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To Induce Or Not To Induce - Is That The Question?

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Originally published on RH Reality Check

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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