Monday, August 31, 2009

The Evidence Says: Inductions

Induction of labor has become a highly controversial topic for the last…51 years.

Most obstetrical and nursing books will site the following as potential clinical indications for induction:

  • 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,

  • postterm pregnancy

The American College of Obstetricians & Gynecologists released Practice Bulletin No. 107 in August: Induction of Labor. In this practice bulletin, it also states that labor may be “induced for logistic reasons, for example, risk of rapid labor, distance from hospital, or psychosocial indications.In such circumstances, at least one of the gestational age criteria in the box should be met or fetal lung maturity should be established. A mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery.”

In such circumstances, at least one gestational age criteria in the box should be met…should…not must….should.

Lacking is the definition of logistical or psychosocial indications for induction. 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.

In the March 2009 issue of Evidence Report/Technology Assessment (Maternal and neonatal outcomes of elective induction of labor by Caughey et al), the conclusion was drawn that the evidence regarding elective induction of labor prior to 41 weeks of gestation is insufficient to draw any conclusion. Further, in the Annuls of Internal Medicine August 2009 (Systemic review: elective induction of labor versus expectant management of pregnancy), RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. Again, 41 weeks and not 39 weeks.

A woman's body goes through a series of preparatory steps prior to beginning labor. As the diagram below indicates, both the fetus and the mother seem to work together in determining when labor will begin. In order for an induction to be successful, oxytocin receptors must be in abundance on the uterus for the oxytocin to bind and produce contractions. That may explain why a woman who is brought into the hospital for induction, may not respond to the Pitocin given to her. Unless her uterus is ready to accept the Pitocin (oxytocin), the induction may not work.

There is a scoring system physicians should use which identifies those women who most likely will respond to an induction. This is known as the Bishop Score (refer to the chart on our website). Women who score relatively high (8-9) will have a greater chance of the induction taking. For a woman with a cervix that is not dilated, effaced, softened, or anterior will likely have a long, difficult labor, often ending in a cesarean delivery. Unfortunately, many doctors are ignoring this assessment and going ahead with an induction which may not be medically necessary.

Methods of induction include cervical ripening agents, stripping of membranes (similar to loosening the edible portion of an orange from the peel to stimulate production of prostaglandin hormones) , artificial rupture of membranes, nipple stimulation , laminaria tents (a mechanical opening of the cervix with seaweed) , Foley catheter (a mechanical forcing of the cervix with a catheter used typically for draining the urine from the bladder), Pitocin (a synthetic derivative of the naturally occurring hormone oxytocin but lacking several important properties), and Cytotec (also known as misoprostol – a medication not FDA approved for use during pregnancy or labor, and has been termed an abortifacient.

The introduction of the practice bulletin states “the purpose of this document is to review current methods for cervical ripening and induction of labor and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research.” Unfortunately, over 50% (50 out of 90) references given at the end of the Practice Bulletin are over 10 years old. The cry still goes out for best practice guides, and evidence-based practice. Perhaps the definition of “best practice” and “evidence-based practice” should also include words such as “current”.

Regretfully, no where in the practice bulletin or nearly any research observed for this blog is any consideration given to the mother (her emotional state, physical state, pain levels, etc) or the newborn beyond the word “outcome”.

Absent are concerns for the newborn’s ability to bond, breastfeed or withstand the mechanical management of labor.

For inductions and maternity care, we have witnessed a gigantic step backwards.

Sunday, August 23, 2009

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Reducing Infant Mortality from Debby Takikawa on Vimeo.

Wednesday, August 19, 2009

The Sheer Power of A Mother's Love & Skin to Skin

Many of us who are also mothers have known instinctually all of our lives the immense power of a mother's love and the power of bare baby skin to bare mother-chest skin. Of course, as always, I could include a plethora of evidence in the research to support it.

But everything I could write would pale in comparison to this story.

Click here and be prepared to be inspired, energized, and well, validated!

Monday, August 17, 2009

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?


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.


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.

Thursday, August 13, 2009

The Evidence Says: Epidurals Do Impact Newborns

There are many controversies in maternity care. The spectrum of debates run to both ends of the spectrum: from those who feel all women should have interventionized maternity care to the home birth advocates. However, one of the most controversial topics in care is epidural anesthesia.

Fueling the flame of the epidural controversy are the diametrically opposite positions published in anesthesia journals vs. those in other medical journals such as nursing, midwifery and family practice.

In most hospitals, laboring women who have received epidural anesthesia are confined to bed as they no longer can rely on their legs for stability. This may severely limit movement and positioning. Additionally, hospitals may have a policy that all laboring women receiving medication, specifically epidural anesthesia, have an internal fetal heart monitor in place. This requires breaking of the amniotic sac or membranes in a procedure known as amniotomy. Occasionally, it may be necessary to augment or stimulate a labor with Pitocin after an epidural has been given, as epidurals have been shown to slow some women's labors – making the labor longer and harder on the woman’s body (Mayberry, L.J., Clemmens, D., De, A. Epidural analgesia side effects, co-interventions, and care of women during childbirth: a systematic review. American Journal of Obstetrics & Gynecology. 2002 May;186(5 Suppl Nature):S81-93.

