Evidence-Based Medicine: Labor Induction

What is labor induction?

Artificial induction begins contractions and dilation of the cervix, essentially starting labor before it begins on its own.  Breaking the water, Foley balloons, prostaglandin gels and tablets, and IV synthetic oxytocin (Pitocin) are all methods of labor induction, with Pitocin being the most popular.

Induction was originally used to deliver babies in women with small pelvises (common side effect of Rickets, a Vit D deficiency) and in cases of pre-eclampsia.  Like many medical practices, it was at first very risky, and was only done when it was more dangerous for the woman to remain pregnant than to induce. Now it is relatively safe and quite common, with over a third of all births occurring through artificial beginnings. [1]

What is the current approach to induction?

Once upon a time, obstetricians believed that prophylactic (preventative) inductions should be practiced in all pregnancies.  Instead of being left at the mercy of spontaneous labor, doctors can now schedule it.  And while it is (fortunately) not practiced in all labors, it is a growing trend, and can even be performed without medical indication (elective).  The most common reason given for induction is “post dates,” or overdue, followed by a maternal health problem, a desire to get the pregnancy “over with,” and concern about the baby’s size.  Pitocin is used in 80% of medical inductions, and most women experience more than one induction method, usually breaking the waters. [2] The American College of Obstetrics and Gynecology (ACOG) recommends against induction before 39 weeks in the absence of a medical indication. [3]

What does the evidence suggest about induction?

Pitocin has been approved by the Federal Drug Administration as safe for use, but there is a noted increase in epidural use, interventions, and c-sections when an induction is attempted. [4] [5]  However, inductions are often unsuccessful, even when combined with amniotomy (breaking the water), which may increase a woman’s chance of a cesarean section. The ideal rate, calculated by the World Health Organization (WHO) is 10%.  [6]

One of the most common reasons given by women and obstetricians for inducing is when a woman is overdue or “post-dates.”  Research has shown a VERY slight increase in fetal death after 41 weeks, but the absolute risk is quite low regardless.  This means that the risk of the baby dying without the induction was also quite small, but induction reduced the risk further. [7]  The risk increases even more after 43 weeks, but very few women ever go that long, even without induction. [8]

Another reason some pregnancies are not allowed to go beyond the due date is the fear that the baby will grow too large to fit through the mother’s pelvis.  However, despite this being a common reason given for induction, there has actually been no evidence to suggest that induction due to suspected macrosomia (big baby) has any benefit to mother or baby.  Also, due to the documented inaccuracy of ultrasounds for determining due date and size of the baby [9][10], induction carries the risk of the baby being premature, or at a low birth weight. [11]

What are the risks of labor induction?

Although Pitocin, one of the most common induction drugs, as well as many other methods of induction, have been proven safe to use, the dangers of induction are more about the resulting interventions that may occur as a result.  For example, the stronger and more frequent contractions that happen with artificial induction cause most women to request an epidural, which while relatively safe, does carry it’s own complications.  The contractions themselves may increase “fetal distress,” since the baby does not have the opportunity to recuperate between contractions, and “fetal distress” is more likely to result in an instrumental (forceps or vacuum) or surgical delivery.  Again, it’s not the induction itself that causes the problem, but rather the resulting “cascade of interventions” that can follow. [12]

The unnaturally strong, long, and frequent contractions can put undue stress on the uterus, leading to higher rates of postpartum hemorrhage and uterine hyperstimulation and rupture.  Women attempting a Vaginal Birth After Cesarean (VBAC) should be especially cautious about using any artificial induction methods, as they are at a higher risk of hyperstimulation and rupture [13], which can be fatal.

What is the alternative?

If at all possible, WAIT.  Studies have shown that in the final days of pregnancy, your baby’s brain and lungs are still developing.  Even just one day could make the difference in terms of your child’s long-term health.  One current theory is that, when your baby’s lungs are ready to breathe on their own, they release a protein that triggers labor to begin. [14] Unless it absolutely essential to induce, you should try to give your baby every opportunity to develop.

Natural induction methods would also be an option, such as breast stimulation [15], acupuncture [16], or good-old fashioned nooky[17].

Final Thoughts

I am always just a little bit nervous whenever I know someone who is being induced.  Too many women I’ve known have experienced C-Sections as a result, and too many babies have had complications.  Just because it is possible to plan your baby’s birthday down to the hour doesn’t make it preferable to waiting for natural labor.  The birth process is amazingly complex, and rushing any part of it could have short-term or even long-term consequences that we have yet to understand.  You absolutely have the right to refuse induction if you don’t believe it is in your or your baby’s best interests.

Conspiracy Theory Time:

Inductions are better for business.  Data from the CDC shows an increasing trend toward births occurring during daylight hours Monday through Friday, indicating that inductions are done at least partly for the convenience of the doctor. [18]

Think about it from the physician’s perspective…Let’s say you have a very busy practice, and you’re trying to have a quality of life, maybe you’ve got a young family, you don’t want to be running out every night to deliver a baby, or not coming home in time for dinner, missing everything that your child is doing. So what happens is you try to get all the births in between 9 and 5, and to do that, you have to make sure nobody goes into spontaneous labor; and to make sure of that, you have to induce them all early. Or let’s say this is the day you have to be on call, it’s best then for you to induce three or four people on that day because you can get them all done at once. Those three or four people aren’t going to call you on the weekend, they’re not going to call you in the middle of the night, they’re not going to interrupt your office hours, they’re not going to give birth at any time that’s inconvenient.

