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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