“Labor Induction: The Reasons for Caution are Many”
by Aryn Michelle Calhoun
First of all, let me clearly state that I acknowledge that I am not a doctor, nurse or midwife and I have never been to medical school. What I am is a mother and friend to mothers and soon-to-be mothers who is concerned. I may not be a certified medical professional, but I am a woman who has done a great deal of reading and research to carefully consider labor and birth in our culture. I’m not writing this post to offend anyone or frighten anyone who has had an artificially induced labor. I’m not trying to draw a line in the sand. I write this humbly in hopes to tell the truth about some conclusion that I’ve drawn, and these are opinions that are very hard to share with my friends when I know they may disagree or may be upset by what I say. If you would like to comment on or dialogue about this post, please read it in its entirety first so that you can fully understand my methods and motives.
The reason I’m writing this post is that I worry for my friends whose doctors may approach the topic of induction lightly and tell them that artificially induced labor carries little to no risks. I worry that these women and their babies may suffer complications as a result of medically unnecessary inductions. Let me also say at this point that I do believe induction may be necessary under specific circumstances. I believe it is a medical intervention that should be used only when absolutely necessary because of the risks that come with it.
The perception among women, caregivers, and hospital administrators is that induction of labor is convenient and cost-effective, and no one seems to be talking about the risks. If you are a mother considering having more children or a mother-to-be, I hope this post will give you information that you may have not yet encountered, and also give you confidence as you move forward in making birth decisions. I have included many quotes, all of which are notated at the very bottom (if you would like to read the books or websites these quotes have come from.)
Pregnancy is not a disease. I firmly believe that most labors can progress normally and naturally without medical interventions like induction. We need to learn to trust in our bodies and the beautiful design that God created. We have powerful, natural hormones that guide our bodies through the process of birth and these hormones work in a very intricately balanced feedback loop with all parts of our and our baby’s bodies. One of these key hormones is oxytocin, which stimulates contractions, dilates the cervix, moves the baby down and out of the body, and limits bleeding at the site of the placenta. We also have endorphins. These are calming, morphine-like, pain-relieving hormones that rise steadily and steeply during un-medicated labor. Disrupting these natural hormones with synthetic ones disturbs the way our bodies were meant to birth most safely and efficiently. Artificial induction disrupts this process.
First let me define what I have found to be considered “medically necessary induction” and “non-medically necessary induction.”
Medically necessary induction:
the risks of induction are outweighed by the risks of the current state of the pregnancy
• Maternal illness (high blood pressure, diabetes, uterine infection, etc.)
• Fetal illness
• Gestation lasting between 41 and 42 weeks and beyond (risk for aging placenta)
• Pre-labor rupture of membranes (broken water) after 37 weeks: Inducing labor may reduce the risk of infection or admission to the neonatal intensive care unit
Reasons doctors often suggest induction that are not proven to be medically necessary or improve birth outcomes:
risks to mother and baby do not outweigh the risks to waiting for labor to occur naturally
• Macrosomia (large baby)
• Convenience in scheduling for doctor or mother
• Oligohydramnios (Low amniotic fluid)
• Gestation between 40 and 41 weeks
• Intrauterine Growth Restriction before 37 weeks
I’d like to deal with each of these non-medical reasons one at a time, and then move on to exploring what risks are involved in labor induction. The following are reasons often used to justify artificial induction, although the research does not support that they are medically necessary or beneficial.