Some say scheduling births is all doctors can do to maintain their level of income while larger and larger portions of it are earmarked for malpractice insurance premiums. If a doctor misses a birth, he loses revenue. Even if an induction doesn’t work, a cesarean is waiting. And from incision to sutures, a cesarean takes less than an hour. In addition to time management, the looming fear of lawsuits drives doctors to act rather than to wait. “Doctors are practicing more defensively,” says Bernstein. It’s irrelevant that an induction might lead to a cesarean. “To be blunt, you don’t get sued when you do a cesarean,” he says. “You get sued when there’s a damaged baby. And if they can find any reason that the woman should have been delivered earlier, then it doesn’t matter whether the damage had anything to do with how you managed the baby. All that matters is did you do everything that you could have possibly done? And that causes doctors to say, `Well, it’s got to look like I’ve tried my best. And trying my best would be to deliver the baby.’ So you explain to the mother that the fluid’s a little low.

Jennifer Block. Pushed: The Painful Truth About Childbirth and Modern Maternity Care (pp. 42-43). Kindle Edition. [*]

Resources

Born in the USA: How a Broken Maternity Care System Must Be Fixed to Put Women and Children First (Wagner, 2008)

The Cochrane Library

Listening to Mothers Survey (2005)

Pushed: The Painful Truth About Childbirth and Modern Maternity Care (Block, 2008)

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Evidence-Based Medicine: Episiotomy

What is Episiotomy?

Episiotomy is simply a surgical cut intended to widen the vaginal opening.  Its use is meant to prevent severe tears and trauma to the perineum during a vaginal birth.  It can also be used to expedite a birth in the case of fetal trauma, or to allow an instrumental (forceps or vacuum) delivery.  The two most common types of episiotomy are medio-lateral and midline, which basically refers to the angle of the cut — midline (toward the anus) or medio-lateral (diagonal, away from the anus). [1]

What does the evidence suggest about its practice?

More than 20 years of research indicates that episiotomies should NEVER be a routine practice [2][3][4][5], and that a restrictive policy is best.  The World Health Organization recommends episiotomy rates of below 10%.  [6]

What is the current practice?

The practice of episiotomy originated in the 18th century, and became widespread over the next 100 years as instrumental deliveries rose in popularity — widening the opening helped doctors maneuver the baby manually or with forceps.  For a long time, it was  assumed that a surgical cut was better than a natural tear, and that it reduced the chances of incontinence (leaking urine and/or feces) and improved sexual function.  At some points in history, it was a routine hospital birth procedure, with upwards of 70-80% of all mothers experiencing one, with first time mothers more susceptible than others. [7]

In 1983, research showed that not only did episiotomy NOT improve incontinence or sexual function, but that it actually seemed to increase the odds of a woman experiencing BOTH. [8] The American College of Obstetrics and Gynecology (ACOG) changed its stance concerning the procedure, encouraging its members to take more preventative measures, and avoid episiotomy whenever possible [9], but it took over 20 years for the policy to become practice.  Some hospitals still have a policy of routine episiotomies. [10]  In 1997, the rate of episiotomies was 29% of all births, but in 2006, the rate of episiotomy was about 9%, [11][12] just under the <10% recommended by the World Health Organization (WHO). [13]

Today, its use is more restrictive, usually only performed in cases of fetal distress where a quick (usually instrumental) delivery is required. [14]

What are the risks of episiotomy?

Most of the consequences of episiotomy effect the mother, rather than the baby, and while they are generally not life-threatening, they can greatly impact her quality of life and make her birth experience more traumatic.  Episiotomy increases a mother’s chance of blood loss [15] during delivery and rate of infection. [16]  Women with episiotomies have a longer recovery time and experience more incontinence [17][18][19] and painful intercourse [20][21], even after the cut has healed.  And, despite claims that episiotomies reduce the risk of severe tears, the procedure actually INCREASES a chance that she will tear further. [22]  Think of how you might snip a piece of fabric in order to rip it in two — same concept.

Why does episiotomy increase a woman’s chances of incontinence?

When a woman is sutured after an episiotomy, the doctors are essentially sewing together her pelvic floor muscles, which are essential to bladder and bowel control, as well as sexual pleasure.  Some doctors have claimed that a sutured vagina is as good as or “better than new,” but as anyone whose had a c-section or major surgery knows, sutured muscle never heals quite like new.  It is weaker and looser (hence the post c-section “pooch”).  This weakness, this looseness, can actually contribute to incontinence and painful intercourse, not prevent it.

Many surgeons believe a surgical cut to be better than a natural tear, although scientific data has proven otherwise. The misperception stems from the fact that obstetricians are surgeons accustomed to sewing up openings that have been made with a scalpel-that is, cuts that are straight and clean-whereas tears are ragged and irregular. It is perhaps counter-intuitive to surgeons that a tear is better than a cut. What they don’t appreciate is that a tear follows the lines of the tissue, which can be brought back together like a jigsaw puzzle. An episiotomy cut, on the other hand, ignores any anatomical structures or borders and disrupts the integrity of muscles, blood vessels, nerves, and other tissues, resulting in more bleeding, more pain, more loss of muscle tone, and more deformity of the vagina with associated pain during sexual intercourse.

