INDUCTION OF LABOR – is it for you or your baby?

Alright everyone…lets talk about inductions!

What a big topic to tackle, and as I sit here I wonder what aspect I should take on. Reasons? Types? Risks? Statistics of…rates…history of….(it’s a huge topic!)

Let’s just start at the beginning and see how far we get. With such a huge topic I will attempt to make it as simple as possible…

DEFINITION
What is an induction? It is using artificial means to start labor when there is no evidence of labor being present with the intention of delivering the baby and ending the pregnancy. Such a clinical definition, but since we’re talking about a clinical act I think it’s appropriate to describe it in clinical terms. Induction of labor is the termination of a pregnancy.

HISTORY AND RATES
Inductions, which used to be reserved as a response to medical complications, doubled in the US from 9.5% in 1990 to 19.4% in 1998. By 2004 it was up to 21.2% and by 2006 we were up to 22.5% . Now, I’m not a rocket scientist…but I think it’s apparent that there is a trend here, and it’s not a good one. I will not be surprised if a full ¼ of all pregnancies ended in an induction of labor by the time the 2010 statistics come out (and there are some areas of the US, like New York, that have induction rates at as high as 53.2% in some counties!)

It is necessary for you to take notice that this is the rate of INDUCTION!  This does not include the rate of AUGMENTATION!  What is the difference? Augmenting your labor means we medically intervene to speed up or strengthen labor that has already started.  The above rates do NOT include the women that arrive at the hospital having mild contractions and who are then kept at the hospital and given medication to cause labor – they consider that an “augmentation”, not an induction.

REASONS TO INDUCE

Reasons that inductions have increased are numerous…

* The number one increase is inducing because the baby is believed to be macrosomic (meaning: above the 90th percentile for size for the gestational age)…this is also known as, “My doctor thinks my baby is getting too big and wants to induce me before the baby gets too big to fit.” The number of inductions for this reason has risen a full 22.5 fold over what it was in 1990, even though there has never been any evidence saying that there is a benefit to doing this unless the mother has type 1 diabetes.

* 10% of all births are induced for being ‘postdates’. I found it interesting (and distinctly disturbing) that our flippant choice to induce for this has actually caused the average gestational age for women who have gone past their due dates to DROP a full 9 days…from 42.2 all the way down to 41.0!

* There has been a 15 FOLD increase in elective inductions!! That means that there is no medical reason (not even the lame “large for gestation” or “postdates” reasons)…not at all!

REASONS NOT TO INDUCE
Our induction rate has more than doubled for a reason…and it’s not medical. If we were doing more inductions for medical indications, then wouldn’t we see an improvement in our outcomes? We are not.  So lets explore the above reasons for induction as well as some other very commonly used excuses and I’ll explain why they are NOT reasons to induce…
Baby’s getting too big to birth: I know that pushing something large out of our vagina can be a scary thought…but this is a ridiculous reason to induce for a variety of reasons. First off– where is the research to show that this is in any way beneficial?? Because I can easily come up with research showing that it’s not! Second off, how much do you think the baby is going to gain over the next few days/week??? Okay, I hear you saying to the computer, “up to HALF A POUND!!” because you’ve scoured the internet and you know that at the end of pregnancy babies can gain ¼-1/2 of a pound a week – good! Now, how much of that is in the baby’s head or shoulders? Seriously – we ‘birth’ the head and the shoulders with the rest of the baby slipping out pretty darn quickly most of the time. I have never HEARD of a baby getting STUCK at their chunky butt, hung up at the rolls on their legs. So understanding that the only thing of baby’s size that really matters is the head and shoulders…how much head/shoulder size is your baby going to grow in the next week if you do not induce?? And how do we know what your pelvis is capable of?? We don’t! (wow, I think this could be an entire blog post…) So long as you don’t have uncontrolled type 1 diabetes (which can cause baby to grow not only unnaturally and healthy large for you and your body, it can cause health issues in baby)….then the research says that inducing for baby’s size is NOT beneficial. Nature wouldn’t routinely make us grow babies too big to birth….that doesn’t make good sense!!! Okay…I’m going to stop here because I do think that this is a blog post I will tackle in the near future. In summary: Large + healthy = AWESOME! Small+healthy = GREAT! Small+unhealthy= sucks Large+unhealthy=sucks. You may see that the main factor here isn’t the size….


Past the due date: Again…poppycock! It’s just our best guess as to when ABOUT you might have your baby! And different babies have slightly different gestations…just because the timer on your oven went DING doesn’t mean the cake its ready to come out! We still poke it with a toothpick and sometimes it needs another couple of minutes! While I could go into more detail than this, I don’t like the feeling of re-writing what’s already been written…(reminds me of the conversation my husband and I had a couple of months ago while he looked at my library of books: “You could write a book!” me: “It’s already been written” him: “No, a different book.” Me: “that one’s been written, too….”) and there was a WONDERFUL article that was written called “The Lie of the EDD: Why your due date isn’t what you think” that I think is phenomenal. Please take a moment to read it…I’ll wait right here for you.

Scheduling: favorite doctor is going on vacation, mother is in town and has to leave in 2 days, etc. Now, I hate to sound judgmental…but are you really comfortable increasing the risk to you AND to your baby for those reasons? Or is it that you don’t believe that there are risks to an induction? If you are looking at inducing because you want your baby born with a certain birthdate or you want a certain person at the birth or because it’s just more convenient…first let me assure you that nothing about having a baby is convenient! And second, ask yourself if it is important enough to you to risk the health of yourself or your baby. If your baby comes slightly premature and with breathing issues, will you as easily and flippantly forgive yourself? Or if you end up in a cesarean – where your risk if dying is 6-8 times higher, your baby is at greater risk of breathing issues, NICU stay (heck – 2% of babies are LACERATED – meaning CUT – during a cesarean section!)….will you not blame yourself for making medically risky decisions?

