midwifery practice. While castor oil is widely used as a self or provider suggested induction technique, its efficacy is not well documented in scientific literature. A randomized clinical trial comparing the administration of castor oil with pitocin for labor induction will be developed to evaluate the effectiveness of castor oil as an method of labor induction. A combination of the Health Promotion Model and Health Belief Model are used as conceptual frameworks guiding this inquiry. This inquiry will explore the beneficial and adverse effects of castor oil for induction and determine variables that predict a successful induction of labor using castor oil as the induction agent.
(375 words)

Chapter One: Statement & Significance of Problem

Castor oil is oil derived from the castor bean of the castor plant (Ricinus communis). Castor oil has been used for induction of labor for many years, even dating back to ancient Egypt (Garry et al., 2000). The scientific literature has very few references on castor oil and its use in midwifery practice. However, the use of castor oil is very widespread, although dosages are not standardized and the exact mechanism of action to stimulate labor is unknown. Of practitioners that implement natural methods of induction with their clients, 93% use castor oil as a method for labor induction. Some providers feel that castor oil is a good option for women who have tried other methods of induction that have been unsuccessful; while others feel that the side effects of nausea and diarrhea make this method less desirable. Ingestion of small amounts of castor oil for labor induction have not been shown to have any serious adverse effects and may possibly bring about contraction, labor and birth. Castor oil is the most commonly used herbal preparation by midwives, however more research needs to be done to determine other serious side effects, safety and appropriate dosages for its use in labor induction. (Knoche, Selzer, & Smolley, 2008).

Castor oil appears to increase the incidence of spontaneous onset of labor when it is used in term pregnancies. The best time for castor oil ingestion for induction of labor is after a good night's sleep. It is thought to act by stimulating the gut, which stimulates the vagal nerve and then stimulates the uterus. The onset of action is between 2-6 hours after ingestion. This method of induction had very few drawbacks, despite the little amount of research done on the topic (Varney, Kriebs, & Gregor, 2004). A proposed physiologic mechanism of action is that ingestion of castor oil decreases the absorption of fluids and electrolytes in the small intestine, which stimulates peristalsis and causes diarrhea and possibly contractions. Castor oil also is thought to promote the release of prostaglandin E2 and enhance cervical ripening and uterine contractions (Knoche, Selzer, & Smolley, 2008).

Scope of the Problem
Labor induction is the use of medications or other methods to bring about labor. Labor may be induced for many reasons. There has been a dramatic increase in the rate of labor inductions over the past 15 years. In 1990 the rate of labor induction was 9.5%, and in 2006 it increased to 22.3% (Fisch et al, 2009). Elective induction before 39 weeks gestation increases the risk for neonatal morbidity and mortality including: prematurity, respiratory distress, hypoglycemia, hyperbilirubinemia, poor feeding, temperature instability and readmissions into the hospital. The American College of Obstetricians and Gynecologists recently updated their guidelines in 2009 for labor induction indications. Inductions may contribute to the growing number of babies that are born "late preterm", between 34 and 36 completed weeks gestation (March of Dimes, 2008). Late preterm babies are more likely to have medical problems compared with babies born at full term including: jaundice, breathing, feeding and temperature difficulties. The March of Dimes recommends that labor be induced only when the health of the woman or baby is at risk (March of Dimes, 2008). Table 1-1 includes the updated induction guidelines set forth by ACOG.

Table 1-1 Indications and Contraindications for Labor Induction
Non-reassuring fetal testing Vasa previa
Oligohydramnios Placenta previa
Preeclampsia/Eclampsia Undiagnosed vaginal bleeding
Diabetes Umbilical cord prolapse
Premature rupture of membranes Malpresentation
Gestational or chronic hypertension Previous fundal surgery
Severe growth restriction Previous cesarean section with classic incision
Post-term pregnancy (>41 completed weeks) Maternal heart disease
Previous stillbirth Multiple pregnancy
Fetal macrosomia Unengaged presenting part
Fetal demise Severe hypertension
Known congenital anomaly
History of precipitous delivery and living far away from hospital (elective)
(American College of Obstetricians and Gynecologists, 2009) (Knoche, Selzer, & Smolley, 2008)

According to the Listening to Mothers II survey done in 2006, 41% of women report having some medical intervention to induce their labor, and 22% attempt self-induction at home. Various reasons were reported by this survey as to why women attempted outpatient or self-induction techniques. The survey reported that 58% of women state their motivation was "getting the pregnancy over with", 33% reported "wanting to avoid medical induction, 15% "wanted to control timing of birth", 10% "provider concerns about baby's size", and 7% "provider concern with avoiding postdates pregnancy" (Knoche, Selzer, & Smolley, 2008). The increase in the number of inductions in the United States is a result of provider and patient desire for convenience of delivery, and lenient guidelines and indications for inductions in practices around the country.

The method of induction should depend on the urgency of delivery, setting for induction and preference of the provider and patient. Before induction of labor is attempted, accurate assessment of gestation age, fetal presentation, fetal and maternal well-being needs to be completed. Likelihood of a successful labor induction is dependent on the condition of the cervix before induction begins. In order to assess the cervix's readiness for labor induction it is important to determine the: dilatation, effacement, station, consistency and position of the cervix. This assessment is known as the Modified Bishop's Score and requires a vaginal exam to assess the condition of the cervix. A total score of 6 or more indicates readiness for labor and is considered favorable for labor induction. A score of 5 or less indicates that the cervix is unfavorable for labor and requires cervical ripening before induction of labor. (Knoche, Selzer, & Smolley, 2008) Table 1-2 includes methods of labor induction, including pharmaceutical, mechanical and natural methods. Table 1-3 describes the Modified Bishop's Score.

Table 1-2 Methods of Labor Induction
Pitocin Membrane stripping or sweeping Castor oil
Misoprostol (Cytotec) Hygroscopic cervical dilators Enemas
Dinoprostone (Cervadil, Prepadil) Artificial rupture of membranes (AROM) Nipple stimulation
Mifepristone Digital stretching Evening primrose oil
Foley bulb or balloon catheter Acupuncture
Sexual activity
(Varney, Kriebs, & Gregor, 2004) (Knoche, Selzer, & Smolley, 2008)

Table 1-3 Modified Bishop's Score
Dilatation (cm)
Effacement (%)
(Varney, Kriebs, & Gregor, 2004)

Significance to Women's Health
More and more women are undergoing induction of labor. According to the Listening to Mothers Survey (2006), many women are receiving care that is against their wishes (Knoche, Selzer, & Smolley, 2008). Most women desire to feel power and control over their bodies especially throughout the labor and delivery process. There is a very complex relationship between pregnant women and their individual views and expectations of labor experiences. Whether induction is for a medical reason or elective, many women are faced with labor induction that may or may not meet their expectations. The various methods should be explained fully along with side effects and mechanisms of action. There also needs to be more research on how labor induction affects the psychological aspect of birth and evaluate a woman's satisfaction of the method used. It is also important to investigate why so many women are seeking out labor induction, as many providers are asked, pleaded and begged to be induced by their clients. A women's desire to have control over her body and pregnancy opposed to the increasing medicalized control of labor and birth management, may make methods of induction such as castor oil ingestion more intriguing to them. Self administration allows women to feel in control of the situation even though it may set into motion a chain of events over which there is no or limited control. It is important to take into consideration each individual woman and her expectations, perceptions and desires so that health care providers can facilitate an experience that is both empowering and satisfying.

Significance to Midwifery
Due to the increasing rates of labor inductions, it is essential that midwives provide safe and effective methods of induction. A successful delivery is one in that the mother and baby are healthy, but we also need to take into consideration the mother's satisfaction with her experience. Midwives can engage women in their induction process by allowing them to participate in choosing a labor induction method, administering it or performing it themselves, and explaining the reasoning behind the chosen method. It is also important that midwives advocate for watchful waiting and educate patients on allowing their body to enter labor on their own if labor induction is not indicated. It should also be explored whether or not psychosocial influences are the reason for desired induction. Providing psychosocial reassurance, on-going assessment of maternal and fetal well-being, support and encouragement to mothers to be patient is essential care provided by midwives."It is a midwife's duty to lead the women we serve on an unknown journey, and to enable that process to reach its fullest potential by offering choices in health care and supporting their outcomes with unwavering guidance and a steady hand" (Knoche, Selzer, & Smolley, 2008, pg 386). There needs to be more research done on the various methods of induction so that the most current and up to date information can be utilized, and health care providers can practice in a safe and effective manner. This inquiry will explore the effectiveness of castor oil for labor induction.

Chapter Two: Literature Review and Conceptual Framework

Restatement of Problem
Induction of labor is dramatically increasing in the United States, and is the most common intervention in modern obstetrics. Labor can be induced for a variety of reasons due to maternal and fetal medical indications, such as post-term pregnancy, diabetes, and non-reassuring fetal testing among others. Induction of labor without a medical indication is defined as elective induction. These types of inductions are increasing more rapidly than medically indicated inductions, which have remained stable because the medical indications have also remained stable. The increase in elective inductions is due to a socially mediated phenomenon. Elective inductions are motivated by many reasons including: a woman's desire to end pregnancy due to physical discomforts; concern regarding a rapidly progressing labor, and insufficient time to get to the hospital; scheduling issues; or concern regarding maternal, fetal, or neonatal complications. Obstetric providers may also have similar nonmedical reasons for recommending elective induction including: prevention of complications in pregnancy, attempt to limit patients discomfort; individual economic benefit and scheduling preferences (Caughey, et al., 2009).

Despite the reason for induction, there are variables that can be utilized to help predict the success of an induction. The overall goal of labor induction is a successful vaginal birth resulting in a healthy mother/baby dyad. Factors that the practitioner should consider before initiating an induction include: parity, cervical length by ultrasound, and Bishop's score (Bueno, et al., 2005). Choosing an induction method depends on these factors in combination with the urgency of delivery, intended birth setting, and preference of the provider and patient. Castor oil is an herbal preparation that has been used by midwives for labor stimulation dating as far back as ancient Egypt (Knoche, Selzer, & Smolley, 2008). Ingestion of small amounts of castor oil to induce labor has not been shown to have any adverse effects and may bring about contractions that lead to labor and birth. However, anecdotal evidence suggests significant side effects exist, so more studies need to be done in order to demonstrate its safety and efficacy (Garry, et al., 2000).

Literature Review
A systematic review of peer-reviewed journal articles and scientific studies regarding castor oil, labor induction and induction techniques was performed. On-line databases such as ProQuest and CINAHL were utilized to find pertinent articles. Professional journal articles and studies were critiqued and evaluated and then linked to this research inquiry. The following qualitative and quantitative studies are the result of a comprehensive search to evaluate the effectiveness of castor oil in induction of labor.

Study #1: "Use of castor oil in pregnancies at term" (Garry et al., 2000).

Statement of Purpose: The purpose of this study is to evaluate the relationship between the use of castor oil and the onset of labor.

Setting/Sample: This study takes place at a community hospital in Brooklyn, NY. The study population includes a total of 103 singleton pregnancies, with intact membranes, at 40-42 weeks gestation that were referred for antepartum testing from July 1992-February 1993. Gestational ages were based on LMP or early ultrasound obtained in the first or second trimester.

Table 2-1
Inclusion Criteria
Exclusion Criteria
Singleton pregnancies Multiple gestations
Intact membranes Ruptured membranes
Bishop’s Score of 4 or less Oligohydramnios
No evidence of uterine contractions on tocometry Intrauterine growth restriction (IUGR)
Abnormal fetal heart tracings
Biophysical profile of 8 or less
Noncephalic presentation
Maternal medical complications
(Garry et al., 2000)

Method: The 103 patients were alternately assigned to either group 1 or group 2. In group 1, the patients received a single oral dose (60 ml) of castor oil, while the other group received no treatment. All women were evaluated on the labor/delivery unit and were placed on an electronic fetal monitor for FHR and tocometric evaluation. A biophysical profile was done and cervical exams were performed on all participants. The 60 ml of castor oil was administered to group 1, diluted in apple or orange juice. Castor oil was considered effective if active labor began within 24 hours after ingestion. Labor was defined as 1 or more contractions every 5 minutes with cervical dilatation of 4cm of more. All women in this study were scheduled for follow up antepartum testing biweekly until delivery.The 2 groups were compared for labor onset within 24 hours, method of delivery, presence of meconium stained amniotic fluid, Apgar scores, and birth weight. Statistical methods for normally distributed variables included 2-tailed Student t-test and chi-square analysis. The accepted level of significance was P<.05. Logistic regression analysis was used to examine the relationship between castor oil ingestion and interval to delivery. (Garry et al., 2000).