Marsden Wagner. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (p. 56). Kindle Edition.

What is the alternative?

Essentially, the natural alternative to episiotomy is tearing, although it is absolutely possible to have a vaginal delivery with neither a cut or tear.  [23]

Take Action!

During pregnancy, exercises such as Kegels and squats have been shown to reduce the chances of a tear by increasing the elasticity of the perineum.  Sexual activity during pregnancy has also been shown to soften the tissue, making it expand easier and with fewer tears.  Perineal massage during the third trimester has demonstrated similar benefits. [24][25]

The choice of birth attendant can also make a big difference as well — Certified Nurse Midwives (CNMs) and younger obstetricians have lower rates of episiotomy. [26][27][28]

The traditional hospital birth position, either lying down or reclined, increases a woman’s chances of tearing or requiring an episiotomy due to the improper positioning of the baby’s head pressing against the perineum. [29][30]

Epidural use, because the woman cannot feel the trauma while it is happening, has also been shown to increase tearing.  She also may be “coached” through the pushing phase, rather than led by her natural urges, which again increases her chances of tearing.  [31]

Instrumental deliveries, such as forceps or vacuum extractions, have also been shown to increase perineal trauma.

Alternatively, laboring and/or birthing in warm water [32], squatting or side-lying positions during pushing, “breathing down” the baby during crowning, as well as the use of hot compresses [33] have been shown to reduce the chances of tearing and episiotomy.

Knowing all this, you have the right to REFUSE THIS PROCEDURE.  In fact, you have the right to refuse any procedure you don’t want.  Exercise that right and get the birth you want! [34]

Final Thoughts

The perceived need for episiotomy seems based in a couple faulty assumptions.  First, that the woman’s body is somehow incapable of giving birth (an assumption rampant in the medical community), and therefore needs help from a doctor in order to be successful.  And secondly, that a cut is better than a tear (which doctors seem to believe are an unavoidable part of giving birth).  Neither of these assumptions are true, and it’s time for hospitals, care providers, and women to consider just who actually benefits from routine episiotomy.

Even though ACOG has recommended against routine episiotomy since 1983, some doctors and hospitals seem not to have gotten the memo.  And it’s not just episiotomy — many practices that have no basis in evidence continue to be routinely practiced in modern obstetrics.  It makes me wonder, just how much time, and how much evidence, do obstetricians and hospitals need in order to stop doing things that hurt women and babies?  Recently, ACOG changed their policy regarding Vaginal Birth after Cesarean (VBAC), but I personally remain skeptical as to how long it will take before attitudes really change. [35]

The rate of episiotomy (and forceps delivery) may be down, but the C-section has risen significantly.  Are we just trading one cut for another?   Is that an improvement? [36]

Conspiracy Theory Time:

When you look deeply into the history of episiotomy, a surprising amount of sexism comes floating to the surface.  Just like many other birth interventions, it is first based on the principal thought that women are incapable of giving birth, that they must need medical intervention.  The benefits of episiotomy are questionable, but the consequences to the mother are devastating — the humiliation of incontinence, a long and painful recovery, and a loss of her ability to feel sexual pleasure.  And still the advocates of episiotomy tout that one of the benefits of the procedure is “re-virginization,” which is clearly a benefit for the woman’s partner, not to the woman herself — because losing her virginity was so great, every woman wants to do it TWICE, right?  Sounds like whoever came up with that line doesn’t have a vagina, if you know what I mean.  Plus, the idea that the only good vagina is a tight vagina, and no man is going to want to be with someone with a used vagina, reduces the woman’s value to one part of her body, and that is blatant objectification.   See, sexism at its finest.
Resources

Avoiding Tears and Episiotomies

Benefits and Risks of Episiotomy

Birth: The Surprising History of How We Are Born (Cassidy, 2007)

Born in the USA: How a Broken Maternity Care System Must Be Fixed to Put Women and Children First (Wagner, 2008)

Cochrane Database

Empower Yourself: Know Your Rights!

Episiotomy and How to Avoid It

Episiotomy: Ritual Genital Mutilation in Western Obstetrics

Ina May Gaskin’s Guide to Childbirth (Gaskin, 2003)


Evidence-Based Medicine: Immediate Cord Clamping

What is Immediate Cord Clamping?

During pregnancy, the umbilical cord transfers oxygenated, nutrient-rich blood from the placenta to the baby.  After birth, when the baby is able to breathe on its own and receive milk for nutrition, the placenta, and therefore the umbilical cord, is no longer necessary for the baby’s survival.  In the wild, many mammals sever the umbilical cord with their teeth after birth, but in the human medical setting, the cord is first clamped and then cut with medical scissors.  Immediate Cord Clamping (ICC) simply refers to the timing of this clamping after birth.  If the cord is clamped and/or cut less than 1 minute following birth, it is considered immediate, or “early,” cord clamping.

What is the current practice toward cord clamping?

Early cord clamping originally came into practice in the 1950s as an attempt to reduce the instance of neonatal jaundice, and was used in the 1970s to facilitate resuscitation.  In the 1990s, the American College of Obstetrics and Gynecology (ACOG) called for early clamping for legal purposes.  Today the procedure is routinely performed by most obstetricians, while most midwives prefer delayed clamping. [1][2]

What does the evidence suggest?

