Originally published on RH Reality Check
Are there "good" reasons for inducing labor through medicalintervention? It's a loaded question for which different providers may give youdifferent answers. Even amongst like-minded communities of midwives - CPMs orCNMS, or more traditional medical providers like ob-gyns, there will bedifferences 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 morecommon to induce electively, what Lamaze International calls "those done forconvenience rather than for medical reasons." In other hospitals, laborinduction can only be done under strict guidelines, for specific medicalreasons.
Medicalinterventions in childbirth have risen over the last 10 years so it makessense that artificial labor induction would as well. In fact, the rate of laborinduction in this country has increased and now stands at 41 percent of all births, according to a study published inApril 2009 in BJOG, thepeer-reviewed journal of the Royal College of Obstetricians and Gynaecologists.Distressingly, the study found that the "bestavailable evidence" does not match most of the reasons that providers give forartificially inducing labor.
According toChildbirth Connection, the investigators for the published study found thatevidence supports inducing labor under particular conditions such as when awoman is at or beyond 41 weeks of gestation or when a woman's membranes breakbefore her body is in labor. Conditions under which there is not good evidenceto support labor induction? When the baby is "large", when a woman is pregnantwith twins, has insulin dependent diabetes or has low levels of amniotic fluid.The study's lead author, Dr. Ellen Mozurkewich, admits however "More researchis necessary to clarify the risks and benefits of induction in thesesituations."
One of thereasons more studies are needed and more attention must be given to this issueis because labor induction leads to increased medical intervention includingcesarean sections - making childbirth more dangerous for mother and baby.
ChildbirthConnection's Director of Programs, Carol Sakala cautions, "Starting labor earlycan lead to negative outcomes for the woman and/or the baby."
Xena Harris Eckert, childbirth educator and doula, notesthat,
"Induction dramatically increases the likelihood of cesarean birth, therisks of which are often underestimated. As a doula, I am always sad if sheagrees to be induced, when the baby or mom's health are not compromised bywaiting, because I know that if she desires to have a natural birth thatpossibility is severely compromised bythe use of pitocin [one of the commonly used drugs given to induce labor]."
One of the ways induction "dramatically increases thelikelihood of having a c-section?" Inducing labor for "having a large baby."According to Lamaze International's recently released "HealthyBirth Practices" paper on labor induction, "Studies have shown thatinducing labor for macrosomia (large baby) almost doubles the risk of havingcesarean surgery without improving the outcome for the baby."
Despite the factthat labor induction is not recommended simply because "the baby is large",this is precisely a reason given to women, by providers, for artificiallyinducing labor. Susan King, a mother of an 11 year-old girl and now pregnantwith her second, told me,
"I was induced at 41 weeks, with pitocin and thenlater breaking my water, because they thought she was going to be "toobig" 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 feelit was unnecessary and regret not being able to experience a normal start tolabor. I wouldn't care terribly if I were induced again if it wasactually necessary, but I really don'tthink their reasoning was valid."
Lamaze's paper on labor induction admits,"many women are confused about when induction is truly necessary" andidentifies (artificial) labor induction as "one of the most controversialissues in maternity care today."
It's no wonder.
If providers cannot always agree on when labor induction ismedically appropriate and when it's not, how do we expect pregnant and laboringwomen to understand the scope of knowledge and information needed to make thebest decisions on behalf of themselves and their newborns?
For example, in addition to the reasons given above for whyinduction may be necessary, the AmericanCollege of Obstetricians and Gynecologists (ACOG) also lists"health problems that could harm you or your baby" as a potential reason forinduction. But even then the conditions vary from woman to woman; and from onedecision 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 sectionand is not sure her induction was necessary:
"I was induced when my blood pressure spiked at 38 weeks andI was technically "full term" so the doctor and my midwife agreed that I washeading towards pre-eclampsia and needed to deliver her. My labor started veryslowly, even with the maximum dose of pitocin for 10 hours...I think she justwasn't ready to be born and inducing was a mistake. She hadn't descended and Iwasn't dilated at all and the monitoring of her showed that she was fine. Ithink if I had gone home to bed rest and lots of slow walks around theneighborhood we could have encouraged her to come on her own."