Macrosomia (large baby): Many doctors encourage women to induce labor because they fear the baby will be “large.” I believe the common fear is that if you wait for natural labor to begin, the baby may by then be too large, will be more likely to get “stuck,” and you will need a C-section. Research shows this is not true; what is true is that you are putting yourself at higher risk for C-section by artificially inducing. “The best evidence suggests that inducing labor when the baby is thought to be big increases the chance of cesarean section without improving outcomes for the baby. In addition, many babies delivered early because of concern about their size are born weighing considerably less than the caregivers had suspected. That’s because both ultrasound and hands-to-belly estimates of fetal weight are unreliable, and both methods are more likely to overestimate than underestimate the baby’s size. It’s also difficult to know whether a large baby will pose challenges during labor. Many women do not experience extra difficulty giving birth to larger babies.” (childbirthconnection.org) Again…“Research shows that inducing for “overdue” babies (before forty-two weeks) increases labor complication and cesareans without improving neo-natal outcomes. Unless you or your baby has a health problem that necessitates induction, it makes sense to wait patiently for labor to start on its own.” (OLG pg 107-108)
Convenience in scheduling for doctor or mother: Many mothers get uncomfortable in the last weeks of pregnancy (understandably so!) and ask their doctors to induce labor after 39 weeks. Please be aware that choosing to induce ALWAYS carries risks to yourself and your baby. Many of these risks include discomforts that will be much more severe than backaches and swollen feet. (I will discuss the risks of induction in the next portion of the post.) Some mothers also ask for induction because they would like to plan the beginning of their maternity leave or for other reasons of convenience. I honestly believe that if you acknowledge the risks associated with labor induction, this is a selfish choice that puts your unborn child at unnecessary risk. Doctors often suggest induction out of convenience for their own schedules. I believe this is also a selfish choice on the doctor’s part, and may come with some ulterior motives. “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.” (Pushed pg. 42)
Oligohydramnios (Low amniotic fluid): I have had several friends who have been told that they required a labor induction due to low amniotic fluid. This reason may seem controversial to some, because there are doctor’s who believe that low amniotic fluid is a serious medical issue. However, research does not support this belief in all cases (especially cases in which the pregnancy has reached full term) In a recent research study, “a single, small randomized controlled trial compared induction of labor with watching fetal wellbeing closely until 42 weeks for women with suspected low amniotic fluid at 41 weeks. The women were healthy and did not have other risk factors or complications. The study found no difference in maternal or newborn outcomes, but was too small to detect some important differences that may exist. No trials of induction for low fluid levels in women with otherwise healthy pregnancies at other gestational ages were found.” (childbirthconnection.org) It has also been shown that the mother’s amniotic fluid levels can change dramatically hour by hour, depending on when the sonogram is taken and how much fluid the mother is taking in.
Intrauterine Growth Restriction before 37 weeks: IGR basically means that the baby is having a growth restriction inside the uterus. This is usually determined in an ultrasound where parts of the baby are measured and compared to normal ranges for the gestational age. Some doctors will convince mothers to induce labor prior to 37 weeks because of IGR, however, inducing labor before 37 weeks is very risky for a baby because most are not fully developed and able to breathe on their own at this point. “A large, multi-center randomized controlled trial of over 1000 women with growth-restricted fetuses between 24 and 36 weeks and abnormal Doppler artery blood flow studies showed that induction increased the likelihood of c-section. In addition, babies born before 31 weeks in the induction group were more likely to have severe disabilities at 2 years of age than babies born before 31 weeks in the await labor group.” (childbirthconnection.org)
Now that we have discussed the reasons most often given or induction, I would like to explore risks associated with labor induction. Again, let me emphasize I’m not writing this post to scare anyone, I just hope that knowledge will give you power to make informed decisions. I will explore each risk in detail after the list of possible complications.
Risks associated with induction of labor:
• The baby’s lungs may not be fully mature
• More pain for mother (Pitocin contractions are stronger and more frequent than natural contractions)
• More likely for mother to require an epidural
• Hyperstimulation of the uterus (which can lead to fetal distress)
• More likely to cause a previous uterine scar to rupture
• Hypertonic uterus (restricts blood flow to baby)
• Requires mother to be immobilized (attached to IV) which can make labor longer and more painful
• Increases risk of other medical interventions including episiotomy, vacuum extraction, need for Electronic Fetal Monitoring, epidural and cesarean section
• More likely for labor to end in C-section, especially in first time mothers
• May cause breastfeeding trouble for baby
• Disrupts natural hormone release (hormones necessary for mother’s quick recovery and baby’s alertness)
• Can result in neonatal intensive care admission and can increase the length of the hospital stay and the overall cost of care
