Let me define induction first. ACOG (The American College of Obstetrics and Gynecology) defines it as "the use of medications or other methods to bring on (induce) labor." ( http://www.acog.org/~/media/For%20Patients/faq154.pdf?dmc=1&ts=20130627T1602376009 ) Essentially, labor induction is using natural or medical means to start labor before a woman's body does it on its own. How is an induction performed? There are many ways. The most common are:
- Pitocin
- stripping the membranes
- AROM (artificial rupture of membranes)
- foley bulb
- cytotec
- cervidil
- sex
- nipple stimulation
- castor oil
Many moms being induced have what is called an "unfavorable cervix" before they are induced, which makes induction much harder, and less likely to succeed (meaning, more likely to have a c-section). Any mom considering induction should make sure she has a high enough Bishop's score ( http://www.hcpro.com/HIM-279560-8160/Learn-about-the-Bishops-Score-and-its-relationship-to-labor-and-delivery.html ) before she goes in to be induced.
So, on to the main point of this post. What are these crazy induction facts and statistics I keep talking about? Here we go, my friends:
- "The induction of labor can be done for many reasons, including many valid medical reasons. However, the rise in the rate of social inductions, or elective inductions is on the rise. As the induction rate rises there are more babies and mothers placed at risk for certain complications. Here are five risks of induction that you may not know about:
- Increased risk of abnormal fetal heart rate, shoulder dystocia and other problems with the baby in labor.
Labor induction is done by intervening in the body's natural process, typically with powerful drugs to bring on contractions or devices that are used to break the water before labor starts. Both of these types of induction can cause the baby to react in a manner that is called fetal distress as seen by fetal monitoring. The nature of induction like contractions may also be more forceful than natural labor. This can cause your baby to assume or stay in an unfavorable position for labor making labor longer and more painful for the mother. It can also increase the need for other interventions as well. - Increased risk of your baby being admitted to the neonatal intensive care unit (NICU).
Babies who are born via induction have not yet sent signals to the mother to start labor. This means that they simply aren't yet ready to be born. This risk is worth it if the baby or mother's lives are in danger, but simply to take this risk for elective reasons may not be well advised. When a baby is in the intensive care unit there is less ability for you to be with your baby or to hold your baby. Breastfeeding usually gets off to a rocky start as well. This can usually be avoided by giving birth when your body and baby say it is time. - Increased risk of forceps or vacuum extraction used for birth.
When labor is induced babies tend to stay in unfavorable positions, the use of epidural anesthesia is increased and therefore the need to assist the baby's birth via the use of forceps and vacuum extraction is also increased. - Increased risk of cesarean section.
Sometimes labor inductions don't take, but it's too late to send you home, the baby must be born. The most common cause of this is that the bags of waters has been broken, either naturally or via an amniotomy. Since the risk of infection is greater, your baby will need to be born via c-section. A cesarean in an induced labor is also more likely for reasons of malpresentation (posterior, etc.) as well as fetal distress. - Increased risks to the baby of prematurity and jaundice.
Induction can be done before your baby is ready to be born, because your due date is off or because your baby simply needed more time in the womb to grow and mature their lungs. Your baby may also be more likely to suffer from jaundice at or near birth because of the induction. This can lead to other medical treatments as well as stays in the hospital for your baby. Being born even a week or two early can result in your baby being a near term or late preterm infant. This means that your baby is likely to have more trouble breathing, eating and maintaining temperature."
http://pregnancy.about.com/od/induction/a/risksinduction.htm
- "What are the risks of inducing labor?
- Your due date may not be exactly right, so your baby may be born too early. Sometimes it’s hard to know just when you got pregnant. If you schedule an induction and your due date is off by a week or 2, your baby may be . If your pregnancy is healthy, wait for labor to begin on its own. If you need to schedule an induction for medical reasons, ask your provider if you can wait until at least 39 weeks. This gives your baby’s lungs and brain the time they need to fully grow and develop before birth.
- Pitocin can make labor contractions very strong and lower your baby's heart rate. Health care providers carefully monitor your baby's heart rate when inducing labor. They may change or lower the amount of Pitocin you’re getting. Using less Pitocin can make your contractions weaker and help keep your baby’s heart rate safe.
- You and your baby are at higher risk of infection if labor doesn’t begin a short time after your membranes rupture. The amniotic sac normally protects your baby and your uterus from infection. But once it breaks, germs like bacteria can get in more easily and infect you and your baby.
