A Product of Our Times
Chances are, you know someone who's had her labor induced. I know I do. Just this year, my neighbor, my friend, and my sister-in-law were all induced. Another acquaintance, due in late December, had her induction date scheduled two months in advance. "I was booked for December 21," says Tiffany Metzger of Mayville, Wisconsin. "That way, I didn't have to worry about being in the hospital over Christmas."
Labor induction -- the process of artificially starting labor -- is an increasingly common procedure. According to statistics from the Centers for Disease Control and Prevention, twice as many women were induced in 1997 as in 1989 (18 percent versus 9 percent). By 2003, the induction rate had risen to 20.6 percent, or about 1 in 5 births.
Experts say the increased induction rate is a product of our times. Advances in medical technology combined with our fast-paced lives mean that more babies are being delivered according to schedule. But like any medical procedure, induction has inherent risks. Getting the facts will help you determine if an induction is right for you.
A Growing Trend
Labor induction is usually recommended when continuing the pregnancy would jeopardize the health of either the mother or her baby. For instance, if Mom has severe high blood pressure, diabetes, kidney disease, or cancer, or if a fetus is not growing properly, the baby may be better off on the outside. The same logic applies if the amniotic fluid levels are low or if the placenta has begun to deteriorate.
New research suggests that overdue pregnancies, premature rupture of membranes at term, and preeclampsia (a pregnancy-related form of high blood pressure that has increased threefold in the past decade) are also best treated by induction. "Those three areas account for most of the increase in the induction rate," says Charles Lockwood, MD, chair of obstetrics, gynecology, and reproductive sciences at Yale University.
For instance, today doctors are likely to induce an overdue pregnancy at 41 weeks instead of 42. And rather than waiting up to 24 hours after a woman's water breaks, labor is now often initiated after four hours.
The Personal Choice
An increase in the number of elective inductions -- those that are not medically necessary -- also contributes to the growing rate.
Amy Kelly, of Westlake, Ohio, had her second and third pregnancies induced because she was concerned about the 35-minute drive to the hospital through downtown Cleveland (her first labor had taken only seven hours). She also needed to arrange care for her older children. "Inducing was safest, so that the babies weren't born on the highway," says Kelly. "It also gave me the peace of mind that my other children were taken care of."
A scheduled induction can also guarantee that your doctor will be present for the birth. Healthcare providers can plan deliveries for daylight hours and avoid midnight runs to the hospital.
According to Sabine Droste, MD, an associate professor of maternal/fetal medicine at the University of Wisconsin at Madison, many elective inductions are done to keep patients happy: "By the time they reach 37 or 38 weeks, a lot of patients are frankly sick of being pregnant."
Just ask Courtney Kyle of Jacksonville, Florida. She had been having regular contractions for more than a month when she saw her doctor four days prior to her due date. She was hot, uncomfortable, and tired of pregnancy. "My doctor knew it was driving me crazy and offered the option of inducing me on Friday when he was on call," says Kyle. "What helped me make the decision was knowing when I would have my baby and that my doctor would be the one who would take care of me."
During the labor, the baby's heart rate dropped, and Kyle ended up with an emergency c-section. Still, she was happy with her decision: "It was not my dream birth, but at least I had my own doctor."
The increased odds of a cesarean is among the risks of inducing. "An induced labor is by nature less effective than a spontaneous labor," says Dr. Droste, "and more likely to result in a cesarean delivery."
But while elective inductions are controversial, some ob-gyns support the practice. "A significant number of obstetricians argue that if you've had a baby before and are 3 to 4 centimeters dilated, an induction is reasonable. As long as patients understand clearly the risks and benefits, I wouldn't say it's a terrible thing to do," says Dr. Lockwood.
Elective inductions can also be inspired by exceptional circumstances. Recently, women have been induced at term before their husbands left for military service in Iraq.
Some doctors admit that liability concerns may also be fueling the induction rate increase. With research suggesting new indications for induction, and more patients requesting them, obstetricians fear being sued if they don't induce and something goes wrong later.
Medical technology has also advanced to make inductions more successful. Cervical ripening agents -- drugs that prepare the cervix for birth -- have revolutionized labor induction. Now doctors can attempt induction even in a woman with a thick, closed cervix (the cervix must thin and open in preparation for labor). And with new, cheap, and easy-to-use drugs available, cervical ripening has become more common.
But even with these advances, there are still risks. Besides doubling your chances of a cesarean, research shows that induction drugs cause longer, more intense contractions that can interfere with oxygen delivery to the baby, leading to fetal distress. Induced babies are more likely to pass meconium (bowel movement) during labor, which can cause lung problems if inhaled. They also have increased rates of newborn jaundice and are more likely to need specialized care after birth.