Even after 50 years of use in US hospitals, there is actually no evidence to support the routine practice of immediate cord clamping.  In fact, all the available research suggests that not only does ICC show no benefit to the baby, but that it actually does damage. [3] This is because of a phenomenon called placental transfusion, where for a period of time after birth, a healthy placenta continues to supply oxygenated, nutrient rich blood to the baby.  ICC disrupts this process, which can have long-term consequences for the baby (see below).

What are the risks of immediate cord clamping?

It is estimated that at least 30% of the baby’s potential blood volume is transferred by the placenta after birth [4] — which means that clamping the cord early frequently results in hypovolemia (too little blood) and anemia (too little iron).  Infant anemia is linked to a variety of problems, such as cerebral palsy, respiratory distress, behavioral and developmental disorders (such as autism).[5][6][7]

“To clamp the cord immediately is equivalent to subjecting the infant to a massive hemorrhage, because almost a fourth of the fetal blood is in the placental circuit at birth.” [Windle, 1969]

Risks to the mother include an increased chance of retained placenta and postpartum hemorrhage, which can lead to some serious complications. [8]

What is the alternative?

In a word, waiting.  Delaying the clamping of the cord to at least two minutes has been shown to prevent anemia during the first year of life, therefore reducing the risk of anemia-linked disorders during childhood. [10]

Although the need for resuscitation has been cited as justification for ICC, it is actually possible, if not preferable to perform resuscitation with the umbilical cord attached, since the placenta continues to provide oxygenated blood to the baby for several minutes after birth.  A newborn’s lungs may not be developed enough to distribute oxygen to the body, but a healthy placenta and umbilical cord usually are.  [9]

Babies delivered by cesarean, as well as premature infants, can also receive the benefits of delayed clamping.  Research has found a significant reduction in infection and bleeding in the brain amongst preemies who received a complete placental transfusion. [11][12][13]

Delaying cord clamping at least two minutes is recommended by the World Health Organization. [14]

Final Thoughts

Immediate cord clamping has demonstrated no benefit to babies or mothers.  In fact, research has shown that it actually does harm, by increasing the risk of anemia in infants, which can cause lifelong disabilities.  The physiological norm is to wait until the cord has stopped pulsing before severing it — immediate clamping and cutting is an intervention that was put into practice without any evidence to support it.  In the absence of such evidence, after 50 years of practice, isn’t it time we acknowledge that it may not be the right choice?  Isn’t it time to admit that maybe Mother Nature knows better on this one?

[ http://www.nurturingheartsbirthservices.com/blog/?p=1542 /caption]

Conspiracy Theory Time:

A large portion of the evidence to support delayed cord clamping has come from midwives, who have continued to practice it even as doctors advocated for immediate clamping.  Ever since birth moved from the home to the hospital, and from doctors to midwives in the early 20th century, doctors (for the most part) have viewed themselves as more of an authority on birth than midwives.  Could it be that doctors (as a group) have resisted the evidence in support of delayed cord clamping simply because it came from midwives?  How much of this practice is because of evidence (of which there is none) and how much of it is simply defending their egos?  Is the pride of doctors worth more than the health of American babies?

One of the conditions linked to immediate cord clamping is autism.  Evidence suggests that babies delivered by obstetricians (more likely to perform ICC) have higher rates of autism than babies delivered with midwives (more likely to delay clamping/cutting). [15]  What if this condition could be prevented simply by waiting an extra minute or two before clamping the cord?

Since immediate cord clamping became routine in many hospital settings, birth has become more and more medicalized.  Interventions such as induction and labor augmentation have led to more diagnoses of fetal distress, as well as a higher rate of cesarean deliveries.  Another change in fetal medicine since the introduction of ICC is the increasing rate of pregnancies resulting from fertility treatments.  These pregnancies are more likely to result in multiples (and therefore higher likelihood of c-section) and prematurity [16], both of which increase a baby’s risk of requiring resuscitation.  Premature, “fetal distress/asphyxia” diagnoses, and babies delivered via c-section all experience higher rates of resuscitation.  Luckily, perinatologists have become more and more adept at saving these “at risk” babies, but what if there were fewer babies to save?  What if doctors and women made decisions about their pregnancies and births based on evidence, and used fewer interventions?  What if we took a proactive approach and made the decisions that would lead to healthy babies in the first place, rather than relying on resuscitation and other life-saving measures simply because they are available?

Take Action

Most newborn procedures can be delayed or done while the baby is held by the mother, reducing the need to clamp/cut the umbilical cord.  Even in the case of problems at birth, it is possible that the natural transfusion between placenta and baby could benefit the baby.  Obstetricians seem to be more likely to ICC than midwives, so keep that in mind when you choose your care provider.

Resources

5 Good Reasons to Delay Clamping the Cord

Birth of a New Earth

CordClamp.org

Delayed Cord Clamping Should be Standard Practice in Obstetrics

Ina May Gaskin’s Guide to Childbirth

Late vs Early Clamping of the Umbilical Cord in Full-Term Neonates

Long-Lasting Neural and Behavior Effects of Iron Deficiency in Infancy

World Health Organization


Evidence-Based Medicine: Continuous Electronic Fetal Monitoring (EFM)

What is Electronic Fetal Monitoring (EFM)?

