Each month, the Science & Sensibility community will review one of Lamaze's Six Healthy Birth Practices in sequential order. Today, new S&S contributor Joni Nichols will discuss Healthy Birth Practice #1: Let Labor Begin on Its Own.

Reviewing the very first recommendation of the Lamaze Six Healthy Birth Practices immediately brings to mind a popular refrain we use in Mexico,

Del dicho al hecho hay mucho trecho!

Literally this expression means that there is a pretty big space between said and done and is akin to the English expression easier said than done.

According to Dr. Wagner ( Born in the USA. 2006, p.39), Federal studies that analyze birth certificates tell us that the percentage of U.S. births that happen Monday to Friday, nine to five, is rapidly increasing; even emergency c-sections are more common Monday to Friday, nine to five...This isn't caused by global warming or the effects of the moon...we are looking at a procedure called Induction.

Rindfuss, Ladinsky, Coppock, Marshall, and Macpherson's Convenience and the Occurrence of Births: Induction of Labor in the United States and Canada used data for the United States and Canada on number of births by day of the week, for their paper in the International Journal of Health Service that pointed to indirect evidence for the widespread incidence of the practice of elective induction. For both the United States and Canada, it found that substantially fewer births occurred on Saturdays, Sundays, and holidays than on weekdays. Controlling for such factors as prenatal care, race, education, legitimacy, birth weight and time, trends strongly suggested that the induction of labor was responsible for the patterns found.

The National US Survey of Women's Childbearing Experiences, Listening to Mothers I, reports that almost half of all mothers reported that their caregiver tried to induce labor. Even more telling:

One-third of those mothers cited a non-medical factor as at least partially the reason for the attempted induction.

As Gail Hart points out in her review of current research booklet, Research Updates for Midwives(2005), If women are being induced for legitimate reasons of health and safety, then mortality and morbidity statistics should be improving. Yet the statistics are quite flat. An induction and augmentation rate of over 35% has not seemed to improve the health of mothers or babies.

So if a medical reason isn't the rationale for this interference in the normal process of labor and birth what is?

NOW you know why this article is being written amidst the hectic activities of the holidays, because major holidays are prime time for inductions!!! Perhaps the caregiver is eager to have assurance that s/he will be able to enjoy the holiday without a call to come to the hospital or birth center. Perhaps the birth facility is enthusiastic about scheduling fewer personnel for Thanksgiving, Christmas and Easter. Perhaps the mother is eager to have the baby's birthday before the holiday, thinking she can enjoy the day with a baby in arms or be assured of spending the holiday with her older children or extended family. Perhaps she has a family member or friend only available to assist her in the days before the holiday but not during the holiday. Oftentimes she fears that her preferred healthcare provider won't be available and will agree to a scheduled early delivery to guarantee that the desired provider will be available for the birth (a common concern of women utilizing group maternity health care practices - regardless of holiday proximity).

Considering that induction of labor brings with it some important risk factors, perhaps induction isn't quite so seductive after all. Five of the documented risks include:

1) abnormal fetal heart rate[1]

2) baby being admitted to the neonatal intensive care unit (NICU)[2]

3) use of forceps or vacuum extraction[3]

4) prematurity, jaundice and breastfeeding difficulties[4]

5) cesarean[1] [5],[6],[7]

Given these risks, the gauzy image of hearth and family and newborn at holiday time can look quite different. Perhaps mother will be scuttling between home and hospital to care for her physiologically premature baby, or struggling with breastfeeding, or recovering from major surgery!

Many women whose experiences I read about in online forums for cesarean support, relay that they signed up for their inductions fully believing they were only hastening a fully developed baby's arrival and report surprise, sadness, regret and often guilt when their births ended in the OR. Not surprisingly, their experiences are corroborated by research findings.

A retrospective study, conducted by 12 institutions participating in the Consortium on Safe Labor, examined electronic medical records associated with 228,668 births between 2002 and 2008 at 19 US hospitals. The overall purpose of the study was to assess contemporary labor and delivery practices. This study offers some observations about why nearly one-third of all US births involve a cesarean delivery and suggests that induction plays a prominent role. Zhang and colleagues found evidence that physicians may be intervening too much and too soon. For example, the researchers found that 44% of women in the study population had their labor induced and that the cesarean delivery rate was twice as high for such womencompared with those who had spontaneous labor (21.1% vs. 11.8%). Additionally, when labor did not progress normally after induction, physicians were quick to perform a cesarean delivery, half the time initiating the procedure before a woman had dilated to 6 cm. Our study does provide some clues that induction might play some role, Zhang said. Coauthor S. Katherine Laughon, MD, a postdoctoral fellow at the National Institute of Child Health and Development suggested more study is needed to determine when induction is clinically necessary and when it might be safe to wait and see if spontaneous labor occurs.

Roger Freeman, MD, professor of obstetrics and gynecology at the University of California, Irvine, said the results of the Zhang study are consistent with previous studies which have suggested that the way labor is managed is contributing to the upward trend in number of cesarean deliveries performed. Freeman said that induction is clearly a contributor, and suggested that physicians avoid elective induction, which can elevate the rate of cesarean delivery and prolong labor without offering the potential benefits of clinically indicated induction.

The single most positive thing you can do to prevent primary cesareans is to avoid elective induction of labor.

On his blog for Frisco Women's Health Care Jonathan R. Weinstein, MD, FACOG states Induction has to be the biggest reason for the rise in [cesarean] rate in the United States, likely only second to your doctor's fear of being sued despite trying to do the best thing for you and your family. Elective induction can be convenient for both the mom and the doctor but buyer beware. If your cervix is not ripe (dilated and thinned out) prior to an attempted induction of labor you have up to a 90% failure rate for your induction which usually translates to you getting a [cesarean section].

