To Induce or Not To Induce – Is That The Question?


Are there "good" reasons for inducing labor through medical
intervention? It’s a loaded question for which different providers may give you
different answers. Even amongst like-minded communities of midwives – CPMs or
CNMS, or more traditional medical providers like ob-gyns, there will be
differences of opinion as to when artificial induction of labor is called for;
and which methods are safe, or safer than others. In some hospitals, it is more
common to induce electively, what Lamaze International calls "those done for
convenience rather than for medical reasons."  In other hospitals, labor
induction can only be done under strict guidelines, for specific medical
reasons.

Medical
interventions in childbirth have risen over the last 10 years so it makes
sense that artificial labor induction would as well. In fact, the rate of labor
induction in this country has increased and now stands at 41 percent of all births, according to a study published in
April 2009 in BJOG
, the
peer-reviewed journal of the Royal College of Obstetricians and Gynaecologists.
Distressingly, the study found that the "best
available evidence" does not match most of the reasons that providers give for
artificially inducing labor.

According to
Childbirth Connection, the investigators for the published study found that
evidence supports inducing labor under particular conditions such as when a
woman is at or beyond 41 weeks of gestation or when a woman’s membranes break
before her body is in labor. Conditions under which there is not good evidence
to support labor induction? When the baby is "large", when a woman is pregnant
with twins, has insulin dependent diabetes or has low levels of amniotic fluid.
The study’s lead author, Dr. Ellen Mozurkewich, admits however "More research
is necessary to clarify the risks and benefits of induction in these
situations."

One of the
reasons more studies are needed and more attention must be given to this issue
is because labor induction leads to increased medical intervention including
cesarean sections – making childbirth more dangerous for mother and baby.

Childbirth
Connection’s Director of Programs, Carol Sakala cautions, "Starting labor early
can lead to negative outcomes for the woman and/or the baby."

Xena Harris Eckert, childbirth educator and doula, notes
that,

"Induction dramatically increases the likelihood of cesarean birth, the
risks of which are often underestimated. As a doula, I am always sad if she
agrees to be induced, when the baby or mom’s health are not compromised by
waiting, because I know that if she desires to have a natural birth that
possibility is severely compromised by
the use of pitocin [one of the commonly used drugs given to induce labor]."

One of the ways induction "dramatically increases the
likelihood of having a c-section?"  Inducing labor for "having a large baby."
According to Lamaze International’s recently released "Healthy
Birth Practices" paper on labor induction
, "Studies have shown that
inducing labor for macrosomia (large baby) almost doubles the risk of having
cesarean surgery without improving the outcome for the baby."

Despite the fact
that labor induction is not recommended simply because "the baby is large",
this is precisely a reason given to women, by providers, for artificially
inducing labor. Susan King, a mother of an 11 year-old girl and now pregnant
with her second, told me,

"I was induced at 41 weeks, with pitocin and then
later breaking my water, because they thought she was going to be "too
big" for my tiny frame to handle if I went any longer past my due date,
which is just ridiculous. My daughter was 7 lbs 9 oz, so pretty average.
There were no other medical concerns – movement was fine, fluid levels fine, etc. In retrospect I feel
it was unnecessary and regret not being able to experience a normal start to
labor. I wouldn’t care terribly if I were induced again if it was
actually necessary
, but I really don’t
think their reasoning was valid." 

Lamaze’s paper on labor induction admits,
"many women are confused about when induction is truly necessary" and
identifies (artificial) labor induction as "one of the most controversial
issues in maternity care today."

It’s no wonder.

If providers cannot always agree on when labor induction is
medically appropriate and when it’s not, how do we expect pregnant and laboring
women to understand the scope of knowledge and information needed to make the
best decisions on behalf of themselves and their newborns?

For example, in addition to the reasons given above for why
induction may be necessary, the American
College of Obstetricians and Gynecologists (ACOG) also lists
"health problems that could harm you or your baby" as a potential reason for
induction. But even then the conditions vary from woman to woman; and from one
decision to induce, many other choices need to be made.

Alex Allred gave birth last year to a beautiful baby girl.
Since then, she’s mulled over the conditions leading up to her cesarean section
and is not sure her induction was necessary:

"I was induced when my blood pressure spiked at 38 weeks and
I was technically "full term" so the doctor and my midwife agreed that I was
heading towards pre-eclampsia and needed to deliver her. My labor started very
slowly, even with the maximum dose of pitocin for 10 hours…I think she just
wasn’t ready to be born and inducing was a mistake. She hadn’t descended and I
wasn’t dilated at all and the monitoring of her showed that she was fine. I
think if I had gone home to bed rest and lots of slow walks around the
neighborhood we could have encouraged her to come on her own."

She adds, however, "All’s well that ends well, though. She
and I are happy and healthy."