- There may be problems with the umbilical cord. For example, if the amniotic sac is broken, the cord may slip into the vagina before your baby does. This is more likely to happen if the baby is breech (when your baby’s bottom or feet are facing down right before birth), or if the baby’s head is still high in the uterus. Or the cord may get squeezed. If it’s squeezed, the baby doesn’t get enough food and oxygen. These problems can be serious for your baby.
- Sometimes induction doesn't work, and you need to have a cesarean birth (c-section). C-section is surgery in which your baby is born through a cut that your provider makes in your belly and uterus.
- You may have a uterine rupture. A uterine rupture is a tear in the uterus. It can cause serious bleeding. If you’ve had a c-section in a prior pregnancy, you’re at higher risk of uterine rupture because ac-section leaves a scar in the uterus. Uterine rupture is a rare complication of labor induction."
- "Years of study have shown that inducing labor often leads to a C-section. 'If you decide to have an induction because your obstetrician is going out of town, or because your husband is going out of town, that may seem like a bona fide reason, but you'll pay the price with an increased rate in C-sections,' said Dr. Michael Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, who's studied C-sections. Klein says studies of first-time moms show that 44 percent of those who are induced end up with a C-section but that only 8 percent of those who go into labor spontaneously end up with a C-section. Doctors say many times, inducing women way before the cervix is ready can lead to unproductive labor, which then necessitates a C-section."
http://www.cnn.com/2007/HEALTH/08/23/ep.csection/
"What risks are associated with inducing labor?
In rare cases, prostaglandins or oxytocin also cause placental abruption or even uterine rupture, although ruptures are extremely rare in women who've never had a c-section or other uterine surgery.
One commonly used prostaglandin, misoprostol, is associated with a relatively high rate of rupture in women attempting a vaginal birth after a cesarean (VBAC) and should never be used in women with a scarred uterus. Some experts don't think women attempting VBAC should be induced with oxytocin, either.
To assess the frequency and length of your contractions as well as your baby's heart rate, you'll need to have continuous electronic fetal monitoring during an induced labor. You'll probably have to lie or sit while being monitored, but some hospitals offer telemetry, which lets you walk around during the process.
Inducing labor can take a long time, particularly if you start with an unripe cervix, and this process can be hard on you and your partner psychologically. (On the other hand, among women who go past their due date, the seemingly endless wait for labor to begin may be even more trying.)
And if the induction doesn't work, you'll need a c-section. Having a c-section after a long labor or unsuccessful induction is associated with higher rates of complications than you'd face with a planned c-section.
Remember that your practitioner will recommend inducing your labor only when she believes that the risks to you and your baby of waiting for labor to begin on its own are higher than the risks of intervening."
http://www.babycenter.com/0_inducing-labor_173.bc?page=3
"A study released this past February may cause antsy moms-to-be to think twice before scheduling induced labor for non-medical reasons, a now-common practice for pregnant women seeking convenience, or simply an end to the seemingly-endless third trimester
.
The report, which was compiled by Australian researchers and tracked
the labors and deliveries of 28,000 women—some of whom went into
spontaneous labor, while others were induced for either medical or
non-medical reasons—documents a significant percentage increase in both
C-section deliveries (67% increased risk—that’s big), and NICU care (64%
increased risk), for women and their babies who undergo non-medically
necessitated inductions."http://www.parenting.com/blogs/natural-parenting/taylor-newman/scheduled-inductions-raise-c-section-rates-should-hospitals-ba
- "As childbirth has become ever safer, and as C-sections are so common
as to be routine, those risks might seem trivial. A paper published in
the current issue of Obstetrics and Gynecology reminds us that they are
not. Labor Induction and the Risk of a Cesarean Delivery Among Nulliparous Women at Term,
by Ehrenthal et. al. is an important contribution to the scientific
literature. The investigators culled the medical records of over 24,000
women who delivered at one large hospital over a period of years. From
that group they identified more than 7,804 women having their first baby
(nulliparous women) between 37-41 weeks. An astouding 43.6% of women
were induced!
