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?

17 Comments

  1. Angela Padilla wrote:

    Thank you for this great topic Steph! I love how you put everything to perspective. It all makes sense!

    Friday, April 2, 2010 at 12:03 am | Permalink
  2. lauren curleyhair wrote:

    holy cow your amazing. I never knew why inductions were bad- i just knew I didn’t like it, and I thought it was very selfish and damaging..gut feelings are usually right…:) great post!

    Friday, April 2, 2010 at 1:12 am | Permalink
  3. Kolleen wrote:

    Great post!! 3 of my 4 births were induced and my non-induced 4th has really opened my eyes to what my body can do and to what an amazing gift the whole pregnancy/birth process is. I know that right now is not the right time to have another baby for me, but my last (all-natural) experience has truly made em love the idea of being pregnant and giving birth again. Truly meeting you and being surrounded by people like you and Kate who love pregnancies and babies equally helped me have a different perspective and a much more enjoyable pregnancy/birth experience. I didn’t look at pregnancy/birth as a means to an end, I saw it for the true miracle that it is and I ENJOYED it so much more. I think that doctors/hospitals (at least the one’s I dealt with) (hopefully) unknowingly take a little of that joy away from the process.

    Friday, April 2, 2010 at 2:24 am | Permalink
  4. Dianne wrote:

    Excellent, excellent post! This info needs to get out there again and again. You already wrote it (as you so rightly told your husband!) so I’ll add it to my blog with a link to your post :0))

    Friday, April 2, 2010 at 12:42 pm | Permalink
  5. Amy Drorbaugh wrote:

    Yes, yes, yes! If my baby wasn’t asleep I would have been yelling at the computer screen. And that LONG post is only a small group of the risks. There are many more, for instance cytotec isn’t even approved for induction of labor, in fact the manufacturer strongly warns AGAINST using it for that because of the high risk for complications.
    I read a birth story recently where the mom had a cord prolapse and had to have an emergency c-section. She wrote in her story that this was a “random complication that could not be predicted or prevented.” Even though it happened right after the OB broke her water. Moms don’t even know what they don’t know! Thank you Stephanie for helping to educate women.

    Friday, April 2, 2010 at 1:00 pm | Permalink
  6. Lindy wrote:

    OMG thank you! The article of EDD was great! You know this was a fear of mine. I still can’t believe LMP is the “standard” for creating a due date! For crying out loud, why doesn’t the medical community realize that not everyone has a 28 day cycle!?! I have averaged 35 days since menarche and depending on stress levels, have often gone well beyond that! What’s so wrong with mainstream health care providers is that they don’t even realize that the only “predictable” thing when it comes to menstruation is that periods begin approximately two weeks after ovulation and that the time between menstruating and before ovulating again can vary from hours to months! Ugh! This is human biology 101- AND most doctors aren’t even aware of it!

    Saturday, April 3, 2010 at 2:52 pm | Permalink
  7. Jenna wrote:

    all day i’ve been debating weather or not to allow my ob to induce me because little man is “too big” & now, i know that i will NOT allow it. I have several differend Due Dates From April 20th – May 9th & your blog has made it even more clear to me how unsafe this would be to my son as well as me. Thank you for sharing.. now off to battle the ob [: armed & ready with info!!

    Wednesday, April 7, 2010 at 12:35 pm | Permalink
  8. Marna Gatlin wrote:

    When I had my son they began to get very nervous when I hit the 39th week and no action down there. I’d had BH’s since week 16. (Go Figure) — they said my fluid was too low and they were worried of a bad outcome (they actually said that to me, thanks a lot)

    So I began down intervention row starting with cytotec (I can hear you all cringing now) and then following up with the balloon and then finally pitocin. After 58 hours of hard labor, an exhausted mother and thankfully a kid with zero decels, I asked for the section. I couldn’t do it anymore. In many ways I felt like a failure. However, I am proud to say my son with apars of 9 and 10. My section was another story…..ugh. But he’s here, going on 10. And all this is behind me.