I think the most important thing to consider when contemplating an elective induction, is to remember that labor starts naturally because the baby sends a signal to the mother’s body that it is fully mature. If you are inducing labor, the baby has not yet sent this signal, and therefore, may not be fully ready for life outside the womb. “In particular, the baby gives a signal when its lungs are mature. For a baby to born implies that the lungs are ready, because to be born is to breathe. When you induce labor, or when you do an elective cesarean section with no labor, the baby has not given the signal. The baby has not said, “I am ready, I am mature.” In other words, induced labor is preterm labor.” (Pushed pg. 140)
Doctors often use the drug Pitocin to induce or augment labor. Pitocin is a synthetic form of oxytocin, a hormone that causes contractions of the uterus, and it is usually given as an intravenous drip. Many women do not realize that induced contractions via the drug Pitocin do not feel the same as natural contractions. Pitocin contractions last longer, come quicker and are generally considered to be more painful than natural contractions. Most women when faced with Pitocin contractions feel like they have no choice but to accept an epidural. “An induced labor is riskier than one that begins on its own. Not only is it more painful-Pitocin causes fierce contractions-induction is more likely to lead to fetal distress [and] more likely to require pain relief.” (Birth p.178) Again, “An induced labor is often fast and furious, so it is more painful than one that starts naturally.” (BYW pg. 23) Pitocin induced contractions augmented by an epidural can lead to problems for the baby. “[When a natural] labor progresses, the contractions become stronger and more frequent, culminating in the “ejection reflex”…Pitocin has no such intelligence. And with an epidural deadening the bodies natural pain threshold, staff can keep upping the dose, which can lead to contractions that fire like a machine gun or that last for minutes, during which time the fetus is oxygen deprived. This is called hyperstimulation (of the uterus).” (Pushed p.137)
In half of all cases of hyperstimulation, the fetal heart rate drops below what is considered normal, and if it stays there, it is considered fetal distress. Fetal distress of this kind may include fetal hypoxia, which is oxygen deprivation. You will most likely end up with a c-section if it is determined that your baby is in fetal distress. Plainly stated, the baby is at risk when its heart rate is lowered, and Pitocin puts your baby more at risk for this complication. Hyperstimulation of the uterus can also cause problems for the mother. “Hyperstimulation of the uterus sometimes results in uterine rupture.” (BYW pg.23-24) A uterine rupture is a rare, but life-threatening complication. Again it is noted that induced labor is“…more likely to cause a previous uterine scar to rupture.” (Birth pg. 178)
If you have an induced labor, you will most likely be hooked up to an IV for the Pitocin. If you receive a Pitocin IV, most hospitals will require that you also be hooked up to a continuous EFM (electronic fetal monitor). There are also risks associated with using an EFM that most doctors won’t tell you about. An electronic fetal monitor is just a simple machine that monitors the fetal heart rate, and the machine itself poses no risk to the baby. However, what makes EFM machines risky is that often times they are wrong or can be interpreted incorrectly. “Evidence shows no difference in outcomes for babies and a higher rate of cesareans and operative vaginal deliveries for mothers with continuous EFM. Why? It’s difficult to interpret EFM printouts. Misread printouts lead to mistaken conclusions, and caregivers often intervene unnecessarily when labor is actually progressing normally and baby is doing fine. In other words: for most labors, more intensive monitoring increases obstetric intervention (and risk) with no clear benefits for babies.” (OLG pg. 117) Being hooked up to a machine can also hinder your labor progress physically and emotionally. “The use of most monitors means that the mother must stay in one place…this immobilization causes unnecessary pain and may slow down contractions and make them weaker so that dilation is slower. Attention turns to the electronic equipment rather than being focused on the woman’s needs, and she loses emotional support. In most hospitals the introduction of electronic fetal monitoring immediately pushes the cesarean section rate up at least threefold.” (BYW p. 27-29)
So, induced labors typically tend to involved Pitocin and EFM, both of which lead to increased discomfort in their own way. Pitocin is making your contractions stronger, longer and more painful, EFM is augmenting the pain by prohibiting you from moving, and the stress and fear of machines and wires and IVs and a hospital room work together to give many mother’s unbearable pain. This mounting pain usually leads women to request an epidural. Receiving an epidural will most times give you instant physical pain relief, but it carries with it its own risks and leads to increased likelihood of further medical interventions. Epidural drugs will work against Pitocin, so most women who receive an epidural will continue to have their labor augmented by more and more Pitocin to keep their contractions strong. Women receiving epidurals are, “more likely to have their blood pressure drop; develop a fever; and have difficulty passing urine, and so are regularly catheterized. Being unable to feel from the waist down makes pushing difficult, and there is a greater risk of needing forceps or a vacuum to complete the job. Though [some] research has shown that epidurals do not raise the likelihood of a cesarean, there is controversy surrounding the issue. One study has shown that epidurals increase the likelihood of the baby presenting in the posterior position-in other words, not fully rotated. Such a presentation does lead to higher cesarean rates.” (Birth pg. 100-101) Some experts take it a step further and assert that epidurals DO increase your risk of cesarean. “There’s some evidence…that epidural use-especially by first time mothers- increases the risk of cesarean.” (OLG pg. 119)
