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!

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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!


Evidence-Based Medicine: Are Epidurals Safe?

The next underlying assumption about epidural use is that it is safe, and judging by some women’s sentiments, free of consequences.  Let’s explore what our sources have to say.

Assumption #2: Epidurals are safe.

First, what does “safe” mean?  This is a very subjective term, meaning different things to different people.  To some women, “safe” would mean completely free from consequence.  To others, simply safer than the other available options.  Lastly, it could mean that the benefits outweigh the cost. So according to each standard, how do epidurals stand up?

Free From Consequence?

Last week, we learned that epidurals can interfere with the natural hormones of labor, therefore impeding its progress.  So what is the risk to a laboring woman if her labor is slowed?  In simple terms, a “cascade” of interventions could ensue.

Epidurals are renowned for slowing down labor, which could mean your labor might be augmented with something like Pitocin (artificial oxytocin).  Augmentation carries it’s own risks, which we will discuss in later segments.  According to Marsden Wagner (former director of Women & Children’s Health at the World Health Organization),  longer second (pushing) stage of labor means a woman has a four times higher risk of a forceps or vacuum assisted delivery, and at least a two times greater risk of a C-Section.  This is partially because the epidural block effects the mechanisms that rotate the baby into the proper position for delivery.

Additional risks to the mother include:

  • Drop in Blood Pressure (both mother and baby)
  • Itching
  • Higher risk of Infection
  • Fever (15-20%) — this could lead to some invasive diagnostic tests of both the mother and baby
  • Temporary (1 in 500) or even Permanent Paralysis (1 in 500,000)
  • Urinary Retention (inability to urinate) (15-35%) — could require a catheter
  • Severe Back Pain from Birth (30-40%) up to a Year (20%)
  • Spinal Headache (2%)
  • Death (1 in 5,000)

According to Wagner, approximately 23% of women will experience some complication associated with their epidural.  That’s nearly 1 out of 4 women!  And while many women may be willing to put themselves at risk for the good of their baby, very few are willing to put their baby at risk for their own personal comfort.

Risks to the baby include:

  • slowed fetal heart rate (75%), a symptom of fetal distress
  • poor neurological function at 1 month
  • increased risk of breathing difficulties
  • increased risk of breastfeeding difficulties

Even if this is only a partial list, clearly epidurals are not free from all risk, just like any other choice you make.  So, the next question becomes: Is it worth it?  (the risk, that is…)

Is an epidural safer than the alternative?

So, if an epidural provides any benefit to the mother and baby over drug-free birth, it could be considered “safer” than the alternative.

There are in fact, some situations where an epidural is beneficial to the woman — for example if she has had a long or difficult labor, it may allow the mother to rest so she has the energy to push.  Recent studies suggest that receiving an epidural during labor may even help preserve a woman’s pelvic floor muscles (you know, the ones that keep you from peeing yourself).  Other women claim that their freedom from pain made their experience more enjoyable or less traumatic, so there may be a perceived psychological benefit as well.

But, it could still be argued, since all of the aforementioned risks of getting an epidural are not present when having a drug-free birth, that an epidural, while it may provide psychological benefit, does put you at a marginally higher risk of complications.  Therefore, if your definition of “safe” is that it’s safer than the alternative, an epidural is not “safe.”

So, is an epidural safer than other pain management strategies?

Hospitals, in almost every arena, are renown for turning to medicine to solve every condition.  Labor and birth are no different.  Men and women become doctors and nurses, at least in part, because they have faith in the way medicine and surgery work.  They have faith in technology.  It logically follows that medical solutions are in the forefront of their minds when presented with a problem.  Sometimes, however, there are non-medical or non-surgical methods that provide the same benefits to the patient, but with fewer side effects.

Women who choose drug-free birth aren’t just martyrs, masochists, or thrill seekers.  It’s not that they enjoy pain, regardless of what other people might assume.  When they go into labor, they have a plan for reducing pain just like every other laboring woman — they’ve just taken the epidural off the table as an option.  So what kinds of methods do they use?

  • Hot water — baths, showers, birth tubs
  • Movement — walking, dancing, yoga balls
  • TENS (trans-cutaneous electronic nerve stimulation)
  • Hypnosis
  • Acupuncture
  • Continuous one-on-one attendance

All of these methods have been proven to be effective pain management, with no side effects to mother or baby.  In fact, freedom of movement is one of the oldest methods to manage labor pain, and has been demonstrated throughout history to not only relieve pain but to also properly position the baby for birth.  Many women may feel the urge to get up and move if allowed to labor naturally.

Finally —

Is it worth it to take a risk on the epidural in order to avoid the pain?

The only person who can answer this question is the woman herself.  As the evidence suggests, one out of four women will experience some sort of complication with her epidural.  But that means that 3 out of 4 women don’t.  Some women might consider that pretty good odds.  Perhaps the biggest threat is not the side effects of the epidural, but the so called “cascade of interventions” that could ensue, leading to a loss of control over the birth experience.  Then, it’s not only the side effects of the epidural she needs to think about, but the possible augmentation drugs, the forceps, the vacuum, or even the c-section.  And when you consider that there are other, risk free options available, the pharmacological option may seem a little bit less appealing.  1 out of 4 may sound like “good” odds, but 0 out of 4 is even better, no?

Another issue to consider with epidurals is what to do if you are one of the unfortunate few whose epidural wears off.  I’ve come across a few testimonials where a woman went into labor intending an epidural, and the medicine wore off right before she was pushing. I can only imagine how caught off-guard and unprepared for the pain she must have been, and how scary that would be.  It got me to thinking that, if I were a woman going into labor with an epidural, it might be to my benefit to research some “back-up” strategies…you know, just in case.

Since many women experience complications with their epidurals, it would be to the benefit of the hospital and its patients to educate women on natural pain strategies, and to implement them more frequently, rather than jumping right to an epidural.  Like I said above, I highly doubt woman would knowingly put herself, and especially her baby, at risk.  I’m sure many women would be interested to at least try more drug-free options, and then if those are ineffective, the epidural is still available.  Or, if she is in the unfortunate position of having a negative reaction to the epidural, she could feel more prepared to handle her labor pains.

At this point, many women aren’t even made aware they have other options, and that is a failure of the system.  All the more reason to educate yourselves, ladies.  After all, you’re more motivated to do what’s best for you and your baby more than anyone else.

Mentioned in this entry:


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