Elective Inductions: Be Thankful not to Have One

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

Your Way–as Long as it’s Our Way: Florida

Jill Arnold is updating the stats at CesareanRates.com, and according to her new tables, South Miami Hospital has the highest cesarean rate in Florida: 62%.  This is nearly double the national average and 4 times the “threshold not be exceeded” identified by the World Health Organization.  Let’s investigate.

Women have babies at the hospital’s Center for Women and Infants.  Their patient brochure begins, “The philosophy toward childbirth at South Miami Hospital encourages your individuality and supports family involvement.”  Such a statement indicates that the woman can call the shots in her own birth–an admirable goal as long as she is given evidence-based information to make choices.  Except it turns out that she doesn’t actually have a lot of choices.  Nor are routine hospital practices based on evidence.

For instance, here are some example from the “Frequently Asked Questions” page (all emphasis and commentary is mine):

3 Q:  Will I be able to walk or use my birthing ball when I am in labor?
A:  We encourage you to discuss this with your physician as you will want to be familiar with your doctor’s practices.

Um…what are the doctor’s birth ball practices?  Should the woman expect to have to share?

6. Q:  Will I be able to eat in labor? How soon will I be able to eat after the baby is born?
A:  While in labor, it is recommended that you have only ice chips. The presence of food in the stomach may cause nausea and vomiting. In the event you should need anesthesia for your labor, vomiting could cause aspiration of food to the lungs, a condition that is dangerous to you. If you deliver vaginally, you will be able to eat once your recovery is complete.  (…)

“It is recommended” by whom?  There is no evidence base for denying women access to food and drink in labor.  A Cochrane review on the subject notes that depriving women of food and drink leads to longer and more painful labors and concludes, “women should be free to eat and drink in labour, or not, as they wish.”  And when would “recovery be complete”?  Isn’t common wisdom that it takes about 6 weeks to recover from a vaginal birth?  That’s a long time to survive on ice chips.

9. Q:  What is a fetal monitor? Do you have wireless monitors in the labor rooms?
A:  The fetal monitor is used to determine the baby’s well-being prior to birth.  It provides a continuous printed record for the evaluation of uterine activity and the baby’s heart response.  Your obstetrician may decide to use an external or internal monitor. Baptist Hospital does have wireless monitors. These monitors are used when appropriate and available.

Continuous monitoring has been shown to raise the risk of cesarean without producing superior maternal or infant outcomes and it is not recommended for low risk women–not even an initial test strip.  In addition, if the wireless monitor is not available, the woman’s movement would be restricted, which would also go against evidence based practice.  Internal monitoring can be painful and introduces risk of infection.  According to Rebecca Dekker at Evidence Based Birth, “evidence clearly demonstrates that the best option for most women and babies is intermittent auscultation” (meaning using a handheld doppler at intervals throughout labor).  Note that the best practice is not mentioned as an option.  Whoops.

11. Q:  Do you have a Jacuzzi?
A:  Use of the Jacuzzi is based on room availability. In early labor, some patients enjoy relaxing in the Jacuzzi. Use of the Jacuzzi will depend on many circumstances revolving around your labor. Your physician will need to approve its use.

It’s interesting that the question is “do you have a Jacuzzi,” but the answer is about all the reasons a woman won’t be able to use one, even though there is a strong evidence base for laboring in water.

It’s also interesting that a physician would need to approve women’s evidence based requests, while the hospital will require women to follow non-evidence based routines.  This does not seem particularly encouraging of individuality.  Or of health.

Women are told they to be admitted at 3 centimeters’ dilation because that is when they are in active labor, even though the most current recommendations state that women should not be considered in active labor until 5-6 cm.  Early hospital admission tends to lead to unnecessary cascades of  intervention that increase birth costs and can lead to cesarean.

Even regarding non-medical issues, South Miami places limits on what women (or their families) can do.  For instance, their video and photography guidelines have some practical information–tripods shouldn’t be used because they get in the way; doctors and nurses should give their permission before being photographed or video recorded.  But the guidelines, which state that “the birth of a baby is an exciting time” also state that no one is actually allowed to photograph or videotape the birth:

1. For vaginal births, videotaping and photographing are permitted, but only after the birth, and when the baby is dried, cleaned and alert.
2. Videotaping is not allowed during a C-section delivery. Photographs may be taken only after the baby is dried, cleaned and alert.

Since a baby should go skin-to-skin with the mother directly after birth and remain with her there for about an hour, it may be a long time before anyone can get a picture of the baby.  Unless South Miami is not following evidence based recommendations about skin-to-skin contact.  Hmm…

We require labels on food packaging to give nutritional information.  It seems we might benefit from hospital labeling to get health information.  If a woman chooses to abide by non-evidence based practice, that is her right.  But it is disingenuous for a hospital to proclaim that it supports a woman’s individuality in childbirth–as long as her individuality fits their mold.

 

You can read the second in this series, an analysis of  the Mississippi hospital with the highest cesarean rate, here.

Rights

There has been a lot of discussion in the pregnancy and birth world about the Irish case of Aja Teehan, who wanted to have a homebirth after cesarean (HBAC).  Irish midwives are professionally prohibited from attending homebirths that are considered too risky, and vaginal birth after cesarean (VBAC) risks a woman out of homebirth.

The question posed was whether the woman had the RIGHT to homebirth.  This leads to some interesting questions about rights and whose rights they are.

In pregnancy and birth, there are several interested parties who may or may not have “rights” in various health-related decisions.  These people include the woman, the man who impregnated her, the person who will be raising the child with her, the fetus/infant, and the practitioners providing reproductive health care and medical services.

For instance, there are rights around getting pregnant.  Here we might ask

• Does a woman have the right to get pregnant?
• Does she have the right not to get pregnant?
• Does a practitioner have the right to refuse assisted reproductive technologies to a woman who the practitioner does not want to serve (for instance because she is single or a lesbian, or because she already has several children)?

During pregnancy

• Does a woman have a right to terminate a pregnancy?
• Does a fetus have a right to reside in a woman’s body until its gestation is completed?
• Does a man who has impregnated a woman have a right to demand that she continue the pregnancy?  Or that she not continue the pregnancy?
• Does a woman have the right to continue a pregnancy that will result in a child who will suffer?  What about a child who will present costs to society or the state?
• Does a woman have the right to medical treatment for her own health conditions while pregnant?
• Does a woman have the right to engage in behavior that could potentially harm a fetus she intends to birth?

During labor and birth

• Does a woman have the right to refuse to birth in the way her practitioner thinks best?
• Does a woman have the right to refuse birth interventions a practitioner believes to be optimal?  Does she have the right to refuse interventions that are standard hospital policy?
• Does a practitioner have the right to refuse to attend a woman who will not follow the practitioner’s medical advice?
• Whose rights to life and health should predominate in the birth process: the woman’s or the infant’s?

The links in the questions above are not all-encompassing, but are examples of issues implicit in these questions.  May we always remember that a woman is a human being whether there is a fetus in her uterus or not.