I have written previously about problems with Pitocin overuse (and about widespread overuse of other medical procedures in birth). Now that the holidays are almost upon us, it seems wise to revisit the Pitocin issue.
Pitocin is a synthetic form of oxytocin, a natural hormone that promotes bonding and also causes cervical dilation and labor contractions. Using Pitocin interferes with the body’s natural output of oxytocin, doesn’t effectively dilate the cervix, and prevents the body’s release of endorphins that naturally alleviate pain. There are sometimes good reasons for inducing labor with Pitocin (for instance, if the baby must be born right away for health reasons). In many cases, however, good reasons are not in the equation when the Pitocin comes out.
In 1990, fewer than 10% of women underwent labor induction. Now, estimates indicate that up to 40% or more of labors may be induced. As scheduled cesarean rates have also gone up dramatically in that same period (see this graph), we know that the proportion of women planning a vaginal birth who are induced has gone up even more. If you doubt that large numbers of births are being scheduled, see this graph that shows that births are disproportionately on Tuesday-Friday, with an extraordinary dip on weekends.
Doctors like to indicate that elective inductions are primarily done at maternal request. While some women definitely do request inductions, pregnant women cannot induce themselves with Pitocin. Doctors seem to have no problem enforcing non-evidence-based practices that women don’t want, such as not eating in labor, but act as if they are helpless in the face of induction requests.
Some doctors also have selective memory when it comes to their own induction practices. According to mothers, childbirth educators, and nurses, it is usually doctors who are encouraging inductions. As one childbirth educator said,
[A]n increasing number [of women] are being encouraged by their physicians to have labor induced. Threats of “your baby is getting too big” or “your blood pressure is a bit high” or “going past your due date is dangerous” and seduction with “your baby is ready, let’s get on with it” are almost routine.
Even some doctors acknowledge that elective induction is often physician driven. Dr. Vivien von Gruenigen writes,
Health care providers may request a patient to have an elective induction of labor and the “fee for service” model is a factor. This routine is common for physicians in solo practice with needed time off call or impending vacation. In addition, many physicians in group practice schedule elective inductions when they are on call for the purpose of financial gain.
Inductions are usually performed without true informed consent. Pitocin is not FDA approved for elective induction of labor and carries a black box warning because it is a high alert medication (prone to errors in administration that lead to catastrophic consequences). It appears that very few women are told that they are receiving a high alert medication that is being used “off label.”
One suggested consent form for elective induction includes the following for women to acknowledge:
- An increased risk of the need for cesarean section (surgical abdominal birth)
- I have also discussed the use of cervical “ripening agents” with my physician and I understand their separate risks of: a. Excessive stimulation of the uterus to the point that my fetus may become compromised and require emergency delivery, either vaginally or abdominally. b. I also understand that rarely the uterus may rupture under these circumstances, and cause death of my fetus and severe hemorrhage or death to myself.
- An increased risk that instruments may be used to accomplish a vaginal delivery if necessary.
- I also realize that if I have a cesarean birth, I am likely to require cesarean births for all of the children I may have in the future, and that each of these will incur the usual risks associated with cesarean section that I might have avoided had I had this birth vaginally.
- I acknowledge that there may be an increased risk for the need of blood transfusion, and I give my full consent to receive blood and blood products as necessary unless specifically stated here:
I have never met a lay woman who was aware of all of these risks, even if she had undergone an elective induction.
Marilyn Curl notes that elective deliveries spike before holidays–but that women do not always realize that the induction is elective:
Few doctors want to be pacing the halls on Thanksgiving or Christmas, waiting for a mother to deliver, so it’s not uncommon to see a surge of women with normal pregnancies being told that there might be an issue and that they should consider scheduling the delivery, coincidentally, right before a holiday.
Jill Arnold has a whole post about the pre-holiday induction phenomenon at The Unnecesarean.
Aside from the health risks, there are many other disadvantages to a pre-holiday induction, namely that there are so many of them being done that the obstetric wards are likely to be overcrowded. Robin Elise Weiss notes that
- Trying to schedule an induction just before Christmas ensures a hugely busy and overworked staff because of everyone else doing the same thing. I’ve personally seen women laboring in the halls or having very long wait for services like epidural anesthesia because of it.
- When you have a baby in the week before Christmas (with lots of other women), you’ve also got a crowded postpartum floor. This means longer waits for being seen by pediatricians, getting pain medicationss, etc.
- Being in the hospital in a crowded induction season can mean that you have to share resources in the hospitals that are already spread thin, like the lactation consultant, breast pumps, birth certificate clerks, etc.
At a recent PCORI conference, consensus opinion was that elective induction of labor before 41 weeks was one of the most important issues facing perinatal care today. As Deborah Bingham pointed out, we don’t give people with normal blood pressure medication for high blood pressure, because that would be dangerous; similarly, we should not be giving healthy pregnant women medication designed for rushing a birth in a medically dangerous situation. And it certainly shouldn’t be done by tricking women into thinking an induction is necessary because of a big baby or other concern that is not an indication for induction.
Not even before Thanksgiving or Christmas.
Update: you may also want to read Public Service Post: The Bishop Score