    Great article. You write very well.

    Friday, April 16, 2010 at 10:04 pm | Permalink
  9. Christine Stavrakis wrote:

    Amen! Why aren’t more women made aware of this information? Births are so medicalised and women are too scared to question why a certain procedure needs to be carried out. We are like lambs to the slaughter.

    Wednesday, April 28, 2010 at 6:42 am | Permalink
  10. Amy Jo wrote:

    Well written, and I was glad you are not discouraging women from getting medically necessary inductions. It would have been nice if you included that a pregnancy can be become dangerously passed due (my first was induced at 43 weeks, with gel when I finally caved and said wow this is not happening).

    Friday, April 30, 2010 at 1:03 pm | Permalink
  11. Christine wrote:

    I just delivered my 4th child – all 4 have been induced with pitocin/oxytocin for being past the due date. (In fairness, after reading this article, 2 of them would be considered augmentation even though it was on the day scheduled for induction.) I did try to argue for the docs to use a conceptual due date (vs. gestational), but they wouldn’t go for it. Anyway, with my oldest, they went with my argument and let me stretch it out to 42.5 weeks on their calendar before inducing, but with my most recent they told me that the AMA rules caused PA to change so that they won’t let a woman go past 41 weeks. Even the midwives in this area go with the 41 week timetable, so it’s not like going to different docs would help. I HATE being induced, and have tried several methods to try to prevent it, but in the end I felt like I had to do what the docs said. I must say, I feel a bit of guilt for letting them do it, particularly as my youngest was clearly not ready to come out and play (it took almost 3/4 of a bag of pitocin and special internal monitors b/c they had to turn the medicine up so high to get it to work this time – we were up to a dosage of 38 on a scale that the nurse told me takes the average woman 10-20) When he did arrive, my son was in good health, but was a good bit smaller than any of my others and I was told by a nurse that she would guess he was only about 38 weeks (coincidentally, much closer to conceptual date). I’m glad my children are here safe and healthy, but I do wish there was not so much pressure placed on the woman to induce!

    Saturday, July 31, 2010 at 8:06 am | Permalink
  12. Karen wrote:

    I had to be induced with cytotec at 39 weeks 4 days because my baby was not growing adequately for two weeks. It turned out that I had unexplained placental insufficiency (I had no medical comorbidities either before or during pregnancy, nor do I smoke) Because of this I am now considered High risk for my current pregnancy and the OBs are discussing preterm induction. It is a terrifying prospect as I have always felt the baby should be carried to term at least. On the other hand, it is an equally terrifying prospect that my child could be harmed while inside my body. So while I agree that induction for reasons like “scheduling” are not a good idea, when a situation is such that a woman is trying to make the best decision for the health of her child, the decision is not so clear cut and is VERY emotional. I hope that can be addressed in a future post.

    Sunday, August 7, 2011 at 8:59 am | Permalink
  13. Lilia Ochoa wrote:

    WONDERFUL Information!! Even for me that my first language is Spanish, it is so easy to understand all the risks that mom and baby have during and after and induction. Sadly, moms don’t really know this. They are only impatient to get through this process and know their babies, so they believe that professionals can help them do this faster and also in a safe manner. I hope one day they take the time to let moms know about this important information. Inductions should be done only when mom or baby is at risk.
    unfortunately, I didn’t know this before. I have four children. The first three times, during labor,they told me that they will give me some medicine to do the contraccions stronger and the last time, the nurse said that breaking down my water will do everything faster. At that time I didn’t know what it was, I thought it was just a pinch, but I remember that it was worse than delivering my baby. Also, due to that process my baby was kind of dry, so it was harder to come out than my other three kids,for these, my water was naturally broken, hours before or close to delivery. Most of times we have a lot of pressure to take these decisions and most of times we agree because we don’t know what the risks are. Good Luck for all those pregnant women!

