Labor induction rates have risen dramatically in recent decades, and along with this and in part as a result, so have cesarean section rates and preterm births. We know that labor inductions are too often done unnecessarily and for inaccurate indications, and they may lead to a host of additional unnecessary interventions that increase risk for mom and baby.
A recent article even speculates that there might even be a relationship between labor induction with the hormone oxytocin (Pitocin) and autism.
While I absolutely don’t want any woman who has had an induction to feel judged or to judge herself as a result of this article, as a midwife and physician I do want to encourage and empower women to say no to unnecessary inductions, and help you be able to assess when induction is appropriate and how to minimize your risks.
Part 1 of this article looks at labor induction rates, reasons for induction, problems with induction, how to gracefully decline or delay an induction that does not seem to be medically indicated, and maximizing yours and baby’s safety if induction really seems necessary.
Part 2 (coming next week) discusses the safety, effectiveness, and risks of natural alternatives to labor induction.
A Story of the Induction that Didn’t Happen
Answering my phone one Friday morning in December some years back, I found Inga on the other end in a panic. She was just told she’d have to be induced in a few days because her baby weighed 10 pounds by ultrasound and her midwife’s physical examination. She said, anguished, “I’ll only be 40 weeks tomorrow. I wanted to have a natural birth. I’m so worried about an induction and they say I might have to have a cesarean because I might not be able to get this baby out vaginally. They’re not even really giving me a chance. I don’t want to be induced but I want to do what’s best for my baby. I just don’t think an induction is best!”
I’d met Inga about 6 months prior. I was teaching a course on herbal medicines in pregnancy at a prominent nurse-midwifery program. She was a student in the program. Now, not only did she find herself being pressured to be induced, but to complicate matters, her midwives were her professors in her training program so she didn’t really feel like she could argue. They told her that if she did not go into labor within a few days, she was going to have to be induced.
She was desperate for a second opinion. I invited her to my office to talk.
At 5’10” and 180 pounds at nearly full term of her pregnancy, Inga was a vibrant, athletic, strikingly good-looking Nordic woman with shoulder-length blond hair and bright blue eyes. Only her furrowed brow revealed a problem. I listened to her concerns and asked if I could palpate (feeling her baby’s size and position) her belly. Based on my exam, backed by 15 years of midwifery experience at the time, I estimated her baby’s weight to be closer to about 8 and a half pounds rather than the predicted 10. The baby was in a perfect head down position. She had no other pregnancy problems and had been preparing to give birth in the birthing center rooms of the hospital affiliated with her program.
I gave Inga a grand pep talk about how, from a size perspective, she could absolutely birth her baby vaginally. I emphasized that if I, at 5’3” and 135 pounds at full term could birth an 8.5 pounder in 4 hours, she should easily birth an even bigger baby should the baby prove bigger than my estimate. We reviewed the data on the natural length of pregnancy being 42 weeks with minimal increase in adverse outcomes in women who go the full length and even into 42 weeks. At her request, I also shared a few natural approaches she could try at home to get labor started if “push” came to induction, as this is one of my areas of expertise, though told her to save these as a last resort as natural is not always safe.
She went on her way with a resolve to birth her baby naturally if possible, to speak directly with her midwife-professors, and with a plan to see what might happen over the next few days. She thought she might try the natural remedies come mid-week if the induction became imminent.
The week came and went, and having not heard from Inga, I finally gave her a call. “Aviva,” she said, answering the phone cheerfully, “I was just sitting here composing a letter to you. I’m so glad you called! Let me read it out loud.” It went like this:
“Dearest Aviva, After I left your office I felt such a sense of relief. It was the first time a midwife or anyone ever said ‘You can do this.’ I felt up-lifted and confident. I went in for an ultrasound Monday and baby looked great. Then I went home, took a hot bath, rested, and went into labor! I never needed any of the natural remedies. My baby was born the next day weighing 8 pounds 4 ounces. I had only 8-hours of active labor with about 2 hours of pushing. I did it all naturally and never even needed the herbs or other methods! My daughter is healthy and beautiful! She’s right here in my arms. Thank you so much for your support and encouragement, and most of all telling me I could believe in myself.”