She adds, however, "All's well that ends well, though. Sheand I are happy and healthy."
Debbie was diagnosed with gestationaldiabetes with her first child and her doctor told her she would need to be induced because theythought her daughter "might be too big if I went late."
ACOG, however, notes that in women with gestationaldiabetes, "Labor...may be induced earlier than the due dates if problems withthe pregnancy arise."
Was Debbie induced because of pregnancy complications orbecause 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 decisionsregarding induction made by doctors on behalf of their patients can seem:
"I wound up having an emergency c-section under generalanesthesia. 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 cesareansection], which were great. No problems and easy recovery. My third daughterwas huge, 9 pounds 12 ounces, and I had a great delivery and an amazingrecovery."
And even when the decision to induce is deemed medicallyappropriate, by what method should women agree to be induced?
ACOG liststhe methods by which labor can be induced. They include: prostaglandins,"stripping the membranes", rupturing the amniotic sac ('breaking the bag ofwater"), and oxytocin (pitocin). One such prostaglandin is a drug sold underthe name "Cytotec", known as misoprostol.
Cytotec is still used by ob-gyns in hospitals to bring onlabor - 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 articlein Mothering Magazine, Marsden Wagner, former Director of Women's andChildren's Health for the World Health Organization, writes that Cytotec is notapproved by the FDA for labor induction,
"...because of insufficient scientific evaluation of risk--awarning often ignored by doctors...New scientific data show that inducing laborwith Cytotec causes a marked increase in uterine rupture..."
Rachel McAuley, a mother of two, planned for amidwife-assisted homebirth for her older son but at 42 weeks, when she hadn'tgone into labor and with rising uric acid levels and potential symptoms forpre-eclampsia developing, her midwife suggested an in-hospital birth.Unfortunately, at the hospital, her midwife had little authority to makedecisions on behalf of Rachel's health:
"When I went in, I was immediately strapped to the fetalstress monitor, and the nurse came in with a pill. She explained what shewas doing, but not what the drug actually was, except that it would"relax" my cervix..."
After experiencing an entire day without labor symptoms, shewas given another round of cytotec and the doctor then needed to break herwater,
"With the doses of cytotec in my system, paired with mywater being broken, I had no transition at all. It was very surreal...
...If I had known what cytotec was, I would have probablyopted 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 surroundingthe safety and "appropriate use" of misoprostol for labor induction andconcludes that with the difficulties gauging doses given to laboring women, andwhat kinds of long term adverse health consequences there may be for the fetusand mother, there isn't much to sell about Cytotec.
"Cytotec's real benefits are convenience for obstetriciansand helping the hospital's bottom line. For women and babies, though, it's aroll of the dice. Most times things go fine, but sometimes the dice come upsnake eyes."
Is it the method, then, that is at issue or the decisionto induce?
Childbirth Connection's book, A Guide toEffective Care in Pregnancy and Childbirth, suggests, "The most important decision to be made when considering theinduction of labor is whether or not the induction is justified, rather thanhow it is be achieved."
As with any and all decisions regarding childbirth, it'simportant that women are fully aware of the consequences of any decisions madeduring 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 tohave but know what your options are in case you are faced with somethingunexpected.
What would Rachel say to another woman?
"Be informed. I was very informed about pitocin andwhat I didn't want in the context of a hospital birth. But when I endedup with a hospital birth, I was not aware of other drugs that could beadministered. I had never heard of it [cytotec] before this experience.
I wish I had the opportunity to let my body do itsthing...In the end, though, I had a healthy baby!"
Questioning the conditions under which labor induction maybe necessary is a critical step towards empowering women in their birthprocess. As long as women are fully informed - and understand when and howinduction may happen they can make the decisions they feel are best, on theroad towards bringing their babies' into this world.