Key Findings: Initially there were 52 women in group 1 (received castor oil) and 51 women in group 2 (received no treatment). However, 3 women in the no treatment group were excluded due to no follow up after initial exam, making group 2 have 48 participants. After administration of castor oil in group 1, 30/52 women (57.7%) went into active labor compared to the 2/48 women (4.2%) receiving no treatment (P<.001). Castor oil was as successful in nulliparous women (11/22) compared with multiparous women (13/30, P=.49). (Garry et al., 2000).

In group 1, when castor oil was successful 25/30 women delivered vaginally (83.3%). The cesarean section rated for those in group 1 was 19.2% or 10/52. The women in group 2, with no treatment, had a cesarean section rate of 8.3% or 4/48 and was not considered statistically different with P=.20. There was no relationship found between castor oil ingestion, birth weight, and mode of delivery (P=.66). The incidence of meconium stained amniotic fluid, Apgar scores, and birth weights was similar in both groups. All of the newborns in this study had a 5 minute Apgar score above 7. However, all women that ingested castor oil were nauseous after ingesting the medication. (Garry et al., 2000).

The logistic modeling of the relationship between castor oil dosing, parity, maternal age and neonatal birth weight demonstrated that the women who received the castor oil had a 36-fold increase in the likelihood of going into labor within 24 hours (Garry et al., 2000). The effect of castor oil was independent of parity, maternal age, and neonatal birth weight.

Study Strengths: This small study was a representation of one of the first attempts to evaluate castor oil for induction of labor. Other strengths of this study are that it is a prospective evaluation study, meaning that the information is first collected and then subsequent outcomes are measured, also known as a cohort study. This study focused on a specific population from which different samples were evaluated at different times (from July 1992-February 1993). It took into account various inclusion criteria for all women before alternately placing them into a study group.

Study Weaknesses: The use of castor oil in pregnancy is under reported. There is little literature containing studies regarding in use and safety in
pregnancy. Weaknesses in this study include: the wide confidence interval that indicates that the risk was unstable as a result of the small number on which the estimate was based. Other limitations include the lack of randomization and placebo control. Randomization means that every subject has an equal chance of being assigned to any group. When there is not good randomization, there is systematic bias in the groups in respect to attributes that could affect the dependent variable (Polit & Beck, 2008). The study would have been strengthened if the control group received some sort of placebo, such as a glass of orange juice. This would have helped rule out the possibility that intervention effects were cause by the "special attention" given to the people in the treatment group. The side effects of castor oil ingestion including unpleasant taste and nausea made the study design more difficult (Gerry et al., 2000). These weaknesses could be improved by developing more randomized control trials on this topic. There needs to be more studies done on castor oil and its use for induction of labor. More cases need to be studied and include a larger population of women.

Link to Research Inquiry: This study links to this research topic because it is one of the few studies that looks at the effectiveness of castor oil for labor induction. This study supports its use and was able to show that with castor oil ingestion there was a 36-fold increase in the likelihood of going into labor within 24 hours. Despite the small size of this study, it was well done and provided good statistical data to support castor oil use in induction of labor.

Qualitative or quantitative world view: This study was a quantitative study, meaning that the investigation of phenomena that lends itself to precise measurement and quantification, often involving a rigorous and controlled design (Polit & Beck, 2008). Quantitative studies use numeric data put through statistical procedures to describe a phenomena or assess the reliability of a relationship. Quantitative researchers use deductive reasoning to generate their predictions that are then tested in real life settings. These studies typically move in a systematic and orderly fashion, involve control and experimental groups. The information that is gathered it quantitative in that it is numeric and is a result of some type of measurement that is analyzed with statistical formulas (Polit & Beck, 2008). Quantitative researchers are not as interested in finding out why something happens as they are in understanding the factors that contribute to an occurrence. In this study the purpose was to determine how effective castor oil is in labor induction, not why it is effective.

Study #2: “Methods of stimulating the onset of labor: an exploration of maternal satisfaction” (Knoche, Selzer, & Smolley, 2008).

Statement of Purpose: The purpose of this study was to discuss the various methods of labor induction and explore maternal satisfaction with the induction techniques.

Setting/Sample: A survey for Childbirth Connection by Harris Interactive and Lamaze International was conducted to assess a variety of topics of concern in women who gave birth in 2005. There have been a total of 3 Listening to Mothers Survey’s conducted, in which women in the United States were polled regarding the maternity experiences. Approximately 1,500 women, ages 18-45, that gave birth in the United States in 2005 participated in the Listening to Mothers II on-line and telephone survey (Knoche, Selzer, 7 Smolley, 2008). Potential respondents for the on-line survey were drawn from the Harris Poll On-line panel of over 6 million active U.S. members. An e-mail was sent to a sample of potential participants inviting them to participate in the survey. The telephone sample was recruited from a list of households with a baby, provided by Survey Sampling International. (Childbirth Connection, 2008).

Inclusion Criteria: All respondents were asked a series of preliminary questions to determine their eligibility for the survey. To be eligible, respondents had to be 18-45 years of age, and have given birth in a United States hospital in 2005 to a single child who was living at the time the survey was conducted.

Method: Harris Interactive conducted the Listening to Mothers II: The Second National U.S. Survey of Women's Childbearing Experiences on behalf of Childbirth Connection. The survey consisted of 1,373 on-line and 200 telephone interviews with women who had given birth in 2005. All interviews were conducted in English and took an average of 30 minutes to complete. Interviews were conducted from January 20, 2006 through February 21, 2006. Topics included in the survey were: planning for pregnancy and pregnancy experiences (examples include: prenatal care and childbirth education); labor and delivery experience (examples include: labor induction techniques, labor interventions, caregivers, vaginal and cesarean birth experiences); postpartum experiences (examples include: breast-feeding, physical care, and mental health); experience with employment and health insurance; choice, control, knowledge, and decision making (examples include: who should make the decisions, knowledge needed to make decisions, and pressure from caregiver); and attitudes, beliefs and preferences regarding experiences. (Childbirth Connection, 2008).

Key Findings: Approximately 41% of women reported having some medical intervention to help induce their labor (Knoche, Selzer, & Smolley, 2008). About 22% of women admit that they attempted self induction by means such as sex, nipple stimulation, acupressure, enemas, or castor oil ingestion. Labor induction and augmentation are becoming more and more popular in maternity care practice. Nearly 58% of women stated that “getting the pregnancy over with” was their motivation for use of self induction, 33% wanted to avoid medical induction, and 15% wanted to have control over the timing of delivery (Knoche, Selzer, & Smolley, 2008). Table 2-2 identifies rates and effectiveness of induction, while Table 2-3 identifies the different reasons for induction according to the survey results.

Table 2-2 Rates and Effectiveness of Labor Induction
Base: All Mothers (n=1573)
Self Induction
Medical Induction
Total (used one of both methods)
Attempted to cause labor to start
Proportion of all labor begun
(Childbirth Connection, 2008)

Table 2-3 Reason for Induction
Self Induction (n=326)
Medical Induction (n=646)
Mother wanted to get pregnancy over with
Caregiver concern that mother was "overdue"
Trying to avoid medical induction
Maternal health problem required quick delivery
Mother wanted to control timing of birth
Mother wanted to get pregnancy over with
Caregiver concern about size of baby
Caregiver concern about size of baby
Caregiver concern mother was "overdue"
Water broken and fear of infection
Mother wanted to give birth with a specific provider
Concern with baby's health
Maternal health problem required quick delivery
Mother wanted to give birth with a specific provider
Concern with baby's health
Mother wanted to control timing of birth
Broken water led to fear of infection
(Childbirth Connection, 2008)

Study Strengths: The Listening to Mothers Surveys were the first national surveys to ask women in the United States what they thought about their labor and delivery experiences, and looked at their satisfaction in regards to their care. This study brings about awareness to health care providers regarding safe and effective methods or care as well as psychological aspects of the labor and delivery experience. The study's projectability was improved by using telephone interviews as well as on-line surveys. The telephone based approach helped reduce biases associated with internet only data collection by providing an outlet for participation to women who many not have internet access. Interviewing staff was monitored on an ongoing basis to maintain interviewing quality, and female interviewers conducted all interviews. Data was also weighted by key demographic variables and by composite variables. Demographic variables used for weighting included: educational attainment, age, race/ethnicity/geographic region, household income, and time elapsed since last giving birth. The propensity score took into account selection biases that occurred when conducting research using an on-line panel (Childbirth Connection, 2008).

Study Weaknesses: This study did not go into detail regarding how the information was obtained, evaluated and resulted. The surveys were done on-line and by telephone interview, leaving people without access to phone or internet out of the study population. The interviews were also all done in English, with no mention of an interpreter for women who did not speak English.

Qualitative or Quantitative World View: This study is a quantitative study due to the large sample size, numeric results obtained, and style of survey. Quantitative studies typically move in a systematic and orderly fashion, involve control and experimental groups. The information that is gathered it quantitative in that it is numeric and is a result of some type of measurement that is analyzed with statistical formulas (Polit & Beck, 2008).

Link to Research Inquiry: This study found that of the 22% of women that attempted self induction, only 4% were successful at achieving induction of labor. This study discussed castor oil as a method of labor induction, and reviewed the physiologic mechanisms of action and reasons why it is thought to be effective.This article is relevant to my research inquiry in that it discusses castor oil as a method of labor induction. This study looked at the effectiveness of various labor induction techniques, as well as maternal satisfaction with common methods used to induce labor and overall satisfaction with maternity care.

Study #3: “Herbal and other complementary medicine used by Texas midwives” (Bayles, 2007).

Statement of Purpose: The purpose of this study was to determine the nature and extent of complementary and alternative medicine (CAM) use by Texas midwives, as well as determine whether licensed midwives and certified nurse-midwives differed significantly in their patterns of use.

Setting/Sample: All licensed direct-entry midwives and certified nurse-midwives registered with the Texas Boards of Midwifery and Nurse Examiners were included in this study. At the time of this study, approximately 400 midwives were registered in the state of Texas (Bayles, 2007).

Inclusion Criteria: In order to be included in this study, all participants needed to be either licensed direct-entry midwives or certified nurse-midwives registered with the Texas Board of Midwifery and Nurse Examiners.

Method: A cross-sectional, confidential survey was mailed to all licensed midwives (n=157) and certified nurse-midwives (n=243) registered with the Texas Board of Midwifery and Nurse Examiners. If the individuals agreed to participate, the 3 page survey needed to be completed and returned within 2 weeks. To help reduce the possibility of selection bias, a statement was included that encouraged midwives to respond even if they did not use or recommend CAM therapies themselves. A definition of CAM was also included as “therapeutic interventions that are not currently part of the conventional medical system, or are not taught widely at United States medical school or available at United States hospitals”. The survey contained open-ended questions. The respondents were also given a list of indications for common conditions of pregnancy and childbirth and asked to provide a “free-list” of any CAM which they used, recommended or referred their clients for during the preceding year. (Bayles, 2007).

The lists were then put into a software program to compute an average “salience” index for each therapy and herb mentioned. This salience index or “Smith’s s” gave each item an average score based on the frequency of mention. Univariate statistics and bivariate analyses were used to describe the characteristics of midwives who use, recommend or refer their patients for specific herbal therapies compared with those who do not. Separate variances t tests and nonparametric Mann-Whitney tests were used as well. (Bayles, 2007).

Key Findings: Completed surveys were returned by 19 licensed midwives (LM's) (13% response rate), and 51 completed surveys returned from certified nurse-midwives (CNM's) (26% response rate). The overall response rate was 69/335 or 21%. Both LM's and CNM's had an average of approximately 13 years experience. Table 2-4 shows the percentages of respondents that used, recommended, or referred their patients for at least one CAM therapy, by clinical indication. Table 2-5 shows the three most frequent CAM therapies for the top three indications as well as the Smith's salience scores. Table 3-3 shows the CAM therapies used for labor induction. In this survey, castor oil was the CAM therapy most likely to have reported an adverse effect (n=7), including one emergency cesarean section as a result of abruption, severe gastric cramping, diarrhea, and dehydration (Bayles, 2007). Table 2-7 shows some of the side effects reported in association with the use of castor oil as a labor inducer.

