The Evidence Says: The Case Against Elective Inductions

(Part 1 will focus on the generalities of Induction. Part 2 will focus on the controversial methods of induction and the international recommendations)

Today, more and more women are opting to induce labor rather than waiting for labor to begin on its own. Although there are numerous reasons why induction is and should be considered for the health of the mom and/or the baby, often labor is induced for other reasons.

Sometimes these reasons are questionable based on the recommended criteria for induction by ACOG (American College of Obstetrics and Gynecologists).

According to ACOG, the reasons for induction include:

*abruptio placenta (placenta prematurely detaches from the uterus),
*premature rupture of membranes,
*severe preeclampsia,
*pregnancy-induced hypertension (PIH),
*intrauterine growth retardation (IUGR)-fetus not growing or thriving, oligohydramnios or polyhydramnios--too little or too much amniotic fluid
*fetal anomalies requiring intervention,
*fetal demise,
*maternal diabetes or heart disease,
*prolonged pregnancy

In general, induction is suggested when delivering the baby is safer for the mom and/or the baby than continuing with the pregnancy. In other words, it is riskier to stay pregnant than it is to assume the risks involved with induction.

Other Reasons for Inductions
Although several of the medical conditions stated above are typically straight-forward and necessitate a prompt delivery, conditions such as a prolonged pregnancy are more difficult to accurately predict. Caregivers use a gestational wheel to determine the EDC or "due date" of the baby. This method assumes that all women cycle the same. The reality, however, is cycles vary as much as a couple of weeks from woman to woman. Usually a more accurate measurement is two weeks plus or minus the due date. Therefore, a woman who carries to 42 weeks may not be "overdue." Unfortunately, many caregivers and pregnant women simply look at 38 or 39 weeks gestation as the date when they feel a baby can safely be born. If the dates are not correct and they choose to induce, the baby may actually be born premature. This, in part, may be a culprit in fueling the high premature birth rate/ late preterm rate in the U.S.

A common concern for a pregnant woman is the size of the baby and whether she will be capable of delivering a large baby. Women seem to be scared to deliver a large baby and may decide to induce rather than risk waiting. For a caregiver who prefers to induce his/her patients, concern for size is widely used as the reason for inducing. If the caregiver voices concern for the size, the patient, more than likely, will also be concerned and feel it is necessary to induce. However, even with the advancement in technology, we cannot be certain of the size of the baby until birth. In fact, ultrasounds systematically overestimate birth weight (Pollack).

Furthermore, a large baby doesn't automatically mean a woman isn't capable of delivering the baby vaginally. A nine pound baby for one woman may be too large, yet for another it may be the "normal" size for her. Some women give birth to large babies with little or no difficulties. Besides, women often choose to induce because they want to avoid a cesarean delivery due to the size of the baby. The reality is if they induce when their body isn't favorable for an induction, they may end up with a cesarean-the very thing they were trying to avoid. In addition, the infant mortality rates do not improve with an early delivery. In one study of postdate pregnancy and fetal size, perinatal mortality rates were examined. Perinatal mortality rates increased six-fold in infants weighing less than 2800g compared to heavier babies. Overall, the study showed no increase in infant mortality rates for up to 44 weeks gestation (Sachs).

Scheduling seems to be a very common reason for induction. Perhaps the baby is due on or near another relative's birthday and the parents want this baby to have his "own" birthday. Maybe the parents want to schedule the birthday to coincide with the arrival of out-of-town relatives or guests. Perhaps the woman has to return to work after six weeks of leave and she wants as much time off with the baby as possible. Or, the woman is just "tired of being pregnant" and wants to get to get on with the labor. On the other side of the coin is the caregiver. It is much nicer for the caregiver to know when their patient will be in the hospital so as to minimize conflicts with their other patients or in their personal life. In fact, the caregiver can even choose the hour of induction to coincide with his/her schedule and sleep. Also, the caregiver can plan vacation time around the scheduled delivery dates. Clearly not all caregivers would choose to encourage a woman to get induced based on his/her schedule, however this is certainly not unrealistic.

Questions to Ask Prior to Induction
When deciding on whether to be induced, a woman should also take into account the typical policies and procedures of her caregiver and the hospital with regards to inductions. The following is a list of questions to ask your caregiver and hospital:

*What is my Bishop Score? This is perhaps the most important question to ask. Become familiar with the chart and make sure your body is ready to be induced. Unless the baby or you are in danger, consider waiting until your cervix is more favorable. Again, fear of a large baby is not always the best reason to induce.
*What is the timing?
*When will I go to the hospital, when will I get prostaglandin gel, Pitocin, or my water broken? Many doctors will have a woman go to the hospital in the evening and start prostaglandin gel right away, then at midnight start Pitocin and break the water sometime in the middle of the night. This scenario clearly benefits the doctor and not the mother, yet is used quite frequently. The woman is then forced to work with labor in the middle of the night when she would normally be sleeping. This is extremely difficult to handle.
*What are my limitations?
*Will I be able to walk, take a shower, labor in a tub, sit on a birth ball, eat light foods, drink, etc.
*Will I need continuous electronic fetal monitoring?
*Can we discontinue the induction if things aren't progressing? At what point?
*How long will I be able to labor before a cesarean delivery becomes necessary?

Conclusion
Each woman's body is on a different time clock and we do not have a method for determining when a woman is ready to give birth. With her body and baby working in harmony, labor usually will begin on its own and at the appropriate time for both mom and the baby. In our society we want everything to be planned and organized. Unfortunately, nature doesn't always work that way. Some things in life cannot or shouldn't be planned; otherwise we open ourselves to potential risks for both mom and baby. According to ACOG, an induction is necessary when the potential risks to mom and baby with birth are less than the risks of carrying on with the pregnancy. Planning a birthday, working around vacation time, or simply being "sick of being pregnant" do not qualify as being risks to the pregnancy.

Therefore, choosing to induce for scheduling purposes is not an appropriate reason and may, in turn, do more harm than good. When choosing to induce, consider all your options, weigh them carefully, and make sure the induction is for all the right reasons-the health and well-being of mom and baby.

References:

Practice Bulletin #107, "Induction of Labor," is published in the August 2009 issue of Obstetrics & Gynecology.

Caughey et al. Maternal and neonatal outcomes of elective induction of labor. Evidence Report Technology Assessment. 2009 March; (176) 1-257.

Pollack RN, Hauer-Pollack G, and Divon MY. Macrosomia in postdates pregnancies: the accuracy of routine ultrasonographic screeing. Am J Obstet Gynecol 1992; 167(1): 7-11.

Reisner et al. Reduction of elective inductions in a large community hospital. American Journal of OB/GYN. 2009 June; 200(6): 674

Sachs BP and Friedman EA. Results of an epidemiologic study of postdate pregnancy. Journal of Reproductive Medicine 1986; 31(3): 162-166.

Lowdermilk and Perry. Maternity& Womens Health Care. Mosby Publishing. 2007.