Debbie was diagnosed with gestational
diabetes with her first child and her doctor told her she would need to be induced because they
thought her daughter "might be too big if I went late."

ACOG, however, notes that in women with gestational
diabetes, "Labor…may be induced earlier than the due dates if problems with
the pregnancy arise
."

Was Debbie induced because of pregnancy complications or
because her doctors assumed she may have a larger than average baby? It’s difficult to say now but her story points to how unclear the decisions
regarding induction made by doctors on behalf of their patients can seem:

"I wound up having an emergency c-section under general
anesthesia. My recovery was a nightmare and A. only weighed 8 pounds 3 ounces
– I could have delivered her. I then had 2 VBACS [Ed. note: vaginal birth after cesarean
section], which were great. No problems and easy recovery. My third daughter
was huge, 9 pounds 12 ounces, and I had a great delivery and an amazing
recovery."

And even when the decision to induce is deemed medically
appropriate, by what method should women agree to be induced?

ACOG lists
the methods by which labor can be induced. They include: prostaglandins,
"stripping the membranes", rupturing the amniotic sac (‘breaking the bag of
water"), and oxytocin (pitocin). One such prostaglandin is a drug sold under
the name "Cytotec", known as misoprostol. 

Cytotec is still used by ob-gyns in hospitals to bring on
labor – despite not being approved by the FDA for this use. Misoprostol is used for a variety of purposes – including in early, medication abortions. In a 2003 article
in Mothering Magazine, Marsden Wagner, former Director of Women’s and
Children’s Health for the World Health Organization, writes that Cytotec is not
approved by the FDA for labor induction,

"…because of insufficient scientific evaluation of risk–a
warning often ignored by doctors…New scientific data show that inducing labor
with Cytotec causes a marked increase in uterine rupture…"

Rachel McAuley, a mother of two, planned for a
midwife-assisted homebirth for her older son but at 42 weeks, when she hadn’t
gone into labor and with rising uric acid levels and potential symptoms for
pre-eclampsia developing, her midwife suggested an in-hospital birth.
Unfortunately, at the hospital, her midwife had little authority to make
decisions on behalf of Rachel’s health:

"When I went in, I was immediately strapped to the fetal
stress monitor, and the nurse came in with a pill.  She explained what she
was doing, but not what the drug actually was, except that it would
"relax" my cervix…"

After experiencing an entire day without labor symptoms, she
was given another round of cytotec and the doctor then needed to break her
water,

"With the doses of cytotec in my system, paired with my
water being broken, I had no transition at all. It was very surreal…

…If I had known what cytotec was, I would have probably
opted for the pitocin. At least it can be gauged in doses. Cytotec is powerful,
and given in a way that is not for its intended use."

Henci Goer writing on Science & Sensibility
– the blog of Lamaze International – dismantles many of the myths surrounding
the safety and "appropriate use" of misoprostol for labor induction and
concludes that with the difficulties gauging doses given to laboring women, and
what kinds of long term adverse health consequences there may be for the fetus
and mother, there isn’t much to sell about Cytotec.

"Cytotec’s real benefits are convenience for obstetricians
and helping the hospital’s bottom line. For women and babies, though, it’s a
roll of the dice. Most times things go fine, but sometimes the dice come up
snake eyes."

Is it the method, then, that is at issue or the decision
to induce?

Childbirth Connection’s book, A Guide to
Effective Care in Pregnancy and Childbirth
,
suggests, "The most important decision to be made when considering the
induction of labor is whether or not the induction is justified, rather than
how it is be achieved."

As with any and all decisions regarding childbirth, it’s
important that women are fully aware of the consequences of any decisions made
during pregnancy and labor, because women need to be their own advocates,
engaged fully with their experiences. Think you know about all of your options?
Make sure you know what’s out there – focus on the birth experience you plan to
have but know what your options are in case you are faced with something
unexpected.

What would Rachel say to another woman?

"Be informed.  I was very informed about pitocin and
what I didn’t want in the context of a hospital birth.  But when I ended
up with a hospital birth, I was not aware of other drugs that could be
administered. I had never heard of it [cytotec] before this experience.

I wish I had the opportunity to let my body do its
thing…In the end, though, I had a healthy baby!"

Questioning the conditions under which labor induction may
be necessary is a critical step towards empowering women in their birth
process. As long as women are fully informed – and understand when and how
induction may happen they can make the decisions they feel are best, on the
road towards bringing their babies’ into this world.