Inga’s is just one of the numerous stories story I could share about women who were told they would need to be induced or told they would not likely not be able to give birth naturally and spontaneously, often because of the baby’s estimated size or for other reasons, for example, that it is too dangerous to allow the pregnancy to go much past the due date. Inga was fortunate to be able to have the experience she hoped for. Sometimes medical reasons do necessitate an induction. Too often, however, they are done unnecessarily, leading to a domino effect of additional interventions including intravenous medications, epidural pain relief, and even a cesarean section.
Are There Too Many Inductions?
Yes, unequivocally, there are too many labor inductions. Even the leading obstetrics organization in the US, the American Congress of Obstetricians and Gynecologists (ACOG), is trying to curb unnecessary and potentially harmful inductions – especially those done prior to 39 weeks of pregnancy, which increase the rate of preterm deliveries.
In 1990 the rate of labor induction in the US was less than 10%. By 2006, it soared to more than 23% of births, and is as high as 44% in some communities, according to the Centers for Disease Control and Prevention and other researchers. Thus, at least 1-in-5 women has her labor induced, maybe more. While some of these inductions are medically necessary, most are only marginally indicated and as many as 40% are unnecessary – or elective. This means that the doctor or midwife suggests it, or the pregnant woman requests it, for reasons of scheduling convenience.
Why the Increased Induction Rate?
By all conventional medical standards, the length of a normal human pregnancy extends all the way to the end of the 42nd week of pregnancy. So why do so many OB’s and family doctors want to induce well before this? Statistically, there is a slightly increased risk of stillbirth after 41 weeks of pregnancy. This small risk represents a major legal concern for doctors who deliver babies. An obstetrician can expect to be sued 3 times in her career, is legally liable until a child turns 18 years old for any problems that can be attributed to a birth she attended, and the stakes of a lawsuit, in addition to the stress, can be financially and professionally devastating. Induction has become the answer addressing risks to baby. Who can blame a doctor for wanting to protect babies?
Further, because the risks of induction have been minimized for the past 20 years, it has become the “new norm” to the extent that many women request labor induction for personal convenience. It allows siblings to share a birthday, it allows family member from afar to time their presence at a birth, it allows women to maximize maternity leave (which, by the way, is far shorter than in many other nations that also coincidentally have lower induction rates!) and it reduces mom’s stress of wondering when the “big event” is going to happen. In our own desire for convenience and control, we have contributed to the problem!
Moreover, many pregnant women feel pressured to undergo obstetric procedures, according to the latest Listening to Mothers III national survey of 24oo mothers who gave birth in US hospitals from mid-2011 to mid-2012.
According to Maureen Corry, MPH, the executive director of Childbirth Connection, New York City, the organization that commissioned the survey, “We also found that the women report being pressured by their healthcare providers to have induction and cesarean sections.”
Eugene Declercq, PhD, professor of obstetrics and gynecology at the Boston University School of Public Health and the survey's lead investigator, told Medscape Medical News that he was surprised by the large number of mothers who felt pressure to receive interventions such as inductions, epidurals, and cesareans.
Houston, we have a problem!
How is Labor Induced?
Labor is induced in one or a combination of several ways including the use of an intra-cervical balloon filled with water to mechanically dilate the cervix, rupturing the membranes, and medications including hormones to soften or ripen the cervix to get it ready to dilate, misoprostol placed in the cervix to soften and dilate it, and most commonly, Pitocin, which is administered intravenously to stimulate contractions. Typically, more than one method is applied, with Pitocin ultimately given in as many as 70% of inductions.
Is There a Problem with Labor Induction?
One major problem is that too often it is medically unnecessary, so any risk associated with it is an unnecessary risk for mom and or baby. Each method of labor induction carries its own small to more significant risks. Balloon catheterization and rupturing the membranes increases risk of infection to mother and baby, misoprostol increases the risk of uterine rupture, and Pitocin can cause a number of medical problems – most notably fetal distress – and generally requires an epidural to reduce the pain from Pitocin-induced contractions. Epidurals also carry risks.
Induction requires you to be in the hospital, which increases your risk of exposure to hospital infections just by being there. Once induction begins you may be prohibited from eating, moving around, and you will likely need to have an IV placed – all of which increase risks of medical problems and complications. You will be subject to repeated vaginal exams, which also increase your risk of infection. You will likely be placed on an external fetal monitor, which is an independent risk factor for an increased cesarean rate due to false positive reporting of problems with your baby’s heart rate or rhythm.
