Friday, October 9, 2009

Induction of labor..what's the harm?

A pregnant woman is 41 weeks and 2 days "overdue". She sits up in her hospital bed as she tries to grab the attention of the obstetrician on call. "Dr H! Wait, come here a second. What are the results of my blood tests? What's going to happen now?". Dr. H responds quite stoically and detached and says in the frankest manner, " Well, if by Monday your labor does not start yet, you'll be induced" and he left with the most hurry of the world. "Induced?!" I thought, "no way!". That same night, I went to bed with the world on my shoulders. When I awoke to go to the bathroom, at 1:30 am, as I got up to get out of the bathroom, IT hit me. "Uffffffffffffff" My eyes got really big and I knew it. I've never been in labor before, but I knew this was it! I grabbed my ipod and set it to stopwatch. Sure enough, I was right. Contractions started at 3-4 minutes apart, lasting 30-45 seconds. I thought, "This is not fair, this is not supposed to be this strong at the beginning!" Feeling the need, I started my coping techniques I learned in CBE classes. I walked around, briefly pausing to breathe through the contractions. Now that I look back I think, 'would you look at that, the night the OB said I'd be induced, the baby must have heard it and was like, NAH AH! I'm deciding on my own time to come out!'. However, on a more sad note, not many women, especially recently, wait for labor to begin on its own.  Some women, blindly trusting in their doctors, give them free rein to induce them at the drop of a hat once they are considered "overdue". These women probably never knew or never considered the numerous risks associated with labor induction/social labor induction.

Today, more and more women of every size are having their labors induced. This is risky because when labor is started artificially, it means that the baby and mother are not truly ready for birth yet, and complications can ensue. (Study references beyond those already linked to can be found in the Healthy Birth Practice Paper, here.)

Inducing labor, especially in first-time mothers, tends to increase the risk for cesareans. The mother's body may not be ready to dilate fully and she may therefore end up with a cesarean for "Failure To Progress" (FTP). Or the baby may not yet be in the easiest position for birth and the mother may end up with a cesarean for "Cephalo-Pelvic Disproportion" (CPD, or baby didn't fit right).

Inducing labor also increases the risks for vacuum- and forceps-assisted births. This is often because the baby had not yet moved into an optimal position for birth, or because the mother has an epidural and the baby cannot rotate easily through the pelvis. Help may be needed to get the baby out, but this help often also comes with the price of an episiotomy (cutting to widen the vaginal opening).

Inducing labor early can also result in a "near-term" preemie which may experience problems with jaundice, low blood sugar, and difficulty breastfeeding. Even close to term, the baby's lungs may not be completely ready to breathe yet on the outside, and as a result, the baby may experience respiratory distress after the birth and end up in the Neonatal Intensive Care Unit (NICU).

Induction also carries direct risks to both mother and baby in other ways as well. For example, the induced mother's uterus may experience "tachysystole" (hyperstimulation) and labor may need to be stopped before it results in uterine rupture (a tear in the uterus) or placental abruption (the placenta pulling away from the uterus prematurely). Induction is also associated with amniotic fluid embolism, and while rare, this can result in death to the mother.

Furthermore, although synthetic oxytocin (a.k.a. "pitocin" or "syntocinon") is chemically the same as the mother's own oxytocin, it does not act exactly the same in the body during labor. As Dr. Sarah Buckley notes:

Synthetic oxytocin administered in labor does not act like the body’s own oxytocin. First, syntocinon-induced contractions are different from natural contractions, and these differences can cause a reduced blood flow to the baby. For example, waves can occur almost on top of each other when too high a dose of synthetic oxytocin is given, and it also causes the resting tone of the uterus to increase.

Second, oxytocin, synthetic or not, cannot cross from the body to the brain through the blood-brain barrier. This means that syntocinon, introduced into the body by injection or drip, does not act as the hormone of love. However, it does provide the hormonal system with negative feedback—that is, oxytocin receptors in the laboring woman’s body detect high levels of oxytocin and signal the brain to reduce production. We know that women with syntocinon infusions are at higher risk of bleeding after the birth, because their own oxytocin production has been shut down.

Induction also carries risks to the baby. Induction often involves breaking the mother's amniotic sac manually at some point during labor, which carries the risk of umbilical cord prolapse. Although rare, this can cause brain damage or even death to the baby and necessitates an immediate emergency cesarean.

The use of labor induction drugs often causes contractions that are harder and closer together than in spontaneous labor, and as a result, baby is not given as much time to recover its oxygenation between contractions. This lack of recovery time can cause fetal distress. This is why babies must be continuously monitored during an induced or augmented labor.

These harder, longer, and more intense contractions often also result in a higher use of pain medications by the mother. There is nothing wrong with choosing to receive pain medications if you need them (and it's great that women have the choice available if needed), but it's important to remember that these are strong medications and they do carry real risks to both mother and baby.

While many women go into labor intending to "go natural" (without pain medications), this becomes very difficult if the mother is induced. Although not impossible, it's a rare woman who is able to complete a whole induced labor and birth without at least some pain medications.

Furthermore, induction increases the risks of further interventions becoming "needed," all of which have their own risks. And induction decreases the mother's ability to utilize the other Health Birth Practices such as move freely, be upright for pushing, etc.

Induction of labor is far from the benign and minimally risky option that many doctors portray it to be. It has real risks, and in many cases these risks are underplayed.

Sometimes induction of labor is truly needed, and as with cesareans, we can be glad that it is available when needed. However, also as with cesareans, its casual overuse without sufficient consideration about possible risks may result in significant harm.

Unfortunately, many mothers, whether first time or for the second or third time around, do not know/are not informed about these facts. To make things worse, many health care providers gloss over these facts and sugar coat a lot of details. In Aruba, it is especially common for the health care provider (ob/gyn) not to explain anything, and sometimes, even when explicitly asked! A young woman I know would constantly ask me  questions about certain scribbles on her file from the midwife. I would explain them to her, but then I once asked her, 'why don't you simply ask your midwife during your appointments?' Her answer : "She said don't worry with those scribbles". Why...why do doctors especially, stop explaining? I think it's simple, because if they were to give the actual details on, for example, labor induction, the vacation your obstetrician was planning will be canceled, oh and the money to pay for it? Well, the cesarean that was "highly neccesary" was not performed...

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