Researchers have linked epidural anesthesia to assisted delivery, or the use of forceps or vacuum extraction during the pushing portion of labor (Torvaldsen, S., Roberts, C.L., Bell, J.C., Raynes-Greenow, C.H. Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database Systematic Review. 2004 Oct 18;(4):CD004457.). Researchers also find that 88% of women who requested an epidural for pain in one study reported being less satisfied with their childbirth experience than those who did not, despite lower pain intensity. Pre-labor survey results suggest that concerns about epidurals and their effect on the baby, greater than anticipated labor pain, perceived failure of requesting an epidural, and longer duration of labor may have accounted for these findings.( Kannan, S., Jamison, R.N., Datta, S. Maternal satisfaction and pain control in women electing natural childbirth. Regional Anesthesia and Pain Medicine. 2001 Sep-Oct;26(5):468-72.

Epidural anesthesia also causes a drop in maternal blood pressure, thus the need for 1000 ml of IV fluids administered prior/during the administration of the anesthesia.

For the newborn, the effects of epidural anesthesia are more hazardous. Women who have epidurals are less likely to fully breastfeed in the first few days and are more likely to stop breastfeeding in the first 24 weeks due to the difficulty newborns have in coordinating sucking and latching. (Torvaldsen, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal 2006 Dec 11; 1:24. Oxytocin and prolactin stimulate milk ejection and milk production during breastfeeding. When used in combination during the labor process, which happens frequently, epidural anesthesia and pitocin influenced endogenous oxytocin levels negatively ~ thus negatively impacting both milk ejection and milk production. Jonas et al. Effects of intrapartum oxytocin administration and epidural analgesia on the concentration of plasma oxytocin and prolactin in response to suckling during the second day postpartum. Breastfeeding Medicine 2009 June; 4(2): 71-82.

Countless other studies including the Journal of the American Board of Family Medicine and Dr. Sarah Buckley all focus on the hazardous impact of epidurals on breastfeeding and the newborn.

This evidence may be an inconvenient truth.

Tuesday, August 11, 2009

Outrageous? You tell me!


Who doesn't like to play? There are brooms, vacuums and sweepers for girls, along with Easy Bake Ovens, Barbies, Girl Gourmet! Cupcake Makers, and Hannah Montana Malibu Beach Houses. For boys, there are guns, tanks, night vision goggles, grotesque monsters and aliens, and Spike the Ultra Dinosaur who eats boulders.

But no new toy has gotten so much attention or outraged so many than bebe Gloton. Perhaps some of the outrage is due to (a) the fact that it comes from a company that wants to promote breastfeeding or (b) the way that the translation of Gloton has gone from greedy to overeating. Having researched the various meanings of the glutton in the American dictionary and knowing the desires of this company to promote breastfeeding, I feel their translation is more of "a person with a great desire or capacity for something" ~ if you have ever seen a breastfeeding baby, this definition fits!

One blogger stated that they were very pro-breastfeeding but that it was completely inappropriate to allow girls to mimic it. Mmm, it is ok for boys to mimic murder, war, and violence but not ok for girls to mimic a perfectly normal body function THAT THEY DON'T NEED A SPECIAL DOLL TO DO ANYWAY!? Oh, and as one female television host said, she'd rather have her daughter own a doll that has a BM than a doll that breastfeeds.

What does she think the origin of that poop is anyway?

Breastfeeding is not a sexual experience, it is an experience of nutrition and health. It is the normal way that all mammals feed their young. Some critics say that this baby doll is not age it is ok for a disproportionate Barbie to be the role model for little girls?

You decide:

Saturday, August 01, 2009

The Evidence Says: Upright Positions Enhance Labor!

Women in industrialized countries are lead to believe that laboring is such difficult work that they should stay in bed and rest. Also, since their center of gravity is off and certain contraction may take them off guard, the chance of falling is present. Staying in or near the labor bed also makes coping with an IV and electronic fetal monitoring (EFM) easier. With regards to the EFM, tracings from the monitor are of better quality when the laboring woman is not only in the bed, but also somewhat still. Finally, vaginal exams are easier for the careprovider to perform and the vaginal more visible when the laboring woman is laying on her back.

However, a Cochrane Database Review (April 15, 2009) studied the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labor on length of labor, type of delivery and other important outcomes for mothers and babies. The review includes 21 studies with a total of 3706 women.

There is now evidence that walking and upright positions in the first stage of labor reduce the length of labor and do not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. Women should be encouraged to take up whatever position they find most comfortable in the first stage of labor.

Labor is a physical and emotional event for the laboring woman. For the infant, however, there are many positional changes that assist the baby in the passage through the birth canal. Because of the resistance met by the baby, positional changes are specific, deliberate and precise as they allow the smallest diameter of the baby to pass through a corresponding diameter of the woman's pelvic structure. Neither care providers nor the laboring woman is directly responsible for these position changes. The baby is the one responsible for these position changes ~ the cardinal movements.

Changing upright positions every 20-30 minutes not only assists the baby in completing the cardinal movements, but also gives the mother a mission ~ something other to focus on besides the discomfort from the regularly occurring contractions. Changing positions can be coupled with using the restroom to empty the bladder. A full bladder has been known to partially or completely block the birth canal ~ adding to pain and pressure, impeding the birth and lengthening labor.

Upright positions or gravity positive positions are best for laboring women and their babies! Upright positions assist with the cardinal movements and, thus, can decrease the length of labor and the amount of discomfort the mother feels. These positions can also hasten the cervical dilating and effacing by keeping pressure on the cervix, much like pressing down on modeling clay. This also has a decreasing effect on the length of labor!

Positions for labor include walking, standing, sitting, rocking, leaning forward, slow dancing, lunging, sitting on a birth ball, being on all fours, and sitting the toilet. Alternating position changes with rest is an optimal way to facilitate labor and have positive outcomes!

For more information, click here.