Special report: Labor induction – what you need to know

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Are you anxiously awaiting the spontaneous announcement from both your body and your baby that it’s time to deliver? Or would you rather put the big day on the calendar and have control over your baby’s birth date? Today, you have a choice.

According to recent statistics published by the Centers for Disease Control and Prevention, approximately 21 percent of all deliveries in the United States are the result of an elective labor induction. This non-medically-necessary procedure is more commonly known as “choosing a baby’s birth date” and there are several important factors to consider before making this choice. Rushing the process could result in severe labor pain, an emergency Caesarean section, or compromised infant immunity. Is it worth the risk?

Pass the Pitocin, please 

The decision to induce labor should not be made without knowing how it’s done and what the risks are. Labor is induced with Pitocin, a drug that mimics oxytocin, the hormone that activates labor. Your cervix, located at the lower end of your uterus, should be “ripe” before Pitocin is administered. A ripe cervix is one that has softened, dilated, and thinned. The measurement of these conditions is called a Bishop score. “If the cervix requires additional ripening, patients come in to the hospital the night before and get a softening agent,” says Diane Hughes, M.D., assistant professor in the obstetrics and gynecology department at University of Texas Southwestern Medical Center at Dallas. Cytotec and Cervadil are most commonly used to artificially ripen the cervix. Cervadil is a vaginal suppository that has strings attached for quick removal if the baby or uterus has a reaction. Cytotec is a tablet that may be cut and placed in the vagina or taken orally; however, it has not been approved by the Food and Drug Administration for cervical ripening.

Before an induction, Hughes advises her patients to have a good lunch and eat a light snack at around 3:00 in the afternoon before coming to the hospital at 7:00 p.m. The baby’s vital signs are traced at that time, and if all looks good, the mother receives her first dose of the softening agent. If the patient already shows signs of cervical softening and is dilated to 2 or more centimeters, she is sent back home, instructed to not eat after midnight, and told to arrive at the hospital in the morning for IV fluids and a tracing of the baby’s vitals. “By about 6:00 to 7:00 a.m., an IV of Pitocin is started. Most patients will deliver between 5:00 and 7:00 p.m.,” Hughes says. One advantage to induction is that there is more hospital staffing ready to facilitate the delivery. “It is a modern convenience that, when used properly, helps streamline and provide potentially safer care,” Hughes says.

It’s all about timing, baby

These days, both patients and physicians initiate elective inductions. “A lot of the push to have elective inductions is coming from patients who are trying to find a time to schedule when it’s not inconvenient for husbands and family,” says Samuel Law, M.D., an ob/gyn at The Methodist Hospital in Houston. “It’s not only because the doctors are interested in trying to have a little bit more ordered life, it’s coming from patients as well.” Some women can’t wait to ask. Hughes reports that 10 to 20 percent of her patients ask about elective induction during their first prenatal visit. She brings up the subject with other patients at around 37  Special report: Labor induction what you need to knowweeks gestation when she has a feel for what their cervices are doing. Fear of pain, feeling uncomfortable, avoiding a mad dash to the hospital, delivering when grandparents can visit, and coordinating around work are common reasons for labor induction. Some who have done it would do it again, and others will not.

Sherry Manero from York, PA, scheduled her induction to ensure the availability of an epidural. “It was my first pregnancy, and I had some concern that I wouldn’t get to the hospital fast enough. My mother had all three of her children very quickly,” she says. Manero was given an epidural at 9:00 a.m. and had her baby in her arms by 5:00 p.m. “I made sure the anesthesiologist was available before the induction was started. If I have another baby, this is definitely the route I would go,” she says.

“I wanted my mom to be there when my son was born, and I was afraid that I would be late going into labor—after she had to go home,” says Micaela Vitello from Dixon, CA. Her mother and grandmother live in Colorado. Vitello says that although her induction went smoothly, she is unlikely to do it again. She would rather wait and let the baby come when she’s sure that he is ready.

“With another child at home who needed to be taken care of, it was nice to be able to have my parents come down that day, get packed, play with my first son, then leisurely head for the hospital,” says Jennifer Wilson from Saukville, WI. Wilson’s first birth was induced as well, and both were scheduled after her due date. “After two inductions, I would be very likely to schedule a third—again, only after my due date—but the idea of actually having a natural childbirth still really appeals to me,” she says.