EFM monitors the baby’s heart rate and the mother’s contractions during labor, and alerts medical staff to any distress.  The most common method of EFM is placing two receivers, held in place with two elastic belts, on the mother’s abdomen.  A less common form of EFM involves inserting a receptor into the baby’s scalp.

EFM was originally intended for use in high-risk patients, and was thought to reduce fetal death and brain damage, including cerebral palsy and retardation due to oxygen deprivation. [1][2]

What does the evidence suggest about its practice?

Despite numerous studies on the matter, no benefit has been found from the  routine use of EFM technology. [3][4][5] There has been no reduction in infant deaths or cerebral palsy, which was the technology’s intended (and advertised) benefit. [6]  Because of this, as well as the documented risks of the practice, both the World Health Organization (WHO) and the US Department of Health and Human Services (DHHS) recommend against continuous electronic fetal monitoring. [7][8]  The technology has never been reviewed by the Federal Drug Administration for safety or efficacy. [9]

How is EFM currently used?

EFM is currently used in almost every birth in the United States, as much as 93% of the time.  Some hospitals require at least a 20-minute observation upon admission to check the health of the baby.  [10]

What are the risks?

Continuous use of EFM has repeatedly been linked to higher rates of intervention, including instrumental delivery and c-section, which carry their own set of risks. [11]  There is a slight increase in the rate of infection to the baby, especially when an internal monitor is used, but these are typically mild and easily remedied.  The patterns on the print out are open to the interpretation of the hospital staff, which frequently leads to misdiagnoses (this is called a “high false positive rate,” and is a sign of unreliability). [12]

In addition to its questionable benefit and documented risks to both mother and baby, the use of EFM has been shown to reduce the quality of care — women complain that the machine becomes the central focus of medical staff and birth attendants, rather than the laboring woman herself.  Movement can cause the machine to malfunction, so the woman is confined to labor in bed on her back, a position that is shown to be more painful and less effective for labor to progress.

What is the alternative?

Intermittent listening with a Doppler or fetoscope has been shown to be just as effective at detecting fetal distress as constant monitoring, while at the same time reducing the risk of instrumental delivery and c-sections due to a “fetal distress” diagnosis. [13]  This is the method recommended by the World Health Organization.

Final Thoughts

Electronic fetal monitoring has been accepted as a normal part of maternity care in the United States, despite any evidence of its benefit to the laboring woman and her baby.  And while it provides the appearance that an individual is receiving continuous care, it has in fact made it possible for medical staff to care for more patients simultaneously, meaning a lower standard of care for each patient. Its high false positive rate means that more women are being subjected to unnecessary interventions and surgery because of the misdiagnosis of “fetal distress.”  By confining women to bed, EFM makes labor more painful and less effective than if the woman was allowed freedom of movement.  Despite claims that it would improve outcomes for mothers and babies, EFM has repeatedly shown NO benefit to either, after 30 years of research.  So WHY IS IT STILL BEING USED??

Conspiracy theory time:

EFM has become so normalized that it is frequently used as evidence in malpractice lawsuits, which is why many hospitals now mandate its use — it is their paper trail.  [14]  EFM gives the illusion of accuracy, but is in fact open to interpretation much of the time, hence its high rate of inaccuracy.  Without it, doctors and hospitals would be more vulnerable to lawsuits, but with EFM they can justify their choices.

EFM is a multimillion dollar technology, whose makers implied that a perfect outcome was possible with its use.  Its widespread adoption reduces costs to hospitals by making it possible to care for more laboring women simultaneously, but the resulting interventions (such as c-section) actually make birth more expensive for patients.  Is it possible that those that stand to benefit financially (the EFM industry and the hospitals that use it) are pushing for its continued use?  Is it possible that these groups are more concerned about their bottom line than what is best for you and your baby?

Take Action

You have the right, as a patient, to refuse any procedure, including EFM.  You can request intermittent monitoring instead, which has been shown to be just as effective in detecting problems, but without the associated risks.  You can choose a care provider that prefers a less technological approach, or give birth in an environment where EFM is not routinely used, such as a birth center or at home.  You do not have to accept any risk you are not comfortable taking.  Take your birth into your own hands — know your rights and know your limits.

Resources

Born in the USA: How a Broken Maternity Care System Must Be Fixed to Put Women and Children First (Wagner, 2008)

The Cochrane Database

Ina May’s Guide to Childbirth (Gaskin, 2003)

Listening to Mothers Survey (2005)

Pushed: The Painful Truth about Childbirth and Modern Maternity Care (Block, 2008)


Evidence-Based Medicine: Are Inductions Safe?

A couple weeks back, I researched the necessity of labor induction.  I learned that, according to the Listening to Mothers Survey from 2005, about 40% of all labors are medically induced.  I also learned that, according to birth experts Ina May Gaskin and Marsden Wagner, induction is only medically indicated in about 10% of births.  This means that about three-quarters of all women who are induced are doing so without medical indication.  If induction is perfectly safe, there would be no concern — so what does the research say?

The stats…

80% of medical inductions were done using a drug called Pitocin, a synthetic oxytocin, which causes the uterus to contract.  Other methods of induction include prostaglandin medications applied to ripen the cervix, stripping/sweeping the membranes, and “breaking the water”  (artificial rupture of membranes (AROM)).  Most mothers included in the survey were subject to 2 or more methods of induction, the most common combination being Pitocin and AROM.