Inaccuracies in estimating due dates increase your baby’s risk of being born preterm if labor is induced, especially if done prior to 41 weeks of pregnancy increase your risk of having a C-section. In fact, the high national cesarean rate, now close to 33%, has in part been attributed to escalating rates of labor induction. A study published in the journal Obstetrics & Gynecology found that among nearly 8,000 first-time mothers, labor induction doubled the likelihood of a C-section compared to women who went into labor on their own. Cesarean sections significantly increase risks of complications for mothers.
High cesarean rates and high rates of preterm births have become such a major problem that some hospitals have now prohibited all but medically necessary inductions prior to 39 weeks gestation. Some hospitals are requiring doctors to provide written medical documentation of reasons to induce labor.
Does Labor Induction Cause Autism?
A recently published paper associates labor induction and augmentation (the use of Pitocin to speed up a stalled or slow labor, which I will discuss in a subsequent article) with increased risk of autism. The large study looked at 625,042 live births linked with school records, and included more than 5,500 children with documented autism.
Compared with children born to mothers who received neither labor induction nor augmentation, children born to mothers who were induced and augmented, induced only, or augmented only had higher rates of autism after controlling for factors such as socioeconomic status, maternal health, and pregnancy-related events and conditions. Male children were more likely to have autism.
One possible explanation for the relationship between autism and induction is through exposure to exogenous oxytocin. Approximately 50% to 70% of women who undergo labor induction receive Pitocin which is a synthetic oxytocin. Biologically, oxytocin signaling plays important roles influencing social behavior and cognitive function.. Exposure during labor induction or in labor may have a yet unidentified genetic or epigenetic effect.
While the jury is still out on the association between autism and induction, which is most likely caused by multiple factors in genetically vulnerable children, it is interesting to note that the increase in labor induction in the past 2 decades has paralleled the increase in autism rates. It should at least give us further pause to avoid unnecessary induction and augmentation, and treat it as a medical intervention with potentially serious consequences, rather than something to be done routinely or electively.
The Myth of the Too Big Baby: When is Labor Induction Truly Necessary?
Medical indications for labor induction include any medical circumstance in which you or baby is safer with baby out than in. These include preeclampsia, eclampsia, HELLP syndrome, diabetes, fetal growth restriction, infection of the amniotic membranes (called chorioamnionitis), and placental abruption.
Surprisingly, given its prevalence, there is a paucity of high-quality evidence proving the benefits of induction for specific medical and pregnancy conditions. However, the above indications are generally very legit.
Pregnancy with twins and multiple babies might be an indication for induction in some cases, but should be evaluated individually based on the health of mom and the babies.
Induction for convenience-sake is never a medical indication and is best avoided.
One of the most common reasons for induction is going past your due date, particularly if the pregnancy gets to 1 week past due. At this point, you’re also probably sick and tired of being pregnant, so may readily agree when an indication is proposed. There is evidence of a small increase in stillbirth in pregnancies between 41 and 42 weeks and another small increase between 42 and 43 weeks. However, between 41 and 42 weeks gestation it would take 527 inductions to prevent one stillbirth. That’s a lot of inductions, and most women, left to the natural course of pregnancy, will go into labor by 41 weeks.
The good news is that pooled data from a lot of studies show that getting induced after 41 weeks gestation does not increase the risk of cesarean section compared with a wait and watch attitude.
Another common justification is that “the baby is getting too big, so we should induce now.” The reality is that ultrasound sizing is only as accurate as the person doing the ultrasound, and even with highly skilled docs, midwives, and techs, there is a wide margin of error – often erring with baby being on the larger side. And many women can give birth to babies weighing 8, 9, and 10 pounds without a problem. Even first babies. The hormones of late pregnancy and the design of the pelvis ingeniously allows the pelvis to “give” to accommodate the baby’s head. So unless mom is diabetic leading to an excessively large baby as a result, and other complications are arising, baby’s size alone is not usually a good reason for induction and as discussed earlier, inducing early can lead to risk of prematurity.