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  • patrice

    When I was pregnant with my last son (who is now 16months), I distinctly remember having a long conversation (long because I basically had to hold my doctor hostage) regarding inductions. It was around my 36week and I remember for a few weeks tossing and turning at night thinking about how I felt I was already being set up for one. I kept being reminded during prenatal checkups that it was looking like I was going to have a “good sized” baby and finally that term was replaced by large baby. And so I decided I wanted to let him know that I absolutely did not want to be induced because of suspicion of a large baby, or an estimation. He assured me that if all things were healthy, I was fine, baby was fine, no induction would be scheduled. Of course, at my 5/8/08 visit, I got a paper scheduling my induction for 5/21/08. That was a week after I was due, my due date being 5/13/08. So already, just a week before my estimated due date, I was scheduled for an induction only a week after my estimated due date. There was nothing medically indicating the need for an induction, I’d already spoken to my doctor about my views on it and yet there it was in black and white, feeling to me like a curse! I was, needless to say, a little perturbed. Not only did I have anxiety regarding induction for the rest of my pregnancy, I also took those negative feelings with me into labor (which started on it’s on May 15th) and when it was time to push a visualization of a super large baby popped into my head. I saw my baby not being able to fit, getting stuck somehow, not breathing and I saw me being cut open only to find my baby severely damaged for my “insolence” towards my doctor and his recommendations about delivering a big baby vaginally. My initial reaction to this horrifying vision, was to tighten up, literally trying to close my cervix, vagina and legs. For a very brief moment I could feel the words “I want you to just take him!” on my lips. I think my boyfriend sensed my hesitation, whispered encouraging words in my ear, and I pushed out my 9lb 3oz baby boy in less than 5 pushes, just as I’d done with my previous other two, weighing in at 8lbs 8oz and 7lb 6oz respectively.

    I avoided an induction, but I did not avoid the anxiety and drama that enforced scheduled inductions can produce in a woman. Feelings that are completely unnecessary in many cases!

  • jillunnecesarean

    On Mom’s Tinfoil Hat, Hilary wrote awhile ago about a study that suggests shoulder dystocia might be iatrogenic (doctor caused) under certain conditions:

    “The triad of labor induction, oxytocin use, and birth weight greater than 4500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0) for shoulder dystocia.”

    For those who don’t understand odds ratios, it says that with that triad (large baby, induction and pitocin), there will be a shoulder dystocia also occurring 23 times more likely than if this triad did not exist. It seems to me that labor induction and use of pitocin actually increases the risk of a dystocia, instead of decreasing it, especially if it is likely that the baby is large.”

    http://momstinfoilhat.wordpress.com/2009/01/06/long-dystocia-reply-turned-post/

    Take home message: Maybe inducing big babies to get them out before they get any bigger is CAUSING the very thing (shoulder dystocia) that doctors are trying to avoid by forcing them out before they get any bigger.

  • amytuteurmd

    Most of what you have written is correct, but some very important information is missing.

     

    First, inductions have risen dramatically, but stillbirths have fallen dramatically as a result. According to the CDC, stillbirths have fallen 29%. That means that inductions are saving lives.

     

    Second, Henci Goer is quite disingenuous in her criticism of Cytotec. It is a safe and effective method of induction as long as a woman has not had a previous C-section.

     

    Cytotec has become something of a "bogeyman" among natural childbirth advocates. They profess horror that Cytotec increases the risk of uterine rupture in women who have had a previous C-section. Yet by far and away the most common risk factor for uterine rupture is attempted VBAC.

     

    That raises the question:

     

    If Cytotec an abomination because it increases the risk of uterine rupture, why is VBAC desirable despite the fact that it increases the risk of uterine rupture?

  • cpcwatcher

    Routine, scheduled inductions without medical indication is far too common. UNFORTUNATELY, i think lots of it comes down to $$$$$$$$

    The doctor who catches the baby is the one who gets the cash (or the doctor who sweeps in after the L&D nurse and catches the last 1/3 of the baby, as the last birth i attended went!), so doctors who have been in attendance to the woman’s whole pregnancy might actually not be on call when she goes into labor and delivers. My last doula client was a Medicaid patient, and her OB is sort of known as “the OB for Medicaid patients”. He has so many at once, because of the way he really does help to ensure women don’t have to pay extra for their hospital births, that he likes to induce 3-4 days before the due date to ensure he can be present for all of them. For the most part i think he’s doing it out of compassion for his patients, but because he’s one of the few all-Medicaid OBs in the area, the system sort of forces him to take measures like rampant induction. And he is a great OB. He really cares for his patients, and i can tell that’s the MAIN reason why he wants to be their attending OB for the birth. But it’s something to think about… our health care system and how it hurts everyone…

  • cpcwatcher

    Dr. Tuteur said:
    “If Cytotec an abomination because it increases the risk of uterine rupture, why is VBAC desirable despite the fact that it increases the risk of uterine rupture?”