Table 2-4 CAM Use by Clinical Indication
Total Sample (n=69)
Cervical ripening/Post date
Labor analgesia
Labor augmentation/Treat dysfunctional labor
Labor induction
Perineal healing
Anemia/Iron supplementation
Physical or sexual abuse/Trauma
(Bayles, 2007)

Table 2-5 Top CAM Therapies
CAM Therapy
% of Users
Smiths Salience Score
Musculoskeletal/Back Pain
Body Work (stretching, tilts…)
Vitamin B12, B6
Cervical Ripening/Post Dates
Sexual Intercourse
(Bayles, 2007)

Table 2-6 Top CAM Therapies for Labor Induction
CAM Therapy
% of Users
Smiths Salience Score
Labor Induction
* Castor oil
* Black cohosh
* Blue cohosh
Nipple Stimulation
Sexual Intercourse
(Bayles, 2007)

Table 2-7 Side Effects Reported with Castor Oil Use
Precipitous and tumultuous labor
Meconium stained amniotic fluid
Severe gastric cramping
Amniotic fluid embolism
(Bayles, 2007)

Study Strengths: This study is a small exploratory study that reveals significant rates of CAM use among Texas midwives. It is a fairly well designed study that helps bring about beginning research on CAM use, and encourages more research on these therapies. Despite the low response rate, the extent of CAM use reported in this study brings up medico-ethical and legal concerns that merit further discussion and investigation regarding their safety and efficacy. Very few herbs most commonly used have been studied specifically for the clinical indications for which they are prescribed or recommended. This study provides a stepping stone in the research of CAM therapies and will hopefully spark more interest into the study of the treatment modalities commonly used.

Study Weaknesses: A limitation to this study is the small amount of respondents to the survey. Smaller samples tend to produce less accurate estimates than larger samples (Polit, & Beck, 2008). A survey format was selected for this study in order to represent a low operational burden to the respondents, however only 69 completed surveys were received. Due to the small sample of responses there is a strong possibility for selection bias with the results, as the individuals that use CAM therapies were probably more likely to respond. This study did not give a percentage of use for castor oil with labor inductions, however it reported that it was one of the most commonly used herbs for induction of labor. Side effects of castor oil were also discussed, but no statistical data on the occurrences were given. Based on general recall as opposed to careful on-going documentation of use, is subject to preferences and biases of the respondents. There was no follow up after the surveys were sent out to encourage more participation, which may have resulted in more completed surveys.

Qualitative or Quantitative World View: This study has a quantitative world view. It takes data and statistically analyzes it to produce numeric data. The researches used a general set of orderly procedures to acquire their information. Numeric values were attached to data collected so that it could be measured and express quantity. (Polit, & Beck, 2008).

Link to Research Inquiry: This study links to this research inquiry because it discusses castor oil as an induction technique, and gives specific adverse effects including: precipitous labor, meconium stained fluid, severe gastric cramping, diarrhea, dehydration and amniotic fluid embolism. According to the results of this study, 75% of Texas midwives recommend or utilize CAM therapies for cervical ripening, 41% for labor induction, and 45% for labor augmentation (Bayles, 2008). Castor oil is one of the most commonly recommended CAM therapies for labor induction by midwives, despite the little research that is done on its safety and efficacy. However, castor oil castor oil was the CAM therapy most likely to have reported adverse effects (Bayles, 2008). There is limited research on this topic, so it is important that more studies are done to evaluate its effectiveness as a labor induction technique. Castor oil is considered a complementary and alternative medicine because it is a therapeutic intervention that is not currently part of the conventional medical system, and is not taught in United States medical schools (Bayles, 2008). However, there is a large population of midwives that are encouraging their patients to use this herb for various reasons, labor induction being one of the most common.

Study #4: "Effect of castor oil, soap enema, and hot bath on the pregnant human uterus near term" (Mathie, & Dawson, 1959).

Statement of Purpose: The administration of castor oil, followed by a soap enema and hot bath, was one of the oldest and most frequently attempted methods used for inducting labor in the 1950's. This study done in 1959 was performed to assess, with the aid of a tocograph, the possible effects of castor oil, a soap enema, and a hot bath on uterine contractility in late pregnancy (Mathie, & Dawson, 1959).

Setting/Sample: Sixty subjects, between 38 and 41 weeks gestation were selected for investigation and divided into four groups of 15.

Inclusion Criteria: Pregnant women between 38 and 41 weeks gestation were included in this study.

Exclusion Criteria: Excluded from the study were cases of cephalopelvic disproportion, malpresentation, antepartum hemorrhage, hydramnios, and anyone showing signs of the onset of labor prior to induction.

Method: The sixty subjects were placed into four groups. In one group, all participants received castor oil, a soap enema, and a hot bath; in the second group, participants received only castor oil; in the third group, participants received a soap enema, and in the fourth group, participants received a hot bath. A control group of 15 other subjects was chosen to compare findings. Changes in uterine activity was assessed using a guard-ring tocodynamometer. The head of the instrument was applied to the anterior abdominal wall over a fluid filled part of the uterus and held in place by an elastic belt passed around the participant. The tocodynamometer was placed in the same position on the abdominal wall with the elastic belt at the same tension for each participant. A recording was taken in each case before and after the four different method were adopted. Each tracing was recorded for at least one hour on a chart moving at a constant speed of 12 in (30.5 cm) per hour. The tocodynamometer was calibrated according to the manufacturers directions to assess accurately the extent of change in uterine activity. (Mathie, & Dawson, 1959). See table 2.8 for methods of assessing each group.

Table 2-8 Methods of Assessing Effects of Interventions
Group #1 Castor oil + Soap Enema + Hot Bath
Group #2 Castor Oil
Group #3 Soap Enema
Group #4 Hot Bath
Control Group
  • The first tocometric recording was taken within 12 hours before administration of interventions.
  • Castor oil (2 1/2oz or 71ml) was given by mouth, and after 2 bowel movements (usually within 3 hours) soap enema was given.
  • A soap enema (2oz of enema soap in 2 pints of water at blood level) was administered and allowed to act.
  • A hot bath was given after the soap enema.
  • Subjects then were returned to bed and a second tracing was started.
  • Castor oil (2 1/2oz or 71ml) was given by mouth at the completion of the first tocometric recording.
  • The second recording was started after at least 2 bowel movements (usually within 3 hours).
  • A soap enema (2oz of enema soap in 2 pints of water) was administered at the completion of the first tocometric recording.
  • The second recording was started after the enema had acted.
  • The first tocometric tracing was obtained and then the subject was given a hot bath.
  • The second tracing taken after bath was completed.
  • Two tocometric tracings were obtained three hours apart with no treatments given.
(Mathie, & Dawson, 1959)

A careful study of the two tracings from each subject was done to assess uterine activity. From the two tracings obtained, the amplitude in grams per square centimeter, the duration of each contraction in minutes, and the frequency of contractions was calculated. To exclude the minor variations in uterine tone, amplitudes of less than 10 grams per square centimeter were excluded from the assessment. The product of the duration and the amplitude of each contraction, and the number of contractions per hour yielded an index of the total contractile work done by the uterus in that hour. In each case, the contractile work done by the uterus per hour before and after the interventions were given was determined and the percentage difference calculated. (Mathie, & Dawson, 1959).

Key Findings: See table 2-9 for the statistical results obtained from the four intervention groups. In the group #4 there was little effect on the contractile work done by the uterus after a hot bath only, and was not statistically significant. In the control group there was spontaneous variation of uterine activity, the standard error was 3.8, and the mean was -4%, not statistically significant. It was concluded that when castor oil, a soap enema and a hot bath were given together there was more uterine change than if they were used individually. The administration of castor oil, a soap enema, and a hot bath to a woman between 38 and 41 weeks causes a marked increase in the contractile work done by the uterus. The most effective component is castor oil (264%), the soap enema produces a considerable effect (95%), while a hot bath produces no change of statistical significance (6%). (Mathie, & Dawson, 1959).

Table 2-9 Statistical Results of Intervention Groups
Standard Error
Mean increase after intervention (%)
Group #1
Group #2
<0.02 but >0.01
Group #3
<0.01 but >0.001
Group #4
(Mathie, & Dawson, 1959)

Study Strengths: A strength of this study is that it evaluates castor oil, soap enemas, and hot baths together and then individually to assess their effectiveness on stimulating uterine activity.

Study Weaknesses: Studies of uterine activity that is recorded with tocodynamometers can have variations from person to person. When comparing tracings between individuals there is a possible source or error, especially when taken at different times. This study tried to keep good control over the study participant by applying the toco to the same location and tightening the belt to the same tension for all women. This, however may not produce accurate results as some women are larger than others and may require different tension or placement of the toco to obtain adequate readings. External tocometric evaluation is not as accurate as internal monitoring, small movements of the participant or fetal movement may change the pressure that is placed on the toco.

Qualitative or Quantitative World View: This study has a quantitative world view. It takes data and statistically analyzes it to produce numeric data. The researches used a general set of orderly procedures to acquire their information. Numeric values were attached to data collected so that it could be measured and express quantity. (Polit, & Beck, 2008).

Link of Research Inquiry: This study links to this research in inquiry in that it evaluates the effectiveness of castor oil on uterine activity. There are very few studies that have been done on this topic, and while this study is older it provides some information on castor oil and its use as a labor induction technique. This study is also a nice historical reference point.

Study #5: “Assessing the effects of age, gestation, socioeconomic status, and ethnicity on labor inductions” (Wilson, 2007).

Statement of Purpose: The purpose of this study was to evaluate the likelihood of cesarean births related to race, ethnicity, socioeconomic status, maternal education, maternal age, and gestational status for labor inductions on primiparous and multiparous women.

Setting/Sample: This study took place at a large tertiary hospital in Arizona where over 8,000 births occurred from January 1 – December 31, 2005. Of the 8,000 births that occurred that year, 17% were Hispanic, 2% Native American, 5% Asian, 0.5% Black, and 75.5% Non-Hispanic White (Wilson, 2007). This study included 1,325 women scheduled for labor induction. Study participants were scheduled for induction according to criteria from two categories: Priority A (medically indicated) or Priority B (elective), see table 2-10 for priority criteria.

Table 2-10 Priority Criteria
Priority A-Medically Indicated
Priority B-Elective
Preeclampsia Gestational age >/= 39 weeks and a recommended favorable Bishop's score
Pregnancy-induced hypertension Inductions listed as indicated due to "postdates" but were less than 41 weeks gestation
Fetal demise History of rapid labor
Gestation > 41 weeks Advanced maternal age
Size > 4,000 grams via ultrasound
Previous 3rd trimester stillborn
Maternal complications
Intrauterine growth restriction confirmed by ultrasound
Oligohydramnios confirmed by AFI </= 5cm
Previous fetal demise
Previous difficult delivery
Unstable lie
(Wilson, 2007)

Inclusion Criteria: This study included any woman that was scheduled to be induced, for either elective or indicated purposes. See table 2-10.

Method: A retrospective, descriptive, correlational design was used with 1,325 women scheduled for induction at a large tertiary hospital in Arizona from January 1- December 31, 2005. Birth outcomes were matched against inpatient hospital scheduling induction logs to verify the reason for induction whether elective of clinically indicated. Inductions could be scheduled up to 1 week in advance, and 4-6 induction time slots were available 7 days per week. The scheduling of induction logs were reviewed by the primary investigator to ensure correct classification and consistency in data collection. The information was then matched to the names and birth outcomes in the Arizona Health Query data base, which is an integrated repository of medical records from public and private data sources. Birth outcomes for 1,325 matched scheduled inductions were then analyzed specifically for: failed induction resulting in cesarean delivery, mother's age, race or ethnicity, mother's education, Medicaid coverage as a proxy for socioeconomic status, and newborn gestational age (Wilson, 2007).

Key Findings: Of the 1,325 women scheduled for labor induction, 43.6% were primiparas, with 204 of those inductions being indicated and 114 elective. There were 747 multiparas scheduled for induction, 214 indicated and 191 elective (Wilson, 2007). Table 2-11 shows the results for primiparous and multiparous women that were in the Priority A, Priority B, and “Natural delivery” groups. “Natural delivery” was the term used for women who were scheduled for induction but spontaneously went into labor and delivered before their induction date. (Wilson, 2007).

Table 2-11 Primipara and Multipara Induction Results
* 1,325 women were schedule for induction*
Priority A (indicated)
204 (35.3%)
214 (28.6%)
Priority B (elective)
114 (19.7%)
191 (25.6%)
“Natural delivery”
260 (45%)
342 (45.8%)
(Wilson, 2007)

A sufficient statistic for evaluating the effect of randomization is the propensity score based on observed data (Wilson, 2007). The propensity score captures the conditional probability of exposures to a treatment, given various preintervention characteristics. It can be used to match comparison groups to enhance internal validity (Polit, & Beck, 2008). The propensity score, based on each participant's characteristics indicated observable differences between those who were induced and those who were not. Under true random assignment, the distribution of independent variables will be the same for the treatment and control groups. Under good quasi-experimental situations, the distributions will not be identical but will show considerable overlap in propensity scores. The propensity scores for this sample were estimated with the independent variables. This distribution of propensity scores for the three groups showed substantial overlap, indicating the design of the approach worked well in making the samples comparable (Wilson, 2007). Table 2-12 demonstrates the mean differences by delivery type for primiparous and multiparous women.