While on a brief epidural tangent, I would also like to submit research showing that epidurals usually lead to more physical harm to the mother and postpartum stress on the baby. Medicating the pain away disrupts the natural progression and built in feedback loops of labor in your body. As to the effects on the laboring mother…“When women are routinely not able to feel the pain and respond to it- to move their bodies- they are more vulnerable to injury…When we’ve got a baby that rams through because its mother doesn’t feel anything, we’re increasing the risk of damage to her pelvis, to her vagina, and to her pelvic floor. And we don’t know whether we’re increasing risk to this baby. We’ve taken a hugely protective part of physiology and gotten rid of it.” (Pushed pg. 173-174) Epidural drugs can also have a negative effect on newborns. “In one recent study 11% of all the babies whose mothers had epidurals showed “profound” and “prolonged” heart rate changes…epidural anesthesia given to the mother results in an indirect but serious complication for some infants. These are babies whose mothers get a fever as a side effect of the epidural. Because infection is a serious threat to a newborn, it is generally hospital policy to put these babies in a high-risk nursery for three days. During this time they undergo painful procedures and are put on strong antibiotics.” (ID2 pg. 8)
Induced labor, EFM and epidural will leave you bed ridden and ultimately immobile. “Being immobilized makes it more likely that dilation is slow, and so the drip is turned up and more artificial oxytocin is fed into a woman’s bloodstream.” (BYW pg 23-24) Immobilization means longer labor, more discomfort and the need for more drugs being pumped into your body. Being restricted to a bed will force you to labor and birth in the “supine” position. Laboring and birthing flat on your back in this position puts you at greater risk for bodily harm. “Today more than 70 percent of American women give birth in supine positions (lying on their backs) They’re encouraged to give birth this way even though research shows its harmful. Lying on the back can lower a laboring woman’s blood pressure, and the weight of her uterus on major blood vessels can reduce blood flow to her baby…Studies show that pushing in upright postures shortens the pushing stage and decreases incidence of severe maternal pain and abnormal fetal heart rate.” (OLG pg.121) Likewise, birthing in a position that is not flat on your back can decrease risk of injury and increase efficiency of labor. “Infants born to mothers in non-supine positions were delivered with significantly less tearing of the perineum.” (jaoa.org) “When you walk or move around in labor, your uterus, a muscle, works more efficiently (Roberts, Mendez-Bauer, & Wodell (1983). Changing position frequently moves the bones of the pelvis to help the baby find the best fit, while upright positions use gravity to help bring the baby down the birth canal (Simkin & Ancheta, 2005). The diameter of the pelvic inlet and outlet can increase as a woman moves around in labor. When labor slows, a change in position often will help you “find your rhythm” again.” (Lamaze International)
Up to this point I have been primarily focused on induction associated with Pitocin. However, some doctors will first rupture the amniotic membranes to induce labor. In this procedure, a sterile, plastic, thin hook is brushed against the membranes just inside the cervix causing the baby’s head to move down against the cervix, which usually causes the contractions to become stronger. Rupturing the membranes artificially also carries risks. “If the baby’s head is not down and membranes are ruptured artificially the first rush of amniotic fluid may bring the cord down and deprive the baby of oxygen, and rupture of membranes can cause infection.” (BYW pg. 23-24) “When your membranes are broken manually, both you and your baby are exposed to greater risk of pressure injury as well as greater risk of infection. Research also shows an increase in cesareans with early rupture of membranes…A systematic review of the research suggests that only women with truly abnormal labor progress should have their water broken, and that only women with truly prolonged labors and sluggish uterine activity should receive Pitocin. Neither intervention should be used routinely.” (OLG pg.118)
It’s a fact: “Induction [by either method] does not always work. Failed induction leads to cesarean section.” (BYW pg. 23) And furthermore, “women having their first baby are more likely to have induction lead to a cesarean section than women who have already given birth vaginally.” (childbirthconnection.org) The midwife Gail Hart notes, “We can make a woman have contractions, but we don’t always succeed in forcing her body to release the baby and give birth. If we start a labor with chemicals, we may very well have to finish it with a surgeon’s scalpel.” (Pushed pg. 14) If you choose a labor induction there is no do-over. It’s either going to work or it’s going to end in c-section. Your body and your baby must be ready to birth. “If the cervix has not already begun to thin out and dilate (“ripen”) or if the baby has not settled low in the pelvis, induction is more likely to lead to a cesarean.” (childbirthconnection.org) If your body or your baby is not ready, you will have to undergo major abdominal surgery that carries with it even greater risks than induction. Putting yourself at risk for a C-section is no matter to consider lightly. Complications associated with C-sections include: infection, hemorrhage, injury to organs, adhesions, extended hospital stay, extended recovery time, risk of infertility problems, the necessity of continuing to have C-sections for subsequent births, increased maternal mortality, premature birth, breathing problems for baby, low APGAR score for baby, and fetal injury. (A thorough discussion of C-sections would require an entirely separate post with much more research presented. I only mention c-sections here because of the way in which they are linked to artificial induction.)