    Thursday, January 12, 2012 at 1:09 pm | Permalink
  14. Laura wrote:

    I just found your blog and I must say I love it! You have some amazing informations on here! I love this post specifically your section on inducing after your water breaks! I waited over 48 hours for my labor to start after my water broke and then I had a really long labor. I went 96 hours from water breaking to my daughter being born. I am so blessed that I had a wonderful midwife who did not presure me into inducing right away! I wish more women realized that they did not need to run to the hospital the moment their water breaks.

    Tuesday, July 23, 2013 at 1:33 pm | Permalink
  15. Emir wrote:

    I think a lot of people who are gtenitg upset are not understanding the difference between a medically necessary c-section and/or induction and elective ones. These hospitals are not banning the procedures if they are deemed necessary by the attending physician. What they are try to prevent is the boutique births where women try to schedule these procedures so that they fit into their schedules or because they are uncomfortable. News flash: pregnancy is uncomfortable. Think about that next time you get knocked up. I have lots of friends who have had to be induced or have c-sections. I don’t look at them any differently than my friends who went into labor on their own, had unmedicated births, or who gave birth vaginally. Every situation has it’s on journey. But for these selfish people who want to determine when and how they give birth for convenience rather than what is best for their own health and that of their child, I say yes, by all means take that privilege away! I also think that hospitals are opening themselves up for malpractice lawsuits by catering to these situations. If there was medically necessary reason to cut someone in half, why are you doing it? As a diabetic, I have a high chance of needing to both be induced at 39 weeks and/or have a c-section because of the size of the baby. But I would never demand one for my own comfort.

    Thursday, December 3, 2015 at 4:09 am | Permalink
  16. Joao wrote:

    I think it’s extreme. There was a pilot pgoarrm which required drs to submit a justification in writing for any induction prior to 39 weeks and low and behold, the number of pre-40 week babies dropped dramatically as did the number of short NICU stays. Sometimes drs cave to the wants of the mother because they figure it’s relatively low risk even when it really doesn’t serve a medical purpose. Making the dr spell out why they’re recommending an early induction was all it took to fix the problem.So why not apply that sort of policy to pre-40 week inductions and c-sections? Elective in medical terms doesn’t always mean unnecessary. I get that. So spell it out WHY this woman needs an elective c-section or induction and sign your name to it. I suspect the number of unnecessary c-sections would go down just like the inductions went down because a dr is going to risk not getting paid by an insurance company if they can’t come up with anything better than some sort of too posh to push type rationale.Or, as I have long advocated, if you can’t prove your c-section is medically necessary, insurance shouldn’t cover it. I can guarantee you that people will think long and hard about how much they want a $20,000 delivery if they know it’s coming out of their wallet.

    Tuesday, December 8, 2015 at 12:07 pm | Permalink
  17. Annette wrote:

    I loved my induction. Just wanted to show the other side. To each her own. Convenience is a big plus for some. Great experience. Easiest way to have a baby. I’m not into stretching out the labor. Can’t speak for all doctors but mine only induces after 39 weeks. My first was spontaneous labor and that just takes too long for me. Now I’m having my third and planning my induction. No cervadil for multiparous women. Just go in at 5am have water broken, a little pitocin to begin, order the epidural and pushed baby out in 10 minutes. Done by 1pm. Like a day at the spa. Got to go home the next day. Great hospital, nurses and wonderful beautiful day. Im blessed to have two very healthy gifted boys.

    Thursday, February 25, 2016 at 3:26 pm | Permalink

2 Trackbacks/Pingbacks

  1. Lets talk about inductions! « Birth in Amador County on Friday, April 2, 2010 at 1:00 am

    […] To read to rest of this entry, please visit: NURTURING HEARTS […]

  2. NHBS › Pit of Despair on Wednesday, April 28, 2010 at 12:19 pm

    […] already did a previous blog post on inducing labor and some of the risks/benefits associated with the decision to induce, so I do not want to rehash […]

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