Not only are many labors medically induced, but many are also augmented using the same methods listed above.  When these numbers are included, about 50% of women are given artificial oxytocin to either induce or augment labor, and 65% have their water broken.

The risks…

  • More painful labor — Common induction methods such as artificial oxytocin can lead to longer and stronger contractions that are closer together.  This means more pain for the mother during contractions, as well as a shorter period of time between contractions to recuperate.  This can quickly exhaust a laboring woman, not to mention tarnish her birth experience.  Many women whose labors are induced or augmented find an epidural to be a necessity.

“I went into labor on my own with my daughter, but was induced with my son.  With my daughter, I found that sitting in a warm bath made the pain very manageable, and I didn’t get the epidural until very late — 7 cm, I think.  With my son, I got an epidural at 3 cm — I just couldn’t stand the pain.”  — Annie, 31

  • Prematurity — Miscalculation of due dates can lead to a woman being induced before her baby is mature.  Iatrogenic (doctor-caused) prematurity is on the rise, and with it comes all the risks commonly associated with prematurity, such as breathing problems.  New research shows that the production of fetal lung proteins trigger labor — meaning that the baby triggers spontaneous labor when its lungs are ready to breathe.  Inducing without medical indication means your baby may not be totally ready to breath independently.  Labor should NEVER be induced before 39 weeks for this reason, and should ideally be around 42 weeks as long as the baby shows no signs of distress.
  • Fetal Brain Damage or Death —  The only time a fetus can get oxygen is during the rest period between contractions, so when those periods are shorter, the fetus gets less oxygen.  Lack of oxygen is associated with an increased risk of brain damage.
  • Maternal death —  According to Marsden Wagner’s book Creating Your Birth Plan, induction of labor is linked to higher rates of uterine rupture and amniotic fluid embolism (AFE), both of which are rare but usually fatal (80% of AFEs are fatal — 50% within the first hour after symptoms appear).  C-Section dramatically increases the incidence of both.  Many women who survive uterine rupture undergo hysterectomies and are unable to have any more children, and most that survive AFEs are severely brain damaged.  Fetal death is also common with both of these complications.
  • “Cascade of Interventions”A woman who is either induced or has her labor augmented artificially is at an increased risk of instrumental (forceps and vacuum-assisted) and surgical (c-section) interventions.  So even if the induction drug itself is considered safe (which Pitocin is), the risks associated with all other forms of intervention must be calculated as well.  While the more severe risks (uterine rupture, AFE, fetal brain damage) are relatively rare, the so-called “cascade of interventions” is fairly common.  A woman who is induced more than doubles her riskof having a C-Section.  A woman who goes in to be induced may find her plans for a low-intervention birth go awry very quickly.

 “I got induced at 41 weeks because they thought she was going to be too big too birth otherwise.  First came the Pitocin, then the epidural for the increased pain, which meant I was tethered to the bed with IVs, so I couldn’t move around.  Then my labor slowed down, and they broke my water to speed things up.  I went into labor thinking that I could manage an induction naturally, but instead I ended up with a C-Section because of failure to progress.”— Silvia, 26 

  • Interferes with Bonding/BreastfeedingArtificial oxytocin alters the mother’s natural hormones during and after birth, potentially affecting her ability to bond with or breastfeed her baby.  Any other interventions she experiences (such as cesarean) can also interfere.  

“When my son was born, I felt like he belonged to someone else.  I kept waiting for that overwhelming feeling of attachment I knew I was supposed to feel, but it just didn’t come — I felt like I was just going through the motions for weeks.” — Patty, 29

What is the alternative?

So if induction carries with it the risks listed above, it could be argued that elective induction is not in the best interest of the mother or baby.  So what’s the alternative?  Well, waiting.  Just remember, every day your baby “cooks,” s/he will be a little bit stronger, a little bit healthier.  As we talked about last week, babies can and have been (vaginally) born past their due dates perfectly healthy.   Trust your baby, and trust your body to go into labor on your own — it’s better for both of you!


Evidence-Based Medicine: Is Induction Necessary?

During my last month of pregnancy, I had a few “false alarms,” where I was convinced I was in labor, but it turned out I wasn’t.  I was so anxious to meet Sweet Pea, a little nervous about what labor would actually feel like, and it started to do weird things to my brain.  After our third false alarm, my husband and I finally sat down and accepted the reality that we had no control, and that Sweet Pea would come when she was ready.  We knew that every day she “cooked,” the healthier she would be.  I went to bed that night at peace, knowing that the best thing I could do for her was to be patient.  The next morning, I woke up in labor – at 39 weeks on the nose.

Many first time mothers experience the same kind of anxiety and anticipation that I did, but the weeks stretch on an on, even surpassing their due date.  And those women and their doctors are talking more and more about artificial induction, using labor-stimulating drugs like Pitocin.  A study from 2006, featured in the New England Journal of Medicine, found that 40% of low-risk, first time mothers were induced into labor.

Induction is definitely a growing trend in America.  But is this trend necessary to improve the outcomes for mothers and babies?  Are there situations where induction is medically indicated?  And how much of this trend is based on convenience — either for the mother or doctor?

When is induction medically necessary, improving the outcomes for mothers and babies?