Finally, research shows that, “labor induction alters not only the process of labor and birth, but also postpartum events. Pitocin doesn’t cross the blood-brain barrier, so your brain doesn’t get the message (as it would with natural oxytocin) to release endorphins. Pitocin short circuits your natural hormone release, so neither you nor your baby experience the catecholamine surge necessary for energy and alertness after birth. Your baby is less likely to crawl to your breast and latch on and is less likely to make the head and hand movements on your chest that stimulate continued oxytocin release, which controls bleeding and helps your milk let down…Your baby may have trouble breastfeeding and is three times more likely to die in the first year of life than a full term baby. (OLG pg 107-108)
So, what can we do armed with the knowledge that labor induction does indeed pose legitimate risks? If you choose to have your birth in a hospital, I strongly encourage you to look into hiring a doula. Doulas are knowledgeable birth advocates who will stay by your side through the entire labor and delivery, will explain benefits and risks of all interventions presented, and will fight for the birth that you desire. Also, I provided here a link with some helpful tips from childbirthconnection.org on how to lower your chances of being artificially induced: http://www.childbirthconnection.org/article.asp?ck=10653
Anyone who has ever had a baby knows that things don’t always go as you planned. But in the midst of the unpredictable nature of labor and birth, it’s always best to be confident in yourself and the decisions you have made before the blessed event arrives. We must take charge of our bodies and our pregnancies and not rely on blind faith that everyone else involved in birthing babies always has our best interests in mind. “For the most part, drugs simply are used as they have been ever since women were brought into modern hospitals for childbirth: they are used to replace human caring and support. They make it possible for administrators to staff maternity units so that nurses can care for three or four patients at a time, and for physicians to continue on with their office hours or their nighttime sleep while their patients labor somewhere else.” (ID2 pg. 78) We must no longer make birth decisions out of convenience, out of lack of knowledge, or out of a culture of fear. “What’s best for women is best for babies. And what’s best for women and babies in minimally invasive births that are physically, emotionally, and socially supported. This is not the experience that most women have. In an age of evidence-based medicine, women need to know that standard American maternity care is not [always] primarily driven by the health and well-being of their babies. Care is constrained and determined by liability and financial concerns, by a provider’s licensing regulations and malpractice insurer. The evidence often has nothing to do with it.” (Pushed pg. 271)
To make an informed decision about induction of labor, we need to consider whether it is more likely to help or harm our babies and ourselves. Induction is an important option for high-risk pregnancies, and should be discussed with your doctor. We must remember that induction carries with it the risk of complications and sometimes fails resulting in a C-section. I’m not writing this post out of judgment, or to make anyone feel guilty, angry or afraid. Many of my friends have had induced births and scheduled C-sections without any complications that I’m aware of, and they reflect on their birth experiences as happy ones with positive outcomes for everyone involved. I am not attempting to belittle their wonderful stories and experiences. However, these may not be the outcomes for everyone, every time and my concern is that as things stand now, induction and all the things that go along with it have become so commonplace that they appear to be without risk. Scientific research shows that induction does carry risks. These risks are not only physical, but as we have seen extend to the psychological — the choice of artificial induction can have a significant effect on how a mother relates to her baby and her birth experience.
I know that commenting on other people’s choices for birth is a very touchy subject and can be cause for offense, which is a big reason why I often hold my tongue. Please know it is never my intention to offend. I just want the people I love and care about to have the freedom to make more informed decisions and continue to have the best possible birth experiences. I hope you know that I have chosen all of these words carefully and out of love and concern for my friends and all mothers and mothers-to-be, and I want you to be safe and well. I would love to have a conversation with you if anything I’ve said causes you to doubt my love and respect for you. Please feel free to email or call me if you want to talk more.
With all my love,
Quotes taken from the following books and abbreviated as follows:
(Birth) “Birth: The Surprising History of How We are Born” by Tina Cassidy
(Pushed) “Pushed” by Jennifer Block
(GMO) “Get Me Out: A History of childbirth from the Garden of Eden to the sperm bank” by Randi Hutter Epstein
(BYW) “Birth Your Way” by Sheila Kitzinger
(OLG) The Official Lamaze Guide
(ID2) “Immaculate Deception II” by Suzanne Arms
jaoa.org (Journal of the American Osteopathic Association)