A carefully planned biological phenomenon 

Now that you know that labor induction is an option and what to expect during the procedure, decide if it’s something you want for you and your baby. An artificial labor usually has an unnatural rhythm. “It’s commonly the case that the pains are more severe, quicker, and so it’s not unusual for a patient who is being induced to need pain medicine sooner, like an epidural or something else,” Law says.

Women expecting their first baby have other things to consider. Michael P. Nageotte, M.D., an ob/gyn at Miller Children’s Hospital at Long Beach Memorial Medical Center in California and past president of the Society for Maternal-Fetal Medicine, reports that the risk of Cesarean section probably doubles for a woman undergoing elective induction during the birth of her first baby. “This is not my own data,” Nageotte says. “The data is from medical literature with the specific indication being induction at term.” The same argument cannot be made as strongly for women who have had a successful vaginal delivery before. “It’s just really important for the patient to be well informed what the risks are.”

Every day in the womb is an important one for a baby, provided that there are no medical concerns that call for an earlier delivery. “There is an active transport of immunities from the mother to the baby during the last trimester of pregnancy, so the shorter the last trimester of pregnancy, the less transfer of immunities,”says F. Sessions Cole, M.D., chief medical officer at St. Louis Children’s Hospital in Missouri. “When the baby is first born, he relies considerably on immunity that has been transferred from the mother to fight off infections.”

Cole also says it’s important to recognize that the onset of labor is a carefully timed biological phenomenon in each woman that coordinates the readiness of both the baby and the mom. “Without any maternal or fetal indications, if there is an induction of short-circuiting that harmonization between the fetus and the mother by starting the Pitocin, I think that you’re not doing anybody any favors,” Sessions says. “You’re especially not doing the baby any favors. Simply thinking that there is some advantage to knowing the day the baby is going to be born rather than going into labor spontaneously is a mistake, in my opinion.”

Because the delivery of healthy babies is so important for the survival of the species, there are a lot of reasons to think that the spontaneous initiation of labor is a good indication that mother and baby are both ready. “There has been a long evolutionary track record of getting this right,” Cole says.

The right to an informed choice

Randy Fink, M.D., a fellow of the American College of Obstetricians and Gynecologists and a Miami-based ob/gyn in private practice, offers elective induction to his patients provided two very important criteria are met: that the cervix is ripe, and that the mother is nearing her due date. “If my examination shows that the pregnant woman’s cervix is ready for labor, my inducing her labor is safe and elective does not increase her risk for Cesarean section. A ripe cervix tells me that she is simply ‘walking the line’ between still being pregnant and going into labor. If I can induce her without unnecessarily increasing the risk of Cesarean section, I am comfortable in doing so,” Fink says.

The importance of knowing the risks as well as the details about every step in the procedure can’t be stressed enough. During three years of research and witnessing several births, Jennifer Block, author of Pushed: The Painful Truth about Childbirth and Modern Maternity Care, is concerned that women are not receiving enough information. She has been told by mothers, nurses, and doulas who have been through and seen both natural and induced labors that the induced ones are more painful. Women who plan to have an un-medicated birth but don’t know this are often disappointed to discover that they can’t handle the pain without an epidural.

Block’s research also shows that many induced women were not told that their water would be broken manually. “Their waters were broken without their even knowing, without their consent,” Block says. “Once your water is broken, you’re on deadline. The hospital will want you to deliver within 24 hours.” If the induction does not progress your labor, you can’t be sent back home until your body is ready. This is a C-section waiting to happen, and once you have one, you might not be able to find a doctor or hospital that will let you deliver vaginally next time. A vaginal birth after Cesarean (VBAC) is no longer allowed in more than 300 hospitals in the United States. As a result, the VBAC rate has declined by 67 percent since 1996 to just 9.2 percent.

“Information is the important thing,” Block says. “There is a common feeling in American culture that we implicitly trust technology; we implicitly trust what our doctors tell us. But there is another question to ask: Are we trusting our bodies less?

— Sharon Anne Waldrop writes from a horse farm in northern Georgia. Her work has appeared in Good Housekeeping, Woman’s Day, Parenting, and Parents magazines.

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