Table 2-12 Mean Differences by Delivery Type
Primiparous Women
Indicated Induction
Elective Induction
Natural Delivery
Mother's age
Mother's education
Medicaid covered
Gestational age
Multiparous Women
Indicated Induction
Elective Induction
Natural Delivery
Mother's age
Mother's education
Medicaid covered
Gestational age
The ta statistic shows the equality of the means of the natural delivery sample against the means of the respective induction group, assuming equal variances.
(Wilson, 2007)

Analysis of mean differences by indicated inductions, elective inductions and natural deliveries for primiparous and multiparous women showed that none of the predictor variables were significantly different from each other with the exception of: gestational age for both primiparous and multiparous women, implying women electively induced in both groups were at statistically shorter gestational ages; and ethnicity for multiparous women, with more non-Hispanic White multiparas being electively induced. Other predictor variables were not significantly different between the groups, which indicated that the groups were homogenous in their characteristics. Table 2-13 demonstrates predictors of cesarean birth in primiparas and multiparas by induction type. The results show that age and gestational age had nonlinear and generally statistically significant effects on the likelihood of cesarean birth. Elective inductions for primiparous women also significantly increased the likelihood of cesarean delivery. Controlling for all other variables, the likelihood of cesarean birth in multiparous women with an indicated induction increased at a decreasing rate, peaking at 35 years of age, approximately two standard deviations above the mean. Conversely, maternal age trended towards significance for cesarean birth in electively induced multiparas. These findings are consistent with other studies, indicating that older women are at higher risk for cesarean birth regardless of labor induction or spontaneous labor. (Wilson, 2007).

The likelihood of cesarean birth also increased with age for primiparas. The independent effect of gestational age indicated that, for both primiparous and multiparous women, the likelihood of cesarean birth decreased with gestational age up to about 40 weeks. The effect of gestational age was statistically significant for primiparous women with elective induction and with indicated inductions for multiparous women, but not for elective induction with multiparous women. Elective induction in multiparous women had no statistically significant increase in cesarean birth based on maternal age, ethnicity, socioeconomic status, or gestation age. Socioeconomic status and ethnicity were not significant predictors of cesarean birth for either group. Primiparous women who underwent elective induction were at significant risk for cesarean birth. Mother's educational level was not a significant predictor for cesarean birth, but only for multiparous women being induced, whether medically or electively. (Wilson, 2007).

Goodness-of-fit was conducted with the Hosmer-Lemeshow method. This test is used to compare the number of observed to the number predicted by the logistic regression model. The test statistic is a chi-square with a desirable outcome of nonsignificance, indicating that the model prediction done not differ significantly from the observed (Wilson, 2007).

Table 2-13 Predictors of Cesarean Birth in Primiparous and Multiparous Participants by Labor Induction Type
Primiparous Women
Multiparous Women
Indicated Induction
Elective Induction
Indicated Induction
Elective Induction
Induction vs Natural
Mother's age
Mother's education
Medicaid coverage
Gestational age (wks)
-2 log-likelihood ratio
Hosmer/ Lemeshow test
(Wilson, 2007)

This study demonstrates that elective inductions should be offered with caution in primiparous patients, due to the increased risk of cesarean birth associated with elective induction. Although labor induction at 41 completed weeks gestation is offered to low-risk women due to the increased adverse maternal and neonatal events for pregnancies that extend beyond 41 weeks, it has been associated with a significant increase in cesarean birth for primiparous patients before term gestation. This retrospective descriptive correlational study demonstrated that maternal age and newborn gestation significantly affect the probability of cesarean birth. Advanced maternal age should also be considered, as it also has shown to be a factor associated with increased likelihood for cesarean birth. (Wilson, 2007).

Study Strengths: A strength of this study is that it addressed the fact that randomization was limited. They attempted to compensate for the lack of randomization by changing the nature of the study design by evaluating all women scheduled for an induction, and then comparing among that group those who delivered naturally with those who had labor induced. The researchers state that a strength of this study was that the classification of labor induction was not based on birth certificate data, which is known to have errors and requires caution with interpretation. However, the researchers also state in the article that not all data was collected per protocol, specifically indication of induction during scheduling. Chart data can have also have errors, and requires caution when interpreting results as well. All labor inductions were reviewed by the investigator, addressed with physicians and rated as elective or indicated based on provider agreement. (Wilson, 2007).

Study Weaknesses: A primary concern for making statistical inferences in studies of labor induction and cesarean sections is the inability for obvious ethical and practical reasons, to perform truly randomized studies. To address this dilemma, the researchers used a natural experiment model and considered all women who were scheduled to be induced, for either elective or indicated reasons and compared them with those who delivered naturally. The researchers implied that by using this type of study model, all participants would be subject to the same risks and have comparable demographic characteristics. However, labor induction in itself has many different risk factors for both mother and baby compared to natural labor and delivery. The researchers also commented on the fact that although the induction process required documentation for all indicated inductions at the time they were scheduled, it was not always completed. Several indicated inductions were listed that did not meed criteria set forth studies original inclusion policy. This led to changes in indications for medically indicated inductions. Another weakness if this study is that it did not specify which methods of labor induction were utilized. Different induction techniques have different risk factors and could alter study results. For example, pitocin has very different risk factors associated with it compared with sexual intercourse or nipple stimulation. It would have been helpful if the researchers described the methods of induction that were utilized in this study. There was also a low percentage of Black women and Hispanic women, making it difficult to determine whether or not ethnicity played a role in the risk of cesarean birth. There was also no measurement of cervical status, nor did the study attempt to measure or record Bishop's score, which can be a predictor of successful labor induction. Lastly, all births took place at a single institution, so the findings are not generalizable. (Wilson, 2007).

Qualitative or Quantitative World View: This study has a quantitative world view in that it generated numeric data through statistical analysis. The researchers were focused on what factors increase the risk for cesarean delivery not why cesarean delivery occurs. (Polit, & Beck, 2008).

Link to Research Inquiry: This study links to this research inquiry because labor inductions have increased dramatically in the United States over the past few years. No matter what method of induction of labor is utilized, the increase in induction rates has also increased the cesarean delivery rates. As providers it is important to address this issue and help to prevent unnecessary inductions and provide women with more education as to the risks of elective induction.

Study #6:The latent phase of labor: diagnosis and management” (Greulich & Tarrant, 2007).

Statement of Purpose: This article discusses the time parameters of the latent phase of labor, and evaluates outpatient relief measures and inpatient medical interventions of prolonged latent phase of labor. Recommendations for policy development are included in the discussion as well.

Treatment Group: This article is a discussion that includes many studies done on the latent phase of labor, relief measures, medical interventions and the effectiveness of each.

Method: Two large cohort retrospective studies were used to compare labor and birth outcomes between low-risk women at term admitted in latent phase of labor (cervical dilatation <4cm) and those admitted in active phase of labor (cervical dilatation >/=4cm). Both of the studies questioned whether the greater rates of intervention in the latent phase of labor group were caused by a higher risk of dysfunctional labor on admission, or whether earlier exposure to the medical system conferred risks not present on admission. (Greulich & Tarrant, 2007).

Another prospective cohort study in San Diego compared labor outcomes in 2,196 term, low risk women who were admitted for spontaneous labor. Admission was considered early if the cervix was less than 4 cm dilated and late if the cervix was greater than or equal to 4 cm dilated. The women were either admitted to either certified nurse-midwife-obstetrician collaborative care or physician only care. (Greulich & Tarrant, 2007).

Another prospective study randomly allocated 209 low-risk, term, nulliparous women in spontaneous labor to either an early assessment (n=105) or direct admission (n=104). In the early assessment group, women that were not in active labor were asked to return home or walk until labor became more active. Once in active labor they were admitted. Intrapartum care was the same for both groups. (Greulich & Tarrant, 2007).

Key Findings: In the San Diego study, nearly half (49.5%) of the women in the physician care group were admitted early compared with 26.2% of the women in collaborative care. Only 10% of the women in this study were managed expectantly (observed, sent to walk, or sent home) in the physician care group, whereas 34.3% or women were expectantly managed in the collaborative care group. In most cases, early admission increased the risk of operative delivery regardless of the provider group. In the collaborative care group, nulliparous women and multiparous women with and with out previous cesarean births, had more spontaneous vaginal births (22.1%, 23.2% and 13.2% respectively) when compared to women in the physician only group. (Greulich & Tarrant, 2007)

In the prospective study on early assessment versus direct admission, women in the early assessment group were less likely to receive oxytocin (OR, 0.44; 95% CI, 0.24-0.80), analgesia (OR, 0.31; 95% CI, 1.26-7.13), and an epidural (OR, 0.40; 95% CI, 0.18-0.90). These women also evaluated their birth experience as more positive. (Greulich & Tarrant, 2007).

In regards to management of prolonged latent phase of labor, intervention is required when there is maternal or fetal indication for expediting the birth, or when outpatient management options have failed. Management involved either stimulation of uterine contractions or rest, and is based on the physical and emotional condition of the mother and well-being of the fetus. The management of prolonged latent phase of labor is controversial. Some people believe that it is due to an underlying labor abnormality and should be managed with oxytocin, whereas others recommend a more conservative approach with therapeutic rest. Table 2-14 shows the different management alternatives for the latent phase of labor.

Table 2-14 Management Alternatives for Latent Phase of Labor
Possible Labor Effect
Ambulation/ActivityHelp decrease perception of pain and result in greater ability to tolerate labor.
BathingProvide relief from pain. Hot showers may stimulate contractions due to upright posture and some mild nipple stimulation. Tub baths can slow labor progress if she enters the tub before active labor begins or remains in the tube more than 1-2 hours.
HydrationCorrecting dehydration many decrease or stop pre-labor contractions, but increase uterine blood flow and decrease pituitary secretion of antidiuretic hormone and oxytocin
AlimentationThe mechanism of eating and its effects on labor are unclear.
SupportCommunication and remaining with the women may decrease anxiety. keeping her informed of status, and providing individualized care increase the women’s coping ability and provides her with reassurance.
Nipple StimulationCauses uterus to contract. Increase levels of oxytocin, which stimulated contractions. Most effective if the cervix is ripe. May cause uterine hyper-stimulation, and should not be used in high risk patients.
Membrane SweepingHas potential to initiate labor by increasing local production of prostaglandins. Procedure causes discomfort, some bleeding, irregular contractions and should only be performed with women’s consent.
Sexual IntercourseSemen contains prostaglandins that can help ripen the cervix and induce labor.
Castor Oil/EnemasLimited evidence.Thought to stimulate contractions.
Small glass of wine Ethanol was used as a tocolytic in the 1960’s. Inhibits the secretion of oxytocin by the posterior pituitary and inhibits contractions. Ethanol passes readily through the placenta and can cause the same effects that are associated with opioid analgesics such as morphine. Used for therapeutic rest.
(Greulich & Tarrant, 2007)

Study Strengths: This metaanalysis includes results of many studies that have been done on the diagnosis and management of the latent phase of labor, it is not a study in itself. It provides information on how the latent phase of labor is diagnosed and criteria for prolonged latent phase of labor. Various management options are explored and explained throughout this article.

Study Weaknesses: In the prospective study on the early assessment versus direct admission, a weakness is that the sample size was too small to detect statistically significant differences in cesarean birth rates (Greulich & Tarrant, 2007). This article is a secondary source research document that describes others studies that were done by someone else. Secondary sources do not provide detail about the studies and are seldom completely objective. However, secondary sources can be useful and provide a overview of the literature and a valuable bibliography (Polit, & Beck, 2008).

Qualitative or Quantitative World View: This article includes quantitative studies and data from them. The studies that were included were done quantitatively in that the researchers produced numeric data from their collection of information and analyzed it statistically. (Polit& Beck, 2008).

Link to Research Inquiry: This article links to this research inquiry because it includes castor oil as a management option for the latent phase of labor. However, the authors state that there is limited research done on this topic and more studies need to be done in order to better understand its effectiveness and safety.

Study #7:Systematic review: elective induction of labor versus expectant management of pregnancy” (Caughey, Sundaram, Kaimal, Gienger, & Cheng, 2009).

Statement of Purpose: The purpose of this study is to compare the benefits and harms of elective induction of labor and expectant management of pregnancy.