According to Ina May Gaskin’s Birth Matters, up to 10% of all labors may call for labor induction.  She lists specific circumstances that may call for induction, such as:

  • cancer
  • hypertension
  • diabetes
  • kidney disease
  • IUGR (intrauterine growth restriction)
  • significant decrease in amniotic fluid
  • intrauterine fetal death (followed by a long (weeks, not days) wait for labor to begin)

Marsden Wagner (perinatologist, and author of Born in the USA) adds two other conditions:

  • documented placental malfunction (placenta losing its ability to nourish the fetus)
  • deteriorating preeclampsia (high blood pressure during pregnancy)

According to Gaskin and Wagner (both specialists in their fields), under these conditions, induction actually improves the outcome (as opposed to spontaneous labor).  But they both state that only about 10% of all pregnancies need to be medically induced.  And when you add up the statistics for each of the above circumstances, it comes very close to 10% of pregnancies.  But, according to Childbirth Connection‘s 2005 Listening to Mothers Survey, half of all pregnant women experience induction.  So why the major discrepancy?

You may notice that two of the most commonly-given reasons for induction — postdate (overdue) pregnancy and big babies (macrosomia) — are not listed.  This may explain the difference in recommendation versus reality.  Let’s see what the evidence says about those two reasons.

Induction Due to Post-Dates (Overdue)

This is the normal distribution for gestational age.  Notice when the largest majority of babies are born — 40-41 weeks.  And approximately the same percentage give birth between 41-42 weeks as do 39-40.   And this is all with spontaneous labor!

I think this about says it all.

Normal, low-risk pregnancies go to 40 weeks and beyond quite often.  First time mothers are especially likely,.

What about the risks of going past 42 weeks?  Isn’t there a risk to the baby?

According to Wagner, a study from 1963 found that a slight increase in the number of stillbirths after 42 weeks, with a significant increase after 43 weeks.  This study has been frequently cited as evidence to support induction before 42 weeks.  But Wagner puts the risk to the individual woman into perspective —  as it turns out, only 3 percent of pregnancies even extend beyond 42 weeks, and even after 43 weeks, only 10 percent (of that 3%) have any problems.  So as you can probably deduce, the chances of going so far past your due date that you put your baby at risk is pretty insignificant (about 0.3%).  You have a much greater chance of going into labor spontaneously before you reach 43 weeks, and an even if you don’t, there’s a good chance your baby will still be born healthy.

Another risk in induction due to postdates is the inaccuracy of EDDs (Estimated Due Dates).  Because of normal variations in the menstrual cycle length amongst average women, and the tendency to base due date on the last menstrual period (LMP), a woman’s due date could be off by 2 weeks or more.  So if a woman gets induced at 40 weeks, her baby could actually only be 38 weeks (or less), which is associated with more health problems for the baby.  This is a phenomenon called iatrogenic prematurity (essentially, doctor-caused prematurity), and is a growing portion of the increasing prematurity rates.

So, post-dates is generally NOT a medically indicated reason to be induced.

“Big Babies” or Fetal Macrosomia

First, macrosomia is defined as a baby weighing over 8 lbs 13 oz.  It legitimately effects about 10% of all pregnancies in America.

Perhaps the one of the most prominent concerns about big babies is a complication called “shoulder dystocia,” where the baby’s shoulders get stuck on the mother’s pelvic bone.  The risks of this complication include paralysis, Erb’s palsy, and fetal hypoxia (baby doesn’t get enough oxygen). Sounds scary, doesn’t it?  And if you are of the unfortunate 1% of women who experience it, it will definitely be treated as scary in the typical US hospital.

So what happens when a woman experiences shoulder dystocia?  Just think ALARMER.

  • Ask for help. This involves requesting the help of an obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant.
  • Leg hyperflexion (McRoberts’ maneuver)
  • Anterior shoulder disimpaction (suprapubic pressure)
  • Rubin maneuver
  • Manual delivery of posterior arm
  • Episiotomy (Does anybody else wonder how cutting open the perineum has any impact on a baby who is stuck on the pelvic bone?  Okay good, me either.)
  • Roll over on all fours

According to Wikipedia, the advantage to this mnemonic is that it goes from least invasive to most invasive.  That sounded all fine and good, until I got to the last method — roll over on all fours.  Wait, what??  How is rolling over on all fours less invasive than say, an episiotomy (you know, where they cut your perineum)?

Turns out “Roll over on all fours” has a name — Gaskin’s maneuver, and was discovered by midwife Ina May Gaskin (yes, the same one mentioned earlier).  This maneuver opens the pelvis (wider than lying on her back) , allowing the shoulders to slide through. Sounds pretty non-invasive.  In one study, the Gaskin maneuver had the following results:

“Half of the eighty-two babies weighed more than 4000 grams (about 8.5 pounds); 17 or 21 percent weighed more than 4500 grams (about 8 pounds, 10 ounces); thirty of the 1-minute Apgar scores were less than or equal to 6, and two were less than or equal to 3; only one of the 5-minute Apgar scores was less than or equal to 6, which is 1.2 percent; forty-nine of the women or 60 percent delivered over an intact perineum, and there were no third- or fourth-degree lacerations; one woman had postpartum hemorrhage not requiring transfusion; and one infant had a fractured humerus.

That sounds a heck of a lot better than an episiotomy to me.  So why aren’t more hospitals using this technique?  Probably the biggest reason is that movement during labor is limited by current birth practices, such as epidurals and electronic fetal monitoring, which generally require the mother to lay on her back.