Water broken and no labor: I know we’ve all heard the “24 hours after water breaking” protocol– but even that protocol isn’t entirely clear. Do you want labor to begin within 24 hours? Birth within 24 hours? Either way it’s not supported with research, and yet it’s just accepted as gospel truth that not having the baby immediately after your water breaks is dangerous – and (are you ready for a revelation?) IT’S NOT! Phew…finally, it’s been said. The problem is that if you present to a hospital with your water broken, the FIRST thing they want to do is “confirm” that your water has, indeed broken. Now, I’ve seen women (more than a couple) who thought their water had broken and it wasn’t, so I can kinda/sorta understand their skepticism….the problem is that in order to check, they will don a glove and possibly a speculum – at any rate, they will invade your vagina. Yes, I said invade because that’s what it is at this point…a DANGEROUS INVASION! And yes, the risk goes up to you and your baby once we have breeched the vaginal opening. But what if we don’t? Study after study has found that “expectant management” (also known as “being patient and just waiting”) was absolutely as safe as inducing (when it comes to the feared ‘risk of infection) – in fact, expectant management was safer because the cesarean rate was notably lower! As quoted on Medscape, “Kappy and colleagues compared outcomes following induction and expectant management with term premature rupture of membranes (PROM). They found no difference in infection rates between the two groups and a higher rate of cesarean sections in the induced group.” They did say that inducing with Pitocin was viewed more favorably than just waiting by the mother – well, yeah!! We’ve told them forever that they were in terrible aweful danger if we didn’t get that baby out IMMEDIATELY! Of course it’s going to cause them stress to wait for days!! Did you know that cost is also a major reason that they recommend inducing labor rather than simply waiting it out?  That one of the reasons they prefer to ‘just induce’ rather than wait is because it is cheaper/faster for them? I find that unsettling.
Low amniotic fluid: You’ve had an ultrasound and it showed that the amniotic fluid is low and so your doctor wants to induce. It is a rare day that someone will ask their care provider to share studies and research backing their recommendations…but now is a good time to ask for it. This is not backed by studies and therefore I’m not sure why we continue to practice this! American Journal of Obstetricians and Gynecologists research says that there’s no benefit, and even the select studies that suggest that it might carry a higher risk for the baby has come into serious question with regards to their methodology and outcome.

ACOG AND INDUCTIONS

ACOG’s (American Congress of Obstetricians and Gynecologists) most recent recommendation on inductions stated that reasons for induction of labor include but are not limited to…
• gestational or chronic hypertension,
• preeclampsia,
• eclampsia,
• diabetes,
• premature rupture of membranes,
• severe fetal growth restriction,
• postterm pregnancy

I find a few things notable and interesting…they specifically recommend induction of labor for being postdates only if the mother is 42 weeks or beyond, yet women are routinely being induced at 41 weeks – if they even make it that far! I’ve seen them induce at 39 weeks because they were AFRAID they would go past their due date! In what world does THAT make sense?

They also say, and I quote, “A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn’t successful in producing a vaginal delivery,” Now, isn’t this eerily similar to the VBAC recommendation which all but snuffed out VBAC’s in most hospitals? I don’t see them banning non medically indicated inductions because of this recommendation, do you?

LET ME SIMPLIFY THIS FOR YOU…
What is a good reason to induce? When there is a health issue currently present either with mom or with baby in which the benefits of ending the pregnancy outweigh benefits of continuing the pregnancy. In other words, when there is a PROBLEM big enough to say “we’re done….this is becoming dangerous.”  If your doctor wants to schedule an induction for NEXT WEEK – that doesn’t sound like a pressing medical issue to me, does it to you?

TYPES AND RISKS OF INDUCING
There are several ways to medically induce (and an even longer list of “natural” induction methods people often try at home such as intercourse and eggplant parmesean for dinner!). The methods we might use in a hospital are…
Breaking your water – one of the more dangerous things we can do to you in labor as the risks include things like prolapsed cord, fetal distress, and risk of infection because in order to break your water we have to invade your vagina with our hands and tools.
A prostaglandin: such as Prepadil Gel, Cervadil, or Cytotec

A Foley Catheter: inserted into the cervix and blown up with saline – also called a mechanical dilation of the cervix

Pitocin – a synthetic form of oxytocin

Each induction method carries with it certain risks…I’m just going to quickly list the risks of choosing to induce AT ALL….
• Prematurity – even slight prematurity carries risk…even a week or two!
• Cesarean – double the risk for a first time mother
• Uterine rupture – even if you’ve never had a cesarean!
• Fetal Distress – relatively common!
• Induced labors can be more painful – if you get drugs, then you must include the risks associated with those as well!
• Need for more interventions (IVs, continuous fetal monitoring, etc.) along with all of the risks associated with those interventions
• Women are left believing that their bodies are not able to birth a baby.
• Asynclitic presentation of baby’s head
• Placenta abruptia
• THE LIST GOES ON

The above list isn’t specific to any one method…inducing you AT ALL carries these risks! There are other risks (such as prolapsed cord, amniotic fluid embolism..) that can be with individual types of induction methods – but this list of risks comes with just the choice to medically induce, regardless of method. It’s not a benign procedure…and it’s not just a decision to give birth. You are interfering in a process that has been perfected over thousands of years and yes, the consequences can be grave. Please ask yourself – is there a pressing reason to induce? Is there a medical issue causing it to be unsafe to you or your baby to continue the pregnancy?  I know you are excited about meeting your baby, but are you willing to be patient for just a few more days…aren’t you worth it?  Isn’t your baby worth it?

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