Setting/Sample: This systematic review was performed by searching multiple data bases (MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials) from 1966-2009 for all English- language studies on elective induction of labor in humans. The researchers also manually reviewed reference lists and the included articles to identify relevant articles. Of 6,117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials and 25 observational studies. (Caughey et al., 2009).

Inclusion Criteria: The studies were required to report maternal and neonatal outcomes for women who underwent induction of labor without a specific indication. The studies must also include mode of delivery. The gestational age group must include women between 37 completed weeks and 41 completed weeks gestation. Articles that were published from 1966 and beyond were included in the literature search. Included in the study were: randomized control trials, cohort studies, and case-control studies. All study designs were analyzed separately. (Caughey et al., 2009).

Exclusion Criteria: Articles that only compared different methods of induction of labor were excluded from this review (Caughey et al., 2009).

Method: The fundamental comparison for the study was between elective induction of labor and expectant management of pregnancy. Two authors each reviewed the title and abstract of all studies that were found throughout the search to determine if they met inclusion criteria. They then reviewed the following from each included study: study period, location/setting of the study, method of labor induction, study design, mode of delivery, maternal and neonatal outcomes, and quality assessment variables. (Caughey et al., 2009).

Specific criteria were developed to evaluate the quality and applicability of the individual included studies. The results were summarized using stacked bars and were summarized as good, fair, or poor. The applicability of the individual studies was assessed by evaluating the population, place and time the study was conducted, and methods of induction used. The individual applicability was also assessed as good, fair, or poor. When grading the overall strength of evidence, the quality and applicability of the individual studies, the consistency of the results and volume of the literature was considered. Each outcome was then also assigned a high, moderate, low, or insufficient grade to represent the overall quality. (Caughey et al., 2009).

Summary odds ratios and summary risk differences were created to analyze the data. The statistical heterogeneity for all computed summary effects was calculated by Q statistics, had a P value <0.050 and an I2 statistic of I2>50% to be considered heterogeneous. Sensitivity analysis was also performed to evaluate the results. (Caughey et al., 2009).

Key Findings: Of 6,117 potentially relevant articles, 36 met inclusion criteria including: 11 randomized controlled trials, and 25 observational studies. Expectant management of pregnancy was associated with a 22% increase in cesarean delivery (OR, 1.22 [95% CI, 1.07 to 1.39] P <0.01) and an absolute risk difference of 1.9 percentage points (CI, 0.2 to 3.7 percentage points; P=0.03). Most of the studies only included women at or beyond 41 completed weeks gestation (OR, 1.21 [CI, 1.01 to 1.46] P=0.04. Three trials reported a non-statistically significant difference in risk for cesarean delivery among women who were induced at less that 41 completed weeks of gestation (OR, 1.73 [CI 0.67 to 4.5] P=0.26), but they were of poor quality. (Caughey et al., 2009).

Six randomized controlled studies were examined for whether or nor the presence of meconium stained amniotic fluid was associated with elective induction of labor. The overall rate of meconium stained fluid in the expectant management group was 29% +/- 0.04% compared with 17% +/- 0.06% in the elective induction of labor group. When combined, these studies demonstrated that the presence of meconium stained fluid was more likely in the expectant management group than in the elective induction of labor group (OR, 2.04 [CI, 1.34 to 3.09] P<0.01). The risk of meconium aspiration syndrome in neonates did not differ between the two groups (OR, 1.39 [CI, 0.71 to 2.72]; P=0.35). However, the overall evidence regarding meconium aspiration was considered low (Caughey et al., 2009).

Thirteen studies provided evidence that the rate of a 5 minute Apgar score less than 7 was no different between the women undergoing elective induction and those having expectant management (OR, 1.18 [CI, 0.67 to 2.06]; P=0.57). Due to the wide CI, this outcome is fairly uncommon and lacks adequate power (Caughey et al., 2009).

The key finding in the systematic review is that the likelihood of cesarean delivery appears to be equivalent or even lower in women who are electively induced compare to those who are expectantly managed. This findings contrasts the widely held opinion about elective inductions, but it is consistent with existing metaanalysis comparing studies of induction of labor with those of expectant management. (Caughey et al., 2009)

Study Strengths: This article did a systematic review of current literature and evaluated each study in regards to elective induction versus expectant management. This article is a metaanalysis that quantitatively integrates results from multiple studies that address a similar research question. The essence of a metaanalysis is that information from various studies is used to develop an effect size. Effect sizes are averaged across studies, yielding not only information about the existence of a relationship between variables but the magnitude that exists (Polit, & Beck 2008). Some advantages of metaanalysis include: objectivity, power, and precision. Decisions regarding how much weight to give findings are made explicit, and the impact of these decisions can be evaluated by readers of the synthesis report. Readers of a metaanalysis can be assured that another analyst using the same data set would come up with the exact same conclusion. Power refers to the probability of detecting a true relationship between the independent and dependent variables. By combining results across multiple studies, power is increased (Polit, & Beck, 2008). Another benefit of metaanalysis is precision. Metaanalysis can provide evidence about how big an effect an intervention has, with a specified probability that the results are accurate. Estimates of effect size across multiple studies yield smaller confidence intervals than individual studies, enhancing precision (Polit, & Beck, 2008).

Study Weaknesses: Limitations to this study were that the researchers did not find any randomized control trials on elective induction of labor at less than 41 weeks gestation. The studies included in the search that had data on induction at less than 41 weeks were of poor quality and not pertinent to current practice.

Qualitative or Quantitative World View: This is a quantitative study in that numeric data was obtained through systematic and statistical analysis. Data was collected and evaluated statistically to bring about numeric results. (Polit, & Beck, 2008).

Link to Research Inquiry: This article links to this research inquiry in that it evaluated the benefits of elective induction of labor versus expectant management. Elective induction is motivated by a variety of reasons including: a women's desire to end pregnancy due to physical discomfort and concerns for maternal, fetal or neonatal complications. Elective inductions appear to be more rapidly increasing than induction of labor as a whole (Caughey et al., 2009). By evaluating the benefits and risks of elective induction, practitioners can better provide accurate information to patients when they insist on induction.

Study #8: “Labor induction: do guidelines decrease adverse outcomes?” (Fisch, English, Pedaline, Brooks, & Simhan. 2009).

Statement of Purpose: The purpose of this study is to evaluate specific guidelines regarding labor induction and any decrease of adverse outcomes because of them.

Setting/Sample: This study took place at Magee Hospital in Pittsburgh, PA where 9,300 births occur per year. All scheduled inductions during 3 time periods were compared and evaluated including: a 3 month period in 2004, the same 3 month period in 2005, and a 13 month period in 2006-2007.

Inclusion Criteria: Included in this study were pregnant women who delivered at Magee Hospital between 2004-2007 and underwent induction of labor.

Method: Magee Hospital in Pittsburgh, PA developed guidelines in 2004 regarding elective inductions. These guidelines stated that elective inductions should not be performed unless the woman was >/= 39 weeks gestation (with accurate dating), and had a Bishops Score of >/= 8 for primiparas and >/= 6 for multiparas. Despite these guidelines, the incidence of elective inductions remained high. In 2006, the staff at Magee Hospital initiated a quality improvement project and stricter induction scheduling processes that were routinely enforced. A retrospective cross-sectional comparison of induction rates before and after the initiation of the quality improvement project and induction scheduling was performed. The researchers compared all scheduled inductions during 3 time periods: a 3 month period in 2004 (n=533), same 3 month period in 2005 (n=454), and a 13 month period in 2006-2007 (n=1806) that followed the adaptation of the policies.

Key Findings: Maternal and obstetric characteristics of women did not differ in any of the 3 time periods studied, supporting the idea that the medical reasons for induction are not changing. See table 2-15 for induction rates during the study period.

Table 2-15 Labor Induction Rates During Study Period
3 months in 2004
3 months in 2005
13 months in
Elective Induction Rate
(Elective induction/Total deliveries)
Elective Inductions Before 39 wks Gestation
(<39 wks elective inductions/total elective inductions)
Total Induction Rate
(Total inductions/Total deliveries)
Cesarean Birth Rate Among Nulliparas with Elective Induction
(Fisch, et al., 2009)

The enforcement of the strict guidelines was effective in lowering the total and elective induction rates as well as the rates of cesarean sections in nulliparous women that were induced.

Study Strengths: This study demonstrated that with strict guidelines in place for elective inductions, the rates of elective and total inductions decrease as well as the cesarean section rate for nulliparas. This study was focused and had good control.

Study Weaknesses: Weaknesses of this study include a population group in only one hospital, no mention of induction techniques, very limited inclusion criteria, and other no mention of any other factors that were considered in the evaluation. It also does not discuss what adverse outcomes are under study and how they evaluate whether not the guidelines affect these outcomes.

Qualitative or Quantitative World View: This study is a quantitative study in that data is generated and statistically analyzed. This study’s purpose is to evaluate whether or not enforcing strict guidelines for elective labor inductions decreased adverse outcomes. This retrospective cross-sectional comparison gathered empirical evidence that was analyzed to then help bring about understanding of what factors lead to adverse outcomes of elective induction (Polit, & Beck, 2008). Retrospective studies involve collecting data on an outcome occurring in the present, and then linking it retrospectively to antecedents or determinants occurring in the past. These studies are typically cross-sectional in that data about both present outcomes, and past events are collected at a single point in time. (Polit, & Beck, 2008).

Link to Research Inquiry: This study has some significance to this research inquiry. Rates of labor induction in the United States have increased in the past 15 years from 9.5% in 1990 to 22.3% in 2006 (Fisch, et al., 2009). Because of the increase in inductions, an increase in adverse outcomes has also occurred. Elective inductions before 39 completed weeks gestation can increase neonatal morbidity including: respiratory distress, temperature instability, hypoglycemia, hyperbilirubinemia, difficulty feeding and hospital readmissions (Fisch, et al., 2009). By developing and implementing strict guidelines in regards to elective inductions, we can help decrease potential adverse effects. Guidelines regarding appropriate techniques for labor induction, including castor oil, need to be developed to better enhance evidence based care.

Study #9:Variables that predict the success of labor induction” (Bueno, San-Frutos, Salazar, Perez-Medina, & Engels, 2005).

Statement of Purpose: The purpose of this study is to evaluate the different clinical and sonographic variables that influence the success of induction and the likelihood of each.

Setting/Sample: This study took place at the Department of Gynecology and Obstetrics at Santa Cristina University Hospital in Madrid, Spain. The sample included 196 pregnant women that were admitted between January 2002 and June 2003.

Inclusion Criteria: Included in the study were term, pregnant women presenting for induction of labor.

Exclusion Criteria: Patients with the following were excluded from the study: previous uterine scars, active vaginal bleeding, or any contraindication to labor induction.

Method: All study participants gave written consent to participate and were approved by the ethics committee of the hospital prior to participation in the study. See Table 2-16 for variables that were under study. Success was considered with a vaginal delivery within 24 hours of induction. Transvaginal ultrasound was performed by 2 expert sonographers separately. Three measures were obtained and the shortest measurement was used for analysis. A senior resident performed clinical evaluation without knowledge of the ultrasound findings. Labor induction was performed according to hospital guidelines. Patients with an unfavorable cervix (Bishop score <7) were induced with Dinoprostone gel, 0.5mg intracervical, repeating every 6 hours until a maximum of 4 doses if needed, depending on their Bishop score. Patients with a Bishop score of 7 or more had artificial rupture of membranes and oxytocin augmentation if unsatisfactory progress was made after amniotomy. Continuous monitoring for the fetal heart rate and uterine contractions were initiated in each case. (Bueno et al., 2005). See table 2-17 for study induction protocols.

Table 2-16 Study Variables
Bishop Score
Transvaginal Sonographic Cervical Length
Biparietal Diameter
Estimated Fetal Weight
Maternal Age
Previous Miscarriages
(Bueno et al., 2006)

Table 2-17 Study Induction Protocols
Bishop's Score <7
Bishop's Score of 7 or more
  • Dinoprostone gel 0.5mg intracervical Q6hr to a maximum of 4 doses if necessary
  • AROM
  • Oxytocin augmentation as needed if unsatisfactory progress of labor made with AROM
(Bueno et al., 2006)

The percentage, mean, standard deviation, minimum and maximum of each quantitative variable were all measured. Receiver-operating characteristics curves were used to assess the ability of ultrasound assessed cervical length and Bishop Score to predict the success of induction. The results were expressed as odds ratios with a 95% confidence interval and a P value of <0.050 to be considered significant. (Bueno et al., 2005).