    Dr. Tuteur, for me it’s not about whether or not Cytotec increases the risk of rupture more than VBAC. For me, as a reproductive justice advocate and birth doula, it’s about the woman’s choice. I think we agree that the woman should have every single perspective on both Cytotec and VBAC available to her, readily, and in plain English. After that, it’s up to her.

    Additionally, VBAC that occurs naturally is far safer than a VBAC where the labor has been induced or augmented by unnatural agents such as Pitocin or Cytotec. The body’s natural defenses allows for VBAC to work the majority of the time. It seems to me, then, that the real culprit of failed VBAC is medical intervention.

  • xenamomma

    Dr. Tuteur,

    When you say that still births have decreased by 29% so induction must be saving lives, that is really some sketchy math/science!  There is no scientific link between the decrease in stillbirths and medically unneccessary inductions.  There are many reasons why stillbirths have fallen.  It is even more irresponsible to imply that the dramatic increase in induction is in direct proportion to the decrease in stillbirth. 

    Amie does not write with the purpose of demonizing induction, only to bring light to the issue and encourage Mother’s to be fully informed.  Including to ask the question, "What happens if we wait?"

  • amytuteurmd

    "There are many reasons why stillbirths have fallen."

     

    Such as?

     

    The primary purpose of induction is to prevent stillbirth. As inductions have risen, stillbirths have fallen. In order to make an informed decision, women should be informed of these facts.

  • patrice

    Dr. Tuteur said:

    “The primary purpose of induction is to prevent stillbirth”.

    If the primary purpose of induction WAS to prevent stillbirth at one point in time in obstetrics, I would certainly argue that now there is a rampant abuses of induction.

    I was healthy, my child was healthy, there was nothing medically indicating that I needed to be induced, not even having a big baby, because I had a tried and tested pelvis for that. I’d never had a stillborn, my placenta was fully functional, my fluid level was good and I was not even close to being overdue when I was scheduled for my induction. And that is just me. I’ve talked to countless women with the same story, or similar stories. There have been women who have had inductions offered to them or mentioned for no real reason at all. It’s just put on the table if that is something she wants to do. What is rarely mentioned in these stories is the doctor also bringing up the risks vs. benefits of induction. And so informed consent was never made. Some women didn’t even know they needed to give consent for such a thing.

    I also know women who need inductions, who benefit from them. One of my best friends gave birth this past July and her induction was medically indicated, but even in that case she wasn’t given informed consent. She and I talked about the risk and benefits of induction, her benefits outweighing the risks, and the risks of not having one being higher than that of having the induction. Having said that, I do not believe that the vast majority of the women I’ve talked to or know NEEDED inductions. While I’ll admit that is a small number of people in the scheme of things, once you multiply that by the women they know, and so on and so on, what you come up with is the point I think this article was making. Yes, there are good reasons to have induction, but there are so many instances where not only is that not what the woman wanted, but nor is was there a good reason for it. And that really needs to stop.

    By the way, I know women who have made decisions to have induction based on discomfort or other personal non-medical reasons, and I support a woman’s informed choice. I think more than anything, that is what it boils down too, allowing women to make informed-choices from a risk/benefit standpoint.

  • progo35

    All I can say is that if the doctor told me to have an induction because my baby was large or whatever, I would go with what the doctor says. I am much more inclined to take Dr. Tuteur’s advice as a doctor than I am the advice of someone advising me from a reproductive choice standpoint. Yes, women should have choices, but none of the women in this story were actually forced to undergo inductions, their health was not in jeopardy because of the induction, and all of children born as a result were healthy. Now, if the doctor involved tells me, “I want to do an induction because it’s more conveinent for me,” that would be another story, but that is very rare.

    "Well behaved women seldom make history."-Laurel Thatcher Ulrich

  • equalist

    All three of my children were induced. My first two because my water broke with no contractions or signs of labor, and my youngest because two weeks before her birth I moved over an hour away from the hospital with a history of very short labors (5 hours and 3 hours from induction) and there was a very real risk of not making it to the hospital in time if I went into actual labor on my own, considering my history and that this was my third child. All three of my inductions were done with pitocin, and there were no complications during labor or delivery, aside from my second child, with whom I had a militant natural childbirth advocating doula who disrespected my wishes, and I fought against my body through the entire process as a result. Once the epidural was administered (at barely 4 cm dialated after two hours, a long stall time for all three of my labors) and I was able to relax, my daughter was born in less than half an hour (despite the doula’s claims that it could be “all day, or at least several hours” before she would arrive). There is nothing wrong with natural childbirth, or avoiding as many interventions as possible or all of them if you can (Even though I insisted on the induction when I was having no signs of labor on my own, and the pain relief during the delivery, I also insisted that I not be given an episiotomy, and postponed the breaking of my waters with my third) but each woman should make that decision on her own, and what’s right for one is not right for all.

    Equal rights, equal responsibilities.