The Choosing Wisely campaign was begun in order to reduce unnecessary use of medicine and medical procedures.  Non-medically indicated use is unsafe for patients as well as being expensive.  Not only are there costs involved in the medicine or procedure itself, but there are also costs in treating side effects and other health consequences.

The American College of Obstetricians and Gynecologists (ACOG) has a list they made for the Choosing Wisely campaign, “Five Things Physicians and Patients Should Question.”  The top two items on the list are about elective induction of labor (these two items also made the American Academy of Family Physicians list).  The first warns against scheduling a delivery (cesarean or induction) before 39 weeks unless there is a clear medical indication.  Here is the text of the second:

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable:  Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

This is similar to the information I provided in my posts on Pitocin and elective inductions.  Before 41 weeks, unless there is a clear medical indication, labor should begin on its own.  Note the caveat that if an elective induction is to occur, the cervix should be “favorable.”  A laywoman might ask what this means.  A favorable cervix is soft, effaced and dilated.  But really the standard that physicians use for determining whether a woman’s body is ready to labor is the Bishop score.

In 1955, Dr. Edward Bishop published a paper (subscription needed to get text) on elective induction of labor in which he looked at the likelihood of induction success based on several factors: fetal position, cervical softness, cervical effacement, cervical dilation, and the “station” of the fetus (how far it was engaged in the woman’s pelvis).  We might question the ethics of inducing labor without medical indication, but Dr. Bishop did find that if the baby was anterior and the cervix was soft,  higher levels of effacement, dilation and engagement made elective inductions likely to work and labors were more likely to be shorter.  This chart from Preparing for Birth sums it up:

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Bishop’s scoring system is still used and has some accuracy at predicting the likelihood of an induction’s success.  Some doctors use a simplified score that just looks at effacement, dilation, and station.

Here are some graphs from Intermountain Healthcare’s care process model on elective induction:

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You can see that higher Bishop scores lead to higher likelihood of a successful induction, and that the higher the score, the shorter the labor.

Nulliparous women (first time mothers) are especially likely to have cesareans when they have lower Bishop scores.  It is important to note, however, that even with a favorable Bishop score, nulliparous women are much more likely to have a cesarean than they would be if labor began on its own, and they are more likely to have operative deliveries (forceps or vacuum).

Dr. Gene Declercq of Boston University and colleagues run a wonderful site call Birth by the Numbers and produced this chart with data from Listening to Mothers III:

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This data does not imply that an induction cannot be successful, that no one should have an epidural, or that a cesarean might not be necessary for reasons having nothing to do with inductions or epidurals.  But the data do give credence to the idea of choosing wisely.  Taking Pitocin to start labor in an uncomplicated pregnancy before 41 weeks is akin to taking high blood pressure medicine when your blood pressure is normal (credit Debra Bingham).  The Bishop score may help to determine if the medicine will not hurt you, but why take it in the first place?  If you do want to go the induction route, however, your Bishop score is a tool to let you know how likely an elective induction is to lead to unnecessary major surgery.

All inductions should be done with full informed consent and should not be scheduled around a care provider’s office hours, vacation time, or child’s birthday party.  The well being of the pregnant woman and her fetus and the woman’s informed choice should be the only considerations.  A woman is a human being and not a vessel to be manipulated for the convenience of others.

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