Key Findings: Vaginal delivery occurred in 144 (73.5%) of inductions, while 26.5% of the women delivered by cesarean section. The most frequent indication for cesarean delivery was failure to progress; occurring in 16 (34%) women. In regards to the total duration of labor, 134 (68.4%) ended in less than 24 hours. Successful induction was seen in 106 (59.5%) of cases, while induction “failed” in 40.5% of cases. (Bueno et al., 2005) This study suggests that parity is the best predictor of labor induction; however both cervical length and Bishop's score are parameters that predict labor induction success. See Table 2-18 for the best cut-off points for the prediction of successful labor induction. Global analysis of transvaginal cervical length, parity, and Bishop score concludes that these factors will all improve the prognosis of labor induction when used appropriately. Figure 2-1 displays the results of the study by parity. (Bueno et al., 2005).

Table 2-18 Best Cut-Off Points for Prediction of Successful Induction
Bishop Score
Ultrasound Cervical Length
0<16.5 mm
1-416.5-27 mm
>4>27 mm

Figure 2-1

Study Strengths: This study was a well done study on the effectiveness of ultrasound measurements of cervical length and Bishop's score in predicting success of induction of labor. It had a large population that was studied and took into account different variables and their impact on the results. This study had a systematic method of data collection and statistical analysis. A correlational study looks at the interrelationship or association between two or more variables, that is, a tendency for a variation in one variable to be related to a variation in another (Polit, & Beck, 2008). Correlational research plays a very important role in research because many problems are not experimental. Correlational research is strong in realism and has intrinsic appeal for solving practical problems. (Polit, & Back, 2008).

Study Weaknesses: A weakness of this study is that only selected induction techniques were used in this study including: amniotomy, Oxytocin, or Dinoprostone. Different methods of cervical ripening or induction of labor may have brought about different outcomes. The study did not give any r-values, which would demonstrate how strongly related the data is.

Qualitative of Quantitative World View: This study is a quantitative study. The researchers systematically collected data, and statistically analyzed the data to come up with an end result. The evidence was empirical and the findings are generalized (Polit, & Beck, 2008).

Link to research Inquiry: This particular study links to this research inquiry in that it recommends looking at parity, cervical length by ultrasound and the Bishop's score when assessing and predicting successful induction. Before any method of induction is considered or attempted these factors should be assessed to ensure that the appropriate method is used. Both subjective and objective data is utilized to predict successful vaginal delivery with labor induction techniques. By assessing cervical readiness for labor and induction, recommendations can be made regarding various induction techniques such as castor oil.

Study #10: “Preinduction sonographic assessment of the cervix in the prediction of successful induction of labor in nulliparous women” (Keepanasseril, Suri, Bagga, & Aggarwal, 2007).

Statement of Purpose: The purpose of the study is to compare the efficacy of cervical assessment done by ultrasound with the Bishop’s score before induction of labor in nulliparous women.

Setting/Sample: This prospective study was done between April 2005 and August 2006 at Nehru Hospital attached to the Post Graduate Institution of Medical Education and Research in Chandigarh, India. The sample included 138 women who underwent cervical assessment with transvaginal sonography followed by digital cervical assessment using Bishop's score before induction of labor. (Keepanasseril, Suri, Bagga, & Aggarwal, 2007).

Table 2-19 Inclusion and Exclusion Criteria
Inclusion Criteria
Exclusion Criteria
Singleton pregnancyPrevious attempt of labor induction
Gestational age 34-41 weeks by last menstrual period OR by 1st or 2nd trimester ultrasoundCesarean section within 1 hour of induction of labor
Live fetus in cephalic presentation
No previous history of uterine surgery
Nulliparous women
(Keepanasseril et al., 2007)

Method: One hundred forty-five women that were undergoing induction of labor for various indications were recruited to participate in this study. Data was obtained from income maternal notes regarding: maternal age, body mass index, and gestational age. Ultrasound was first performed by one examiner to evaluate specific parameters. Next a different examiner performed a digital examination to determine a Bishop’s score. Both examiners were blind to each others' findings before induction of labor was initiated. Induction of labor was initiated using intravenous oxytocin or intravaginal misoprostol. Women with a Bishop score of <5 (considered an unfavorable cervix) were induced with either intravenous oxytocin after cervical ripening with intracervical Dinoprostone gel or misoprostol alone. A successful induction was defined as a vaginal delivery. The researchers expected the successful prediction of labor induction, resulting in a vaginal delivery by both ultrasound examination and by Bishop’s score to be 75%. Statistical analysis was done using a Mann-Whitney test, X2 test, receiver operating characteristics curves and logistic regression analysis. Statistical significance was achieved at a P value of < 0.05. See Table 2-10 for assessments performed by U/S and Bishop's score. (Keepanasseril et al., 2007).

Table 2-20 Assessments Performed for Study
U/S Measurements
Bishop's Measurements
Cervical LengthDilatation
Posterior Cervical AngleEffacement

Key Findings: Intravenous oxytocin was used as the induction agent in 100 (72.5%) patients, of which 39 (28.2%) required cervical ripening with intracervical prostaglandin gel. Intravaginal misoprostol was used in 38 (27.5%) women as the induction agent. Successful vaginal delivery occurred in 106 (76.8%) women. There were 32 (23.2%) deliveries by cesarean section, 21 (65.6%) for failure to progress, 9 (28.1%) for fetal distress and 2 (6.3%) for placental abruption. There was no statistically significant difference between the women who delivered vaginally and those by cesarean section regarding maternal age, gestation age at induction, body mass index and the mean birth weight. (Keepanasseril et al., 2007)

Univariate analyses indicated that successful induction of labor was significantly related to the total Bishop Score, sonographic cervical length, posterior cervical angle, and funneling. Multiple logistic regression analysis showed that only cervical length and posterior cervical angle assessed by ultrasound were independent predictors of successful outcomes after labor induction. As analyzed by the receiver operation characteristic curves, the best cut-off point for the prediction of successful induction of labor was 3.0 cm for cervical length, 100 degrees for posterior cervical angle and a score of 3 for Bishop score (Table 2-21, 2-22, and 2-23). (Keepanasseril et al., 2007).

Table 2-21 Relationship Between Successful Labor Induction and the Independent Variables Analyzed by Multiple Logistic Regression
Odds Ratio
95% CI
TVS Cervical Length
P = 0.000
Posterior Cervical Angle
P = 0.031
P = 0.415
Bishop Score Total
P = 0.252
P = 0.509
P = 0.816
P = 0.972
P = 0.959
P = 0.981
Bold figured indicate independent predictors
(Keepanasseril et al., 2007)

Table 2-22 Statistical Results
Univariate Analysis
Multiple Logistic Regression Analysis
Receiver Operating Characteristic Curves
Total Bishop Score
P = 0.006
P = 0.252
P = 0.007
Area under the curve 0.657
P = 0.019
P = 0.509
P = 0.008
P = 0.816
P = 0.031
P = 0.972
P = 0.035
Ultrasonographic Cervical Length
P = <0.001
P = 0.000
P = <0.001
Area under the curve = 0.926
Posterior Cervical Angle
P = <0.001
P = 0.031
P = <0.001
Area under the curve = 0.742
P = 0.050
P = 0.415
(Keepanasseril et al., 2007)

Table 2-23
Cervical Length of 3 cm
Posterior Cervical Angle of 100 Degrees
(Keepanasseril et al., 2007)
Sensitivity is the ability of a screening instrument to correctly identify cases or diagnose a condition.
Specificity is the ability of a screening instrument to correctly identify noncases. (Polit, & Beck, 2008).

This study’s findings indicate that transvaginal ultrasound assessment of the cervix prior to labor induction may be used as an independent predictor of successful induction in nulliparous women. Ultrasonographic assessment can help identify those women who have a higher chance of a successful vaginal delivery with induction.

Study Strengths: This study acknowledged some earlier studies done on this topic and adjusted their parameters and criteria to address weaknesses found in previous studies. This study evaluated the cervix prior to induction to determine what technique would be most powerful for prediction of successful induction. Demographic characteristics such as maternal age, gestation age, body mass index, and birth weight were considered and evaluated as potential contributors to failed induction. This study helped to define different parameters such as: parity, cervical length and posterior cervical angle that can be used as additional information to the practitioner when developing a plan for induction of labor.

Study Weaknesses: This study is relatively small and only looks at induction with intravenous oxytocin, intravaginal misoprostol and intracervical prostaglandin gel. It is possible that different induction techniques have an impact on the mode of delivery and successful induction of labor. Limiting factors for widespread use of ultrasound are cost of the equipment, and the longer learning curve in comparison with the Bishop’s score.

Qualitative or Quantitative World View: This study is a quantitative study in that numeric information is the result from some formal measurement that is analyzed with statistical procedures (Polit, & Beck, 2008). The study is systematically performed and gathers empirical evidence regarding assessments of the cervix and predicting successful induction of labor. The researchers measure data collected and attach numeric values to determine effectiveness, making this a quantitative study (Polit, & Beck, 2008).

Link to Research Inquiry: This particular study addresses preinduction cervical assessment. Labor inductions are becoming one of the most common interventions in modern obstetrics (Keepanasseril et al., 2007). It is vital that practitioners accurately assess all factors of the cervix before determining the appropriate induction technique. Both the Bishop’s score and ultrasonographic assessments are essential to the evaluation and predictions of successful induction that should be utilized when discussing appropriate induction techniques with our patients. These factors are helpful when determining which induction techniques are appropriate and recommending specific methods of labor induction, including castor oil.

In summary, there is limited research on the use of castor oil for induction of labor. Despite the fact that it has been used for many years by midwives as a method of induction; little is known regarding the safety, mechanism action, appropriate dosage, adverse effects, and efficacy of this medication. There have been promising results in one trial for castor oil's efficacy despite the high rate of minor side effects including nausea and diarrhea; other research on the topic has been of poor quality but suggests that not only do patients use this method of labor induction, but some providers suggest its use as well. When developing a plan of care for induction of labor, many factors need to be considered to ensure a safe and successful vaginal birth. Maternity care practitioners need to be skilled in assessing cervical readiness for induction and incorporating that information with parity and necessity for delivery when deciding on a method for induction. Another important aspect of labor and delivery care is a woman's expectations, understanding, and satisfaction with her experience. Midwives provide high quality care while keeping a level of respect and encouragement of patients to have control over their own experience.

Conceptual Framework

The framework of a study is the overall conceptual rationale. Every study has a framework even though every study may not be based on a formalized theory or conceptual model. Generally the framework of a study helps to organize and bring about better understanding of the concepts and research findings. Theories, conceptual frameworks, and models are not discovered; they are created and invented (Polit, & Beck, 2008). Observations and evidence are used to create a framework that pulls information together to show how it all relates to each other. The overall purpose of a theoretical or conceptual framework is to make research findings meaningful and generalizable (Polit, & Beck, 2008). These models can also show areas where more research needs to be done, and help develop studies that advance knowledge and evidence based research.

Castor oil is derived from the castor plant (Ricinus communis) and is a potent cathartic. The mechanism of action of castor oil for labor induction is unclear but it is thought to involve the production of prostaglandins followed by uterine activity. Ricinoleic acid is the main component of castor oil and is responsible for its cathartic action. When tested in rats, there was an increase in portal vein prostaglandin E and F following administration of castor oil. Some side effects reported with the use of castor oil as a method of induction include: unpleasant taste, nausea, vomiting, diarrhea, abdominal cramping, and increased risk of meconium-stained amniotic fluid. Because castor oil use in pregnancy is under-reported worldwide, the scientific literature does not contain adequate studies regarding its mechanism of action, recommended dosage, safety and efficacy. (Garry, et al., 2000)

Castor oil is generally used for bowel preparation and for the treatment of constipation. Typical dosages are 15-60ml PO either x1 or daily. Contraindications to its use include: hypersensitivity to the drug, suspected appendicitis, fecal impaction, intestinal obstruction, menstruation, and caution in rectal bleeding. There are no significant drug interactions found with this medication. Some common adverse reactions include: dizziness, electrolyte disorders, abdominal pain, nausea, and diarrhea. It is metabolized in the gastrointestinal tract and there is minimal systemic absorption. It is excreted in feces and its half-life is unknown. The known mechanism of action is that it causes an increase in peristalsis. (Epocrates, 2009)

Two conceptual frameworks were used in this research inquiry. The Health Promotion Model focuses on explaining health-promoting behaviors and entails activities that maintain or enhance a person's well-being (Polit, & Beck, 2008). This model incorporates interpersonal and situational influences on an individual's actions. The second model that was used in this inquiry is the Health Belief Model. This model suggests that health seeking behavior is influenced by a person's perception of a threat and is associated with actions that help reduce that threat. The main components of this model include: individual perceived susceptibility, perceived severity, perceived benefits, motivation, and enabling or modifying factors (Polit, & Beck, 2008). The combination of these models helps to explain how individuals perceive the "threat" of labor induction or of impending labor; which is a common fear among pregnant women, and helps describe health promoting activity that aims to enhance their overall well-being.