In addition, if a baby is induced before term, he has the risk of complications that come with prematurity. When Sue Romanowski's third child, Jacob, was induced at 37 weeks due to pregnancy complications, he had difficulty breathing, spent the night in an incubator, and was almost transferred to intensive care. "It was a horrible experience," says the Mayville, Wisconsin, mom.
Labor induction is risky for mothers as well. Overstimulation of the uterus; excessive bleeding after birth; uterine rupture (a tear in the uterus), especially if you've had a previous c-section; and even death are possible.
Get the Facts
If you're considering an induction, it's important to get all the facts before making a decision. If your doctor recommends one, make sure you understand why. In some cases it's very clear: Crissi Grooms of Charleston, South Carolina, was induced due to the combined risks of having gestational diabetes, preeclampsia, and kidney failure.
"They wanted to get the pregnancy just far enough along to where the baby would be okay," says Grooms, who was induced at 36 weeks. "My body wasn't going to take much more."
But sometimes the reason is murkier. Krista Beale's first child was induced after a routine 40-week check revealed she was two centimeters dilated. "My obstetrician suggested induction because I am not a big person, and the baby was perhaps too big for me to deliver vaginally if we waited. I went right from her office to the hospital," says Beale, a mother of two from Oregon. Four hours later, her daughter was born at 7 pounds 14 ounces.
While inductions for big babies are common today -- and Beale was happy with her outcome -- not everyone thinks they are medically appropriate. "The truth is one does not necessarily prevent a cesarean delivery by inducing babies early that are deemed too big," says Dr. Droste. The advantage gained by delivering a slightly smaller baby is offset by the fact that an induced labor is less productive and may end in a cesarean anyway.
If you are uncomfortable with the idea of an induction, ask your doctor about alternatives. "I think it's fair for a patient to ask if this is necessary, if this is my only option," says William Rayburn, MD, chair of obstetrics and gynecology at the University of New Mexico at Albuquerque. Increased monitoring and surveillance, including stress tests and ultrasounds, may be one option. Also ask about trying natural methods first, such as nipple stimulation or sexual intercourse, to initiate labor.
Understanding the differences between an induced labor and a spontaneous one can help you know what to expect. "When you agree to an induction," says Peg Plumbo, a certified nurse-midwife and an instructor in the nurse-midwifery program at the University of Minnesota, "you're also agreeing to a loss of control over many aspects of the birth. You'll spend the entire labor with an IV running, attached to a fetal monitor."
Ask in advance about the guidelines for eating and drinking and the use of IVs, monitors, and the tub (for water therapy). Talking to someone else who has been induced can also give you a realistic picture.
Most moms agree that an induced labor is more painful and intense. "It was by far the most difficult of my three labors because of the strong contractions brought on by the Pitocin and because my uterus was not at all ready for birth," says Stephanie Nash of Franklin, Virginia.
Make sure to ask in advance about what pain management options are available to you, when they can be administered, and about any side effects. And keep in mind that inductions don't always work. If, despite all interventions, your labor is not progressing, you may be sent home to try again another day. However, if the induction was medically necessary and/or your water has already broken, you will likely have a time limit on your labor (usually 24 hours).
If you have not delivered within that time, you will probably require a c-section. But induction or not, keep the end result in mind -- a beautiful baby.
Most inductions use a combination of methods. Some of the most common are:
- Cervical ripening. If your cervix has not begun to soften or dilate (open), most doctors will apply a prostaglandin, a hormone-like "ripening" agent. Prepidil comes in a gel that is applied directly to your cervix; Cervidil is delivered via a tampon-like device. Misoprostol (Cytotec) is another prostaglandin drug that can be placed near the cervix or taken orally. (Cytotec is primarily an anti-ulcer drug and has not been approved by the FDA for labor induction, although doctors can prescribe it "off-label." It can cause serious side effects, such as severe bleeding and uterine rupture. Fetal and maternal deaths have also been reported.)
Be aware that cervical ripening can take days. Also, prostaglandins -- especially Cytotec -- should not be used on anyone who has had a previous c-section because of the increased risk of uterine rupture. If needed, doctors can manually stretch the cervix using balloon-like devices.
- Pitocin. Given through an IV, Pitocin (a synthetic form of the contraction-inducing hormone oxytocin) stimulates labor. The dose is slowly increased until a satisfactory labor pattern occurs.
- Breaking your water. Your care provider can manually break your bag of water with a small hook. This may start labor or jump-start a stalled labor. However, it increases the possibility of infection and, in rare cases, can lead to a prolapsed cord (a condition in which the cord is compressed with each contraction, cutting off oxygen to the baby). Because your uterus is now open to infection, it also puts a time limit on your labor (usually 24 hours).
- Nondrug techniques. They include stripping your membranes -- your caregiver uses a gloved finger to separate the bag of water from your cervix, causing your body to release natural prostaglandins.
Jennifer L.W. Fink is a writer in Mayville, Wisconsin, and a mother of three.
Originally published in American Baby magazine, August 2004.