Gail Hart succinctly chronicles the way even a simple uncomplicated induction can begin an avalanche of interventions. Beginning with the cervical stretching and sweep to ripen the cervix, then to IV Pitocin, electronic fetal monitoring and amniotomy, then perhaps an intrauterine pressure catheter, amnio-infusion for unusual fetal heart tones, an epidural for the pain of Pitocin-induced contractions, mal-rotation or poor descent for fetal distress. It goes on and on. The mother ends up with a lifelong injury to her uterus. Her baby may be stressed and separated from the family. A normal birth turns into a nightmare and that's only if all goes well!

Her conclusion is quite chilling: If we start a labor with chemicals, we may very well have to finish it with the surgeon's scalpel. This is hardly the scenario a mother imagines when she requests or concedes to the suggestion of nudging her baby out from the uterus to beat the holiday rush!

The chapter on Induction in the 3rd edition of A Guide to Effective Care in Pregnancy and Childbirth by Keirse, Neilson, Crowther, Duley, Hodnett and Hofmeyr reminds us that,

there is very little methodologically sound research on the indications for elective delivery. Irrespective of whether the induction is for social/ elective purposes or is medically indicated, current and recent research focuses instead on HOW to achieve the induction rather than what constitutes the need for induction vs. cost-benefit analysis.

If, given all these concerns over induction for both mother and baby, a woman still wishes to continue a dialogue about elective induction with her caregiver, then a comprehensive explanation of different induction methods ought to ensue. These methods were nicely reviewed in a May 2003 American Family Physician journal article: Methods for Cervical Ripening and Induction of Labor by Josie L Tenore, M.D., S.M. Likewise, a similar fact sheet written from a midwife's perspective provides similar content found at Nicole Deelah's Sage Beginnings.

Both resources mentioned above review the non-pharmacologic approaches to cervical ripening and labor induction such as herbal compounds, castor oil, hot baths, enemas, sexual intercourse, breast stimulation, acupuncture, acupressure, transcutaneous nerve stimulation, as well as mechanical and surgical modalities such as stripping of the membranes and amniotomy. Pharmacologic agents utilized for cervical ripening and labor induction include prostaglandins, misoprostol, mifepristone, relaxin and oxytocin (Pitocin). Ms. Deelah's information provides the realities of what each entails for the mother and its attendant risk for both her and her baby.

Both authors concur that in the absence of a ripe or favorable cervix, a successful vaginal birth is less likely. Therefore, cervical ripening or preparedness for induction needs to be assessed before any induction regimen is selected. Assessment is accomplished by calculating a Bishop score. In 1964, Bishop systematically evaluated a group of multiparous women for elective induction and developed a standardized cervical scoring system. The Bishop score helps delineate patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth.

No discussion of elective induction is complete without considering the impact on the baby. Although we certainly understand that at 37 weeks many women are exhausted from pregnancy and feel they are ready to give birth, their baby is physically not ready, says Cindy Fahey, MSN, RN, PHN, Executive Director, PAC/LAC. (Perinatal Advisory Council: Leadership, Advocacy and Consultation) Inducing labor before 39 weeks, with no medical indication, is dangerous for the newborn, and has been clearly shown to lead to increased complications at birth and beyond. We strongly urge pregnant women who plan to be induced to wait until at least 39 [completed] weeks of pregnancy.

The last few weeks of pregnancy are critical to both lung and brain development. Complications of elective deliveries between 37 and 39 weeks include:

• Increased NICU admissions
• Increased respiratory distress and TNN (transient tachypnea of the newborn)
• Increased need for ventilator support
• Increased rate of sepsis
• Increased feeding problems

We can't state strongly enough that early induction without clear medical cause is not only unnecessary; it can be damaging to the baby's health, says Fahey. We encourage women who are planning to be induced to discuss early induction and its associated risks with their physicians to ensure that they make the best choice for their baby.

Cara Terreri recently shared some astute observations on Giving Birth With Confidence about how to avoid a trip down the road to avoidable prematurity and describes the red flags a woman may encounter that tip her off to her caregiver's interest in proposing a medically unsubstantiated induction.

Yes, awaiting spontaneous labor can be inconvenient - but it also has many health advantages! A Cochrane Pocketbook: Pregnancy and Childbirth which focuses on the effectiveness of interventions on the health and well-being of pregnant women and their babies derived from the Cochrane systematic reviews reminds us that labor induction is considered when the benefits of earlier labor outweigh the risks of labor induction. Those of us who read the evidence behind the Lamaze Six Healthy Birth Practices perceive the benefits of waiting and the risks in inducing. Those who have only perceived the purported benefits of induction while bemoaning the risks of staying pregnant a few days or weeks longer may discover that one of the best holiday gifts they can offer their baby, themselves and their family is permitting the baby to choose his or her own birthday.

Post by: Joni Nichols BS MS CCE CD(DONA) (CBI)

[1] http://www.ajog.org/article/0002-9378(95)91415-3/abstract

[2] http://journals.lww.com/greenjournal/Abstract/2000/08000/Forty_Weeks_and_Beyond__Pregnancy_Outcomes_by_Week.26.aspx

[3] http://aje.oxfordjournals.org/content/153/2/103.full

[4] http://www.marchofdimes.com/pregnancy/vaginalbirth_inducing.html

[5] http://www.ncbi.nlm.nih.gov/pubmed/20027037

[6] http://www.aafp.org/afp/20000215/tips/39.html

[7] http://www.ncbi.nlm.nih.gov/pubmed/10511367

Published: December 26, 2010

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