Another issue with justifying induction because of macrosomia is the accuracy of the diagnosis.  Macrosomia is generally diagnosed using an ultrasound, which has been found to be inaccurate in nearly two-thirds of cases.

And according to Wagner, while macrosomia has been used to justify induction, evidence does not support this practice.  In fact, C-Section rates increase with induction due to macrosomia, with NO improvement in outcomes.  As he puts it in Born in the USA, “trying to hammer out too large a baby can harm the baby.”

Conclusion:

  • Evidence suggests that induction rates of less around 10% are essential to optimal outcomes for mothers and babies.
  • About 50% of pregnant women experience induction in the US.
  • Gestational ages range, and 42+ weeks pregnancies can still be healthy and deliver spontaneously.
  • Due dates can be up to 2 weeks off.
  • Big babies have a higher risk (1%) of developing “shoulder dystocia,” which has serious complications.
  • Diagnoses of macrosomia can be inaccurate up to two-thirds of the time.
  • If you induce due to macrosomia, you have a greater risk of undergoing a C-section

Oh, and:

  • Episiotomies widen your vagina (skin/muscle), not your pelvis (bone).  Just say “no” to episiotomy.
  • Patience is key.

With all that I’ve read, I have to say I come down on the side of “very wary” of induction.  Unless you are in the 10% whose medical condition requires it (see above), it’s probably better for you to wait until your baby is good and ready to come out.

Here are some more natural ideas for inducing labor:

  • Walk.  A lot.  — I walked more in the last month of my pregnancy than I did in the previous 8 months combined.  Which was nice, since I couldn’t walk farther than 4 feet without pain for about a week after she was born.
  • Have sex.  A lot. — As awkward as it sounds, the prostaglandins in semen help soften the cervix.  And it might sound a little dirty, but let’s admit it, that’s how we all got into this predicament to start with.
  • Start a lengthy project.  — Not only does this fill your time, but you are almost guaranteed that your baby will come before you can finish it.
  • Buy expensive concert tickets for right around your due date.  — Along the same vein, it’s likely that you won’t get a chance to use them.

HAPPY WAITING!


Build-A-Birth: Are Epidurals a Necessity?

What better place to start our investigations than one of the most common birth practices in US hospitals — the epidural.

Many women today plan for their birth to take place in a hospital, and of those women, most of them plan to receive an epidural for management of pain.  It’s kind of the assumption that a birthing woman will want relief from pain, and that a pharmacological method is the best kind of pain management.  But is this true?  Let’s see what the evidence suggests.  We’ll start with one very fundamental assumption.

Assumption #1: Pain Management is a “necessity” in labor and birth.

I don’t know how many times I’ve heard women say, regarding labor and birth, “why should I suffer if there’s a way to avoid it?”  The assumption is that if it’s available, any woman (in her right mind) would accept pharmacological relief for labor pain.  Since epidurals are available in most every developed country in the world, if this assumption were correct, it would logically follow that those other countries have a similar attitude toward pain management in labor.  So do they?

According to Marsden Wagner’s Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First, a woman’s culture strongly influences her attitude toward pain, both in what kind of pain she expects and how much she feels is tolerable.  In countries such as the Netherlands and Japan, women accept labor pain rather than view it as something to be numbed, and the rate of epidural use in both countries is much lower than in the US.  So why do American women get epidurals so frequently?  According to Wagner, the way a woman views pain during labor and birth are strongly shaped by how her obstetrician views pain.  He states:

“The two great evils in a doctor’s world are pain and death, and they see it as their job to fight them at all costs.  The physiological fact that pain is an essential component of a normal labor, that it is necessary for the release of hormones that control the progress of labor, is either not understood by most American obstetricians or simply ignored.”

So, part of the American pregnant woman’s mindset is influenced by how doctors, specifically obstetricians, view the role of pain in labor and birth.  But surely doctors aren’t 100% to blame.  Think of all the birth stories you’ve ever heard.  How many of them emphasized the pain of birth, or the fear?  If you’re anything like me, a large portion probably did.  So, the attitudes of other women also play a part in our perception of labor pain.  And what about the media?  If I based my perception of birth on “A Baby Story” alone, I would probably think that birth was always chaotic, scary, and horrendously painful.  And it’s not just reality TV — depictions of labor and birth in dramas and sitcoms are also pretty one-sided.  Shows like this litter the airwaves, and it would be silly to think that we are beyond their influence.

It’s been thoroughly established that birth hurts.  Aside from the fortunate few who experience “orgasmic birth,” most women experience some amount of pain when giving birth.  But, unlike most pain we experience in our lives, the pain of birth does not indicate injury.  It is “pain with a purpose.”  To embrace that idea has the power to increase a woman’s confidence while at the same time reducing her anxiety and fear, which in turn can reduce the amount of pain she experiences.  This is demonstrated by the testimonies of women who have had drug-free births, especially those who have chosen to give birth at home, away from even the possibility of pharmacological pain management.

I think the evidence for this assumption suggests that epidurals are not so much a necessity as they are a luxury.  A shift in a woman’s perspective can strongly influence her birth experience, as is shown in other countries where epidurals are available but less commonly used than in the United States.

“We have a secret in our culture,

and it’s not that birth is painful;

it’s that women are strong.”

— Laura Stavoe Harm