Maternity care providers should have a primary goal to enhance each patient's health and well-being. In situations when labor induction is indicated, the ultimate goal is a successful birth with a healthy mother and baby in the end. The Health Promotion Model focuses on this enhancement of well-being. It is important that a method of labor induction is utilized that helps to promote well-being and produce the desired outcome. Each circumstance needs to be evaluated individually in order to appropriately choose an effective method of induction when necessary. Obstetric care providers are also obligated to encourage health promoting behaviors in patients so that they have a sense of control and satisfaction with their health and health outcomes. By instilling this sense of control over their health, and providing care that is focused on the enhancement of their well-being; their individual perception of health will greatly increase. The Health Promotion and Belief Model can pertain to both the patient seeking and utilizing health promoting behaviors, as well as the provider counseling and recommending specific health promoting treatments. Health care providers have the obligation to counsel patients and encourage them to choose health promoting behaviors and treatments. However it is also the patient's responsibility to choose and follow through with health promoting behaviors. Patients and health care providers often have two different sets of beliefs that need to come together in most situations to negotiate a plan of care that is mutually acceptable for both parties. The health care provider can recommend certain therapies for labor induction but ultimately it is the patient's decision to follow through. In the case of using castor oil for labor induction, providers can counsel patients on its use and educate them on the potential adverse effects, and potentiated mechanism of action; however castor oil can be obtained without a provider knowing and taken by a patients as a self-treatment without disclosing it to a provider for approval.

The Health Belief Model focuses on an individuals perception of a threat and their actions as a result of that threat. Labor and delivery can be perceived as a "threat" that many people fear. The pain and discomfort of labor is what many pregnant women focus on as they anticipate the birth of their child. With induction of labor, maternity care providers can potentiate this threat and often times make it worse. The patient's perceived susceptibility is their perception that labor and delivery is relevant to them and that it will inevitably happen. Their perceived benefits are their beliefs that in then end they will have a baby. The perceived costs are the duration, accessibility and complexity of the experience that are often times unknown. Many people do not know what to expect, how long or how difficult labor may be. Their motivation is the desire to get their pregnancy over with and have their baby. This model helps us to understand the perception of an experience and how an individual reacts to their perceptions.

Conceptual Map

Chapter 3: Methodology

Research Design
"Research is the systematic inquiry that uses disciplined methods to answer questions or solve problems in order to expand a body of knowledge" (Polit, & Beck, 2008, pg 3). Knowledge in medicine is always changing and expanding. As health-care providers, it is essential to provide current and evidence based care to patients. There are many things that are done in medicine that are not evidence based, but rather simply because "it is how things have always been done"; however this is not a defensible rationale. Quantitative research is based on the traditional or positivist scientific method. This method refers to a general set of orderly, disciplined procedures that are used to acquire information. Quantitative researchers use deductive reasoning to generate predictions or hypotheses, that are then tested in the real world. Data gathered in quantitative research is numeric information that results from some sort of formal measurement that is analyzed by statistical procedures. Results are discussed and inferences are made that are then applied to practice. (Polit, & Beck, 2008).

Randomized clinical trials are considered by many to be the gold standard for yielding reliable evidence regarding cause and effect (Polit, & Beck, 2008). The design of this study contains manipulation, control, and randomization; all which are characteristics of a true randomized control trial. Manipulation is achieved by administering castor oil to Group A, and not to Group B. The control group is Group B that receives standard treatment, Pitocin, for labor induction. Pitocin is one of the most popular methods of labor induction, therefore making it a good control method. Randomization is demonstrated by randomly assigning subjects to the two study groups. Randomization means that every subject had an equal opportunity of being assigned to either group. When subjects are placed into groups randomly, there is no systematic bias with respect to attributes that could potentially affect the dependent variable. Randomization is the preferred method for equalizing groups, there is no guarantee that the groups will, in fact, be completely equal (Polit, & Beck, 2008).

Internal Validity
"Internal validity concerns validity of inferences that, given the existence of an empirical relationship, it is the independent variable, rather than other factors, that caused the outcome" (Polit, & Beck, 2008, pg. 287). Internal validity is the primary threat to the findings of a study that is assessing the effects of a specific intervention. It is important that the observed response is a result of the intervention, and not resulting from other possible causes or alternative explanations. Randomization is the most effective method of controlling individual confounding variables. By randomly assigning subjects into study groups, all sources of extraneous variation are hypothesized to be controlled without any conscious decision by the researcher (Polit, & Beck, 2008). This is then tested by comparing demographics data on the randomly assigned groups. The assumption is made that if age, parity and other relevant variables are not statistically different between group, then other confounding variables may also be equally distributed and that any difference between the groups is due to the treatment itself. Table 3-1 describes the potential threats to internal validity and the measures taken to control validity.

Table 3-1 Threats to Internal Validity and Measures Taken to Control Validity
Threats to Internal ValidityMeasures to Control Validity
Variation in provider assessment of Bishop's Score.Provide specific guidelines for practitioners involved in assessing Bishop's Score.
(See Table 3-2 Bishop's Scoring System)
Maternal position changes and activity in labor.Encourage all laboring women to make frequent position changes and ambulate.
All patients will remain on continuous EFM throughout the labor induction process. (A telemetry unit will be utilized to promote ambulation and position change)
Onset of labor prior to labor induction.Participants with evidence of active labor prior to induction will be excluded from the study.

Table 3-2 Bishop Scoring System
Dilatation (cm)
Effacement (%)
(Varney, 2004)

External Validity
External validity refers to the generalizability of the study findings. This is the validity that inferences about observed relationships that will hold over variations in persons, setting, time, or measure of the outcomes (Polit & Beck, 2008). In a randomized clinical trial, it is the sample that determines representativeness, the study participants will be representative of the sample population. By involving all pregnant women scheduled for labor induction in Aroostook County, the overall population of this area has equal chance of being involved in the study. External threats to this study are that in Aroostook County, the diversity of the population is less than desirable. Measures to overcome this external threat involve providing access to all pregnant women that live in Aroostook County to be involved in the study.

2008 Data for Aroostook County, Maine
Population estimate-71,676
Female persons-51.2%
White persons-96.3%
Black persons-0.7%
American Indian persons-1.5%
Asian persons-0.6%
Hispanic persons-1.1%
(U.S. Census Bureau, 2010)

Sampling Methods

Objective: The objective of this study is to evaluate the effectiveness of castor oil administration compared with Pitocin administration for induction of labor.

Setting: This study will take place at Cary Medical Center, a community hospital in Caribou, Maine. Cary Medical Center is a 65-bed acute care hospital that does approximately 200 births per year. There are three other small community hospitals within 15 minutes to an hour away from Cary that serve the people of Aroostook County.

Population: The target population includes all pregnant women in Aroostook County. The accessible population consists of all pregnant women in Aroostook County that will undergo labor induction at Cary Medical Center.

Sampling: A convenience sample of all pregnant women that meet inclusion criteria and are scheduled for labor induction will be considered for participation in this study. This method of sampling is beneficial for this study because of the ease of availability of study participants. All patients scheduled to undergo labor induction will be screened, provided information regarding the study and asked for consent to participate. By using convenience sampling, the researcher has access to all possible study participants and can include all of those that meet study criteria. There is a high risk for bias with this sampling method, however no attempts will be made to control or manipulate which subjects will be involved in this study. The desired sample size is 50 subjects, however if more women meet study criteria and consent to participate, they will be included as well. In order to obtain statistical conclusion validity, careful attention must be paid to the sample size of quantitative studies. Power analysis is a procedure that can use used to estimate sample size needs, and it builds on the concept of an effect size. The effect size expresses the strength of relationship among research variables. The larger the sample, the more representative of the population it is likely to be. However, practical constraints such as time, subject availability, and resources often limit sample size (Polit, & Beck, 2008). Last year approximately 200 deliveries were done at Cary Medical Center each year. About 29% of those deliveries were either repeat or primary cesarean sections, and nearly 36% were labor inductions. Unfortunately not everyone invited to participate in a study agrees to do so, so when developing this sampling plan a target sample size of 60 women will be recruited with expected refusals. Attrition describes the loss of participants over the course of the study, which can create bias due to changes in the composition of the sample that was initially drawn (Polit, & Beck, 2008). In order to allow of attrition, a power table was used and 20% was added to the desired sample size.

Inclusion Criteria
Exclusion Criteria
Singleton pregnancyMultiple gestations
Gestational age >/= 39 weeks by LMP or 1st trimester U/sActive vaginal bleeding
Live fetusActive labor prior to induction
Cephalic presentationAbnormal FHR tracing
Bishop's score of 6 or greaterPrevious uterine surgery
Documented indication of labor inductionAny contraindication to vaginal delivery or labor induction
(See table 1-1)

Ethical Considerations
Permission and approval for this study will be sought from administration at Cary Medical Center and from the Philadelphia University Institutional Review Board, to ensure that the subject's rights are honored and protected. The study participants will be informed of the purpose of the research study and methods utilized to determine the effectiveness of castor oil for labor induction. Privacy and confidentiality will be upheld throughout the study. The participant's identifying information as well as data forms will be coded for data entry, stored in a secure area away from their responses, and destroyed after the study is completed.

Data Collection Procedures

Interventions: The study population includes singleton pregnancies at >/= 39 weeks gestation by LMP or by first trimester ultrasound, admitted to L&D for labor induction. All study participants will need to have a documented reason for labor induction, and provide written consent to participate. They will be evaluated in the labor unit, and placed on electronic fetal monitoring for fetal heart rate and tocometric evaluation. A cervical examination will be performed by the obstetric provider to assess Bishop's score (See Table 1). Women with multiple gestations, active vaginal bleeding, evidence of labor prior to induction, abnormal FHR tracing, previous uterine surgery, or any other contraindication to labor induction and vaginal delivery will be excluded from the study.

A table of random numbers will be utilized to assign participants into Group A or Group B. Group A will receive Castor Oil for labor induction, while Group B will receive Pitocin to induce labor. (See administration protocols below). Induction will be considered successful if active labor is achieved within 24 hours of administration of the induction technique. Labor progression will be evaluated by the obstetric provider. The two groups will be compared for onset of labor within 24 hours, method of delivery, presence of meconium-stained amniotic fluid, Apgar scores, birth weight, and patient satisfaction of technique. Adverse effects of the treatments will also be evaluated, see table 3-3. Data will be collected and analyzed from December 1, 2010 to December 1, 2011.

Table 3-3 Potential Adverse Effects of Castor Oil & Pitocin
Castor Oil
VomitingUterine hypertonicity
Uterine tetany
Uterine rupture
DiarrheaAbruptio placentae
Electrolyte disordersArrhythmias
Abdominal crampingHyperbilirubinemia (neonate)
Unpleasant tasteLow Apgar scores
Meconium-stained amniotic fluidNausea
Postpartum hemorrhage
Vaginal and cervical lacerations
Fetal distress
Bradycardia (fetus, neonate)
Arrhythmia (fetus, neonate)
Permanent CNS damage (neonate, fetus)
Seizures (neonate)
Retinal hemorrhage (neonate)
(Epocrates, 2010) (Garry, et al., 2000)

Administration Protocols:
Group A - Castor Oil
1. Obtain written order from Physician/Midwife.
2. Explain procedure to patient and obtain baseline vital signs.
3. Obtain a minimum 30 minute baseline fetal monitor strip. Record fetal heart rate and contraction pattern, including intensity and resting tone of contractions.
4. Obtain IV access. (INT or HepLock)
5. Administer 60 ml PO of Castor Oil mixed in 8-12 ounces of apple or orange juice (per patient preference). Best time to administer castor oil is in early morning after a good night's sleep. (Varney, 2004)
6. Maintain constant electronic fetal monitoring and tocometric evaluation.
7. Obtain vital signs per hospital protocol.
8. Notify provider for any of the following:
* Non-reassuring fetal heart rate pattern
* Tetanic contractions
* Severe nausea, vomiting, or diarrhea
* Rupture of membranes
9. Encourage ambulation, and multiple position changes throughout labor for comfort.