Increased and regular monitoring of the baby with ultrasound to measure amniotic fluid and non-stress testing is commonly recommended once pregnancies reach 40 weeks and a few days. However, there is really no evidence for any specific type of monitoring improving outcomes for mom or baby. If any problems arise with baby’s heart rate or there is too little amniotic fluid, induction in the hospital is recommended for optimal safety.
Saying No to Induction
There is rarely a need for an emergency induction, so there is generally time to have a conversation with your doctor, do your homework, and make an informed choice. Are there alternatives? What are the real risks of waiting? Is induction likely to be successful (see below)? It’s your body and your baby so you have a right to ask questions and make an informed decision.
A lot of obstetric providers are really scared of nature. I’m serious. Because in their eyes, nature can be dangerous for mom and baby. And “bad births” lead to a lot of grief for everyone. So to them it seems safer and smarter to induce – because that's controllable and legally defensible (please remember, I am sharing this as a physician it's not jaded propaganda).
But what if you’re not comfortable or in agreement with your doctor's assessment or suggestions? Sometimes this can get tricky and rarely it can even get legal, but most of the time, a reasonable conversation can be had and buy you time. Try to approach the conversation in the spirit of partnership. A good OB, family doctor, or midwife is going to want to make sure everything is safe, but ideally will also want you to feel comfortable and satisfied with your birth. Start by acknowledging your appreciation for her concern for you. Then ask if she really thinks the induction is absolutely medically indicated and if it has to be done right away. If she says yes, ask for a clear explanation of the reason(s). Ask her if she would consider waiting a few days, and what would make her feel comfortable doing so, for example, if you came in for an extra ultrasound in a couple of days and everything looked good would this reassure her?
If your OB or other provider really sticks to her guns on the need for induction, it could also be that it really is indicated. It could also be that she previously had a bad experience in a similar situation to yours and is afraid to repeat it. Again, try to talk it out.
If you cannot reach a resolution that you feel good about you’ll have to decide whether to acquiesce or take your birth elsewhere. You could at least obtain a second opinion if you have good reason to believe that the induction in not indicated.
Wait and Watch Past 42 Weeks?
Many midwives and natural birth proponents encourage letting nature take its course, even if pregnancy extends well into or beyond 42 weeks gestation. In most cases things turn out just fine. But things don't always come up roses.
Births past a full 42 weeks are sometimes longer, with more challenging labors, and have more complications including increased risk of bleeding for mom and greater need for emergency resuscitation of the baby. Not all homebirth midwives are experienced or skilled in handling these complications effectively. If you are planning a home birth and are post due, please make sure you truly understand the risks and make sure your midwife actually knows how and is prepared to handle complications that could arise.
Making an Informed Decision and Maximizing Your Safety
If labor induction is truly indicated, there are ways to maximize its success while minimizing risk to you and your baby.
One of the most important indicators of success is how ready your cervix is for labor. It has to be both very soft (effaced) and ready to open (dilate) for induction to happen readily. Your midwife or doctor can use a simple scoring system called the Bishop’s Score to see if you are ready. The better your Bishop’s score, the more likely you are to be induced successfully. If your Bishop's Score is low, ask your doctor for the best options to help your body get ready for labor – but don't just let them start pitocin against an “unripe” cervix – this is a common recipe for failed induction and need for cesarean.
Some methods of induction are more effective than others. Cervical ripening with medication before attempting to induce contractions may be more effective than starting out with Pitocin.
Rupture of membranes is commonly recommended to facilitate labor and regular vaginal exams are commonly done to see if you are progressing. Neither are recommended as they increase your risk of infection.
Request that you be allowed to keep up your nutrition, keep your loved ones and doula nearby, move around during labor, and have your vision of how you’d like to birth be respected as much as possible (i.e., quiet at the time of birth, delayed cord clamping, baby to momma’s breast rather than warmer).The more you maintain your power over decision-making and the less you succumb to the role of “patient,” the more likely you are to feel empowered by your experience in the end. And empowerment is ideally a natural outcome of birth and a positive feeling with which to enter motherhood.
Coming in Part 2: Are There Natural Alternatives to Medical Labor Induction?
Wishing you a healthy, joyous pregnancy and an empowering birth,