… Indications for labor induction as identified by the medical provider were fetal indications in 13.6% of cases, fetal macrosomia in 3.3%, maternal indications in 24.9%, postterm pregnancy less than 41 weeks of completed gestational age in 14.3%, postterm pregnancy 41 or more weeks of gestational age in 18.3%, and 25.6% elective. The overall percentage of elective inductions, if postterm inductions less than 41 weeks were included, was 39.9%…Since the likelihood that an induction will work is related to the state of readiness of the cervix, the authors were careful to documenent the Bishop score (state of the cervix) for all women.
Among women undergoing labor induction, 40.7% underwent preinduction cervical ripening indicating a Bishop Score less than 6 [an unfavorable cervix]; among women with an elective indication, the proportion was 37%.These numbers of quite dramatic. More than 43% of women expecting a first baby were induced.Of these nearly 40% were being induced for convenience. More than 1/3 of women undergoing induction for convenience had a cervix that was known to be unfavorable for induction.
The authors looked more closely at the 4,863 women who delivered and had no medical risk factors or pregnancy complications. The overall C-section rate for those women was 25.5%. Being induced doubled the risk of ending up with a C-section, from 13.6% to 25.5%. [note: this section amended to correct percentages that were given incorrectly in the first version].
… Within this low-risk cohort, the risk of cesarean delivery for women with indicated inductions was RR 1.92 (1.61–2.29) and elective inductions was RR 1.84 (1.59 –2.12) when compared with women with spontaneous labor. The odds of cesarean delivery associated with induction for this low-risk group were estimated using logistic regression, and after adjustment for the other risk factors, was adjusted OR 2.03 (1.7–2.4)…In other words, it was induction itself that increased the risk for C-section, not pregnancy complications or other risk factors. In the case of the indicated inductions the increased risk for C-section is justified by the benefit of reducing perinatal deaths. However, there is no offsetting benefit for inductions without medical indication.
Using a very conservative analysis, the authors estimate that fully 20% of all C-sections done at their institution were the result of inductions for convenience. In other words, if inductions for convenience were banned, the C-section rate would be 20% lower. In their hospital that would mean a reduction in the primary C-section rate for nulliparous women from 25.5% to approximately 20% with no decrease in safety."
http://www.skepticalob.com/2010/07/inductions-increase-risk-of-c-section.html
"Induction of labor
In
parallel with the increasing cesarean rate, the rate of labor induction
also has increased significantly in many developed countries, including a
doubling of the U.S. rate between 1990–2000 (from 9.5% in 1990 to 20.2%
in 2000, and 22.6% in 2006). In comparison, the overall induction rate was 35.2% in our study
(around 2006); the induction rate in women attempting vaginal delivery
was 43.8%. These findings suggest that the national figures based on
birth certificates may have been an underestimate of the true national
induction rate. For
medically-indicated induction of labor, the benefits for the mother
and/or the fetus are indisputable. However, controversies arise when
labor is induced for women with absent or marginal clinical indications. Our data show that induced labor was twice as likely to result in
cesarean delivery than spontaneous labor. Half of cesarean sections for
dystocia in induced labor were performed before 6 cm of dilation,
suggesting that clinical impatience may play a role in decision-making.
Some studies also suggest that induction of labor increases the risk of
postpartum hemorrhage and blood transfusion. Therefore, while more research is warranted, caution is needed to
perform elective labor induction, as it may result in maternal morbidity
and repeat cesarean deliveries in subsequent pregnancies."
So what conclusions have I personally drawn from these studies (and these are just a few examples)? Induction raises, often doubles, the rate of c-section. Having an "unfavorable cervix" increases those chances drastically. Maternal and infant outcomes tend to be worse in inductions than in spontaneous labor. Women are more likely to fall victim to the "cascade of interventions" and feel their birth experience spiral out of their control. Women are more likely to request pain medication, which often leads to more interventions. Overall, if there is no medical necessity for an induction, and you want an unmedicated birth and/or to avoid a c-section, it seems that induction is not the best way to achieve that, according to the current statistics. Again, I will reference the chart from Improvingbirth.org and Evidencebasedbirth.com:
So if you decide that the potential benefits outweigh the risks in your case, then by all means go for it. But do so knowing all the facts. If you want a vaginal birth, and that is important to you, induction will greatly lessen your chances of achieving your goal, so bear that in mind, and be prepared for whatever the outcome may be. There are things you can do to improve your chances, but an induction is the first step towards medical interventions, and one often leads to another, so surround yourself with supportive care providers (OB, doula, partner, etc.) to help keep the control in your hands if you choose to be induced.
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