Group B - Pitocin
1. Obtain written order from Physician/Midwife.
2. Explain procedure to patient and obtain baseline vital signs.
3. Obtain a minimum 30 minute baseline fetal monitor strip of the fetus. Record fetal heart rate and contractions pattern, including intensity and resting tone of contractions.
4. Obtain large bore IV access. Start primary IV of Lactated Ringers or Normal Saline @ 125ml/hr. (Adjust as needed. Total infusion rate of primary IV and Pitocin should be 125ml/hr).
5. Pitocin MUST be administered via IV pump. Pitocin will come premixed from pharmacy as 20 units of Pitocin (oxytocin) in 1000ml of Lactated Ringers solution.
6. Piggyback IV Pitocin solution into main line IV solution and start infusion at 2 milliunits/min. Dose can be increased by 2 milliunits/min every 20 minutes until active labor is established.
7. Maintain constant electronic fetal monitoring and tocometric evaluation.
8. Prior to increasing the rate of Pitocin each time, the RN must obtain the following:
* Maternal vital signs
* Contraction pattern including
- Frequency
- Duration
- Intensity (done by palpation unless IUPC inserted)
- Resting tone (done by palpation unless IUPC inserted)
* Fetal heart rate pattern
(Notify provider for any abnormal findings)
9. The RN may titrate Pitocin to establish regular labor pattern. Pitocin should be given at the lowest possible dose that will maintain an active labor pattern.
10. Stop Pitocin and notify provider immediately for any of the following:
* Non-reassuring fetal heart rate pattern
* Tetanic contractions
* Increased uterine resting tone
* Precipitous delivery
11. Notify provider if an effective labor pattern is not established after titrating Pitocin to 20 milliunits/min.
12. Encourage ambulation, and multiple position changes throughout labor for comfort.

Instrument Reliability & Validity
Reliability is the degree of consistency and accuracy in which an instrument measures the attribute that it is designed to measure. Validity is the degree in which an instrument measures what it is supposed to measure (Polit & Beck, 2008). Both reliability and validity are important to consider when evaluating instruments used in quantitative study. This study evaluates the effectiveness of labor induction using castor oil as a induction technique compared with pitocin. Instruments used in this study include: Bishop's score, electronic fetal monitor and an IV pump.

Cervical exams are used as a clinical assessment tool to identify labor progress. A cervical exam must be done to evaluate a patient's Bishop score prior to induction. The Bishop's score is a tool that measures specific components of the cervix to evaluate readiness for labor induction and the likelihood of a successful induction. Components of the Bishop's score include: dilation, effacement, consistency, cervical position and fetal station. Each component is evaluated on a scale of 0 to 3. Subjective findings regarding these components among examiners reduces its reliability. The degree of error will be assessed through training of providers in assessment of Bishop's scoring and use of a standardized chart. Inter rater reliability will also be determined. (see table 3-2).

The fetal heart rate monitor that will be used throughout this study is the Hewlet Packard Series 50 IX, Viridia Series 50XM model, with telemetry availability. These monitors will undergo inspection every year or as needed to ensure reliability and validity. Each patient will be continuously monitored to evaluate fetal well-being and for tocometric evaluation. The IV pumps that will be used to administer IV pitocin are the Hospira Plum A+ model. They also will undergo inspection yearly and as needed to ensure reliability and validity. Further data is available on these instruments in their handbooks and manuals located on the Maternal/Child unit.

Data Analysis Plan
Data will be collected and obtained by obstetric providers, nurses and research assistants. Training to all staff members on all shifts regarding the data collection protocol will be done. The researcher will be a regular presence on the unit, checking in a couple of time a week during the length of the study. All data collectors will be trained in labor and delivery care. There will be a standardized method of collection and testing of data in regards to the labor induction techniques. Initial demographic information will be obtained as an initial interview on admission to the labor and delivery unit. This information will be collected by the admitting registered nurse (Appendix B). Data that will be statistically evaluated include: the number of hours to onset of labor after induction method given, length of labor by stage, parity, method of delivery, presence of meconium stained fluid, Apgar scores, and birth weight (Appendix C). A survey will be given to all study participants at their 2 week postpartum visit, to evaluate patient satisfaction with their labor and delivery experience and the labor induction technique that was utilized (Appendix D).

Frequency distributions will be used to organize the numeric data obtained. Frequency distributions are used to arrange numeric values from lowest to highest and to count the number of times each value was obtained. This allows the researcher to see what the highest and lowest values were and what the majority of the data shows. The data will be displayed in frequency counts and percentages for score value (Polit, & Beck, 2008). The demographic data will be explored for patterns and entered as covariates in further analyses as needed. Groups will be tested for equivalence on selected variables using the independent t-test and a p value of 0.05.

Data obtained in this study will be analyzed using a multivariate analysis or MANOVA. This method of analysis is used to test the difference between the means of two or more groups, for two or more dependent variables simultaneously. The dependent variables include: onset of labor, method of delivery, presence of meconium stained amniotic fluid, Apgar scores, birth weight, and maternal satisfaction with induction technique. Descriptive statistics will be utilized to provide an overview of the study participants and the results of the independent variable, castor oil. (Polit, & Beck, 2008). Software that will be used to analyze data will be available through the Statistical Package for the Social Sciences (SPSS).

Plan For Disseminating Findings
The data that is obtained in this study is relevant to all obstetric providers that provide care to pregnant women in the antepartum and intrapartum period. Midwives will be most interested in the data from this study, as they are more likely to recommend castor oil as a labor induction technique. As a result, a manuscript of the findings of this study will be submitted to the Journal of Midwifery and Women's Health (JMWH). The researcher also plans to present the results of the study at the ACNM Maine Affiliates meeting.


Appendix A-Informed Consent


I, ________________________, consent to participate in the research study entitled "A Comparison of Castor Oil Administration Versus Pitocin Administration for Labor Induction".
I understand that the purpose of this study is to examine castor oil as a labor induction technique. Both castor oil and pitocin will be evaluated for effectiveness in regards to labor induction. This study will provide information that will enable health care providers to provide optimal and evidence based care to pregnant women in the labor and delivery setting.

I acknowledge that I have had the opportunity to obtain additional information regarding this study, and that all questions or concerns that I have raised have been answered to my full satisfaction. I also acknowledge that I fully understand this consent form. Participation in this study is completely voluntary, and I may withdraw my participation at any time. If I am selected for participation in the castor oil study, I will agree to provide basic demographic data about myself which is relevant to the study. I understand that I will be randomly assigned to either the castor oil group or the pitocin group, without knowing which group I will be in before hand. Once assigned into a group, I will be made aware of the labor induction technique that I will receive. I understand that there are risks to any type of labor induction and these risks have been explained to me. I understand that I will be monitored throughout labor and my baby's heart rate will be continuously monitored for well-being.

Participation in this study poses no known threat to the safety of myself or that of my unborn baby. The medical needs of myself and my baby take precedence over this study and will be promptly addressed by appropriate medical personnel should it be needed. Although problems seldom occur with labor induction, there are risks. Risks of labor induction include: fetal distress, umbilical cord problems, overstimulation of the uterus, uterine rupture, and infection (American College of Obstetricians and Gynecologists, 2009). Possible side effects of castor oil include: nausea, vomiting, diarrhea, dizziness, electrolyte disorders, and abdominal cramping (Epocrates, 2010). Possible side effects of pitocin include: hypertension, uterine hypertonicity, abruptio placentae, anaphylaxis, arrhythmias, hyperbilirubinemia (neonate), low Apgar scores, nausea, vomiting, and postpartum hemorrhage (Epocrates, 2010).

Refusal to participate will not have any detrimental effects on the care that is given to myself or my baby. A copy of this consent has been given to me. To protect human rights, I understand that this research study was reviewed and approved by the Philadelphia University Institutional Review Board and administration of Cary Medical Center and its affiliates.

Data that is obtained from this study will be coded for data entry. My identity will be protected and will not be reported or published. At the completion of this study, all identifying information will be destroyed. For further questions or concerns, call 1-800-325-4896 or e-mail

Date:______________________ Signature:_______________________________________________________

Date:______________________ Signature:________________________________________________________

Appendix B-Demographic Data Form/Admission Data
(To be completed as admission questionnaire by admitting nurse)
Subject ID Number:__________

Date:__________ Date of Birth:____________ Age:_________

Weight:________ Height:_________________

Emergency Contact Person: ______________________ Phone #:_____________________ Relationship:_______________________

Coach:______________________________________ Phone #:_____________________ Relationship: _______________________

Ethnic Background:
_____ Asian/Pacific Islander
_____ Black/African American
_____ Hispanic
_____ Native American Indian
_____ White
_____ Other---Specify_______________________________

Medical/Surgical History:___________________________________________________________________________________________________________________________


Obstetrical History:
EDC (By LMP)________ EDC (By Ultrasound)__________ Gestational Age: _____________
LMP____________ Week prenatal care started:________ Regular care: Y N (Circle one)

Prenatal Risk Factors:_____________________________________________________________________________________________________________________________


Complications in Pregnancy:________________________________________________________________________________________________________________________


Blood Type:_________ Rubella:_______________ Group B Strep:______________ Serology:___________________

HIV:_______________ AFP:_________________

Fetal Assessments Prenatally (e.g. Ultrasound, Amniocentesis, BPP, NST, CST)__________________________________________________________________________________

Psychosocial History:
Support system
____ Married
____FOB Involved
____FOB Not Involved

Highest level of education:____________ Occupation:_______________________

Personal, Cultural or Religious Practices:___________________________________________________________________________________________________________________


Vaginal Bleeding
___Bloody Show
___Frank Vaginal Bleeding

Vaginal Discharge/Drainage
___Meconium Stained (consistency_________________)

Cervical Exam
_____Bishop's Score (done by obstetric provider)

___Ruptured (date and time)________________________

___Unable to determine
___Confirmed by Ultrasound

Fetal Heart Rate

___Intensity (by palpation)

Appendix C-Delivery Data Form
(To be completed by L&D nurse after delivery)

Subject ID Number__________ Group A/Group B___________

Admission Date_____________ Admission Time_____________

Time of Initiation of Labor Induction and Dose______________________________________

Date & Time Active Labor Achieved_____________________________________________
(regular contractions, cervical dilation of >/=4cm with progressive cervical dilation)

Date of Delivery_____________ Time of Delivery_____________

Type of Delivery_____________ Reason for Cesarean__________
(If Applicable)

Birth Weight_________________ Apgar Scores_______________

_____ Meconium Stained Fluid
_____ Fetal Distress (Non-reassuring FHR)
_____ Neonatal Resuscitation
_____ Meconium Aspiration
_____ Shoulder Dystocia
_____Emergency Cesarean Section
_____ Other--Specify___________________________________________________________

Appendix D-Postpartum Interview
(To be completed by patient at 2 week postpartum office visit)

Subject ID Number:________


1. I feel that the purpose and methods of the castor oil study were explained to me well.
______Strongly Agree
______Strongly Disagree

2. I feel that the method of labor induction that I received was effective.
______Strongly Agree
______Strongly Disagree

3. I am satisfied and happy with my labor/delivery experience.
______Strongly Agree
______Strongly Disagree

4. I am happy with the care that I received.
______Strongly Agree
______Strongly Disagree

5. I would recommend the method of labor induction that I received.
______Strongly Agree
______Strongly Disagree

6. I believe that the possible side effects of the labor induction technique I received, were explained to me well.
______Strongly Agree
______Strongly Disagree

7. If I had to be induced again, I would want to use the same method of induction.
______Strongly Agree
______Strongly Disagree

8. I feel that my needs were met throughout the labor and delivery experience.
______Strongly Agree
______Strongly Disagree

9. I would consider undergoing labor induction again
______Strongly Agree
______Strongly Disagree

10. My labor was induced for:
______Medical indications
______Personal preference and desire to be delivered
______Provider suggestion

11. Things that I liked about the labor induction technique that I received include:_______________________________________________________________________________________


12. Things that I disliked about the labor induction technique that I received include:_____________________________________________________________________________________


Appendix E-Budget

Secretarial time to prepare consents, data collection forms and questionnarires--$300.00
Printing and copying of consents, data forms and questionnaires--$200.00
Assistance with statistical analysis--$1,000.00
Research Assistant--(Based on a 20,000/year salary) 0.2FTE x 18 months = $6,000.00
Research Midwife--( Based on a $75,000/year salary) 0.2FTE x 18 months = $22,500.00
Total Budget--$30,000

Appendix F-Timetable

Proposal from Philadelphia University IRB Approval--1 month
Proposal from Cary Medical Center Approval--1 month
Data Collection--12 months
Data Analysis--2 months
Dissemination of Findings--2 months
Total Time--18 months

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