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Sidebar: Medical Indications For Inducing Labor [1]
By Nancy Griffin
Issue 105, March/April 2001
It was a sunny Friday afternoon, and Tracy was three days past the due date for her first baby. After finishing up the tenth call of the day from well-meaning but anxious friends and relatives, she headed out the door for her weekly checkup with her obstetrician. "If you don't go into labor by your next appointment, we may have to induce you," her doctor had advised. Tracy wondered if the slight menstrual-like cramps she'd had the past few days meant that something was happening at last.
At the doctor's office, a vaginal examination revealed that Tracy was 2 centimeters dilated, her cervix 80 percent effaced, with the baby at minus one station. According to an ultrasound scan, her amniotic fluid levels seemed borderline low, and because she was having mild contractions, the doctor suggested that she "go on over to the hospital and have a baby today!"
Excited, Tracy called her husband at work. He rushed to meet her at the hospital, where she was admitted and hooked up to an IV. Eight hours later, with no further progress, Tracy received an epidural, and labor was induced by the intravenous administration of the commonly used drug Pitocin. A few hours later, her bag of waters was broken artificially; 36 hours later, Tracy was recovering from a C-section after delivering a healthy, 7-pound baby girl. Why did Tracy have to undergo a C-section? What, if anything, had gone wrong?
Nearly two decades ago, Roberto Caldreyo-Barcia, MD, former president of the International Federation of Obstetricians and Gynecologists and an eminent researcher into the effects of obstetrical interventions, made the stunning statement that "Pitocin is the most abused drug in the world today."1 According to the Journal of the American Medical Association, 16 percent of expectant mothers are induced in the US; another 16 percent go into labor spontaneously but are helped along ("augmented") by Pitocin or a variety of other labor-stimulating interventions.2 Other estimates range from 12 to 60 percent of mothers, depending on whether the numbers refer to type of induction or augmentation, the population sample, or the mother's socioeconomic background.3-18
Pitocin is a synthetic oxytocin (the natural hormone that induces labor) made from pituitary extracts from various mammals, combined with acetic acid for pH adjustment and .5 percent chloretone, which acts as a preservative. The World Health Organization deplores routinely using Pitocin. The Physicians' Desk Reference says that Pitocin should be used only when medically necessary, beginning with a minimal dosage, as there's no way of predicting a pregnant woman's response. The induced mother should receive oxygen, be continuously monitored by EFM, and have competent, consistent medical supervision. At the first sign of overdosage, such as or fetal distress, Pitocin should be discontinued, and the patient treated with symptomatic and support therapy. After being induced, the laboring mother can still help her labor progress through natural techniques such as walking (if she's not had an epidural), changing positions, emptying her bladder once an hour, and nipple stimulation. Pitocin can cause increased pain, fetal distress, , and retained placenta; and recent research suggests that exposure to Pitocin may be a factor in causing autism.19-20
A survey by Robbie Davis-Floyd, a cultural anthropologist at the University of Texas, found that 81 percent of women in US hospitals receive Pitocin either to induce or augment their labors.21 Regardless of exactly how many labors are induced in the US today, the majority aren't medically necessary, and between 40 and 50 percent resulted in failed induction.22 A review of the medical literature on routine induction of labor reveals that disagreement among medical researchers in different countries is rampant, and no conclusive evidence exists that routine induction of labor at any gestational age improves the outcome for either mother or baby.23 Caldreyo-Barcia concluded that induction is medically required in only 3 percent of pregnancies24 and that therefore approximately 75 percent of all inductions put both the mother and baby at risk.25
The "Cultural Warping of Childbirth"
Induction of labor is defined by the American College of Obstetricians and Gynecologists (ACOG) as "the stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing delivery"--that is, artificially starting a labor that has not begun naturally on its own. Augmenting labor, often confused with induction, is a slightly different process, used to help or speed up a labor that began on its own. Midwives, physicians, and other healthcare providers have been inducing labor for as long as the human race has attempted to gain control over the processes of nature. A basic fear of the natural process of childbirth has led, over many centuries, to what President of the American Foundation for Maternal-Child Health Doris Haire describes as "the cultural warping of childbirth." Justifiable fear about the possible death of a baby or mother in childbirth, combined with beliefs in magic, rituals, drugs, herbal remedies, and much later, technology, has led to the use of a whole host of "cures" for labors that didn't seem to start "on time."
In his classic book Husband-Coached Childbirth, Robert Bradley, MD, compares the arrival of human babies by nature's schedule to fruit ripening on a tree. Some apples ripen early, some late, but most show up right in season. Along with Grantley Dick-Read, the father of what we now call "natural childbirth," Bradley advocated relaxation, trusting nature, and allowing babies to show up when nature intended.
Artificial oxytocin, or Pitocin, was successfully synthesized in 1953, and two years later it was available to physicians for the inducing and augmenting of labor. By 1974 it was well known that Pitocin had a 40 to 50 percent induction failure rate;26, 27, 28 and in 1978, largely due to the work of Doris Haire, Pitocin was investigated by the US Senate and the General Accounting Office. Between 1978 and 1981, Haire testified at three congressional hearings on obstetric care, which included reports on the dangers to mothers and babies of the routine and elective induction of labor. (Elective induction is defined as the induction of labor without a clear medical indication.)
One compelling theory, presented at the 1996 annual meeting of the American Psychiatric Association by Eric Hollander of in New York, links autistic children with Pitocin-induced labors. Hollander suspects that Pitocin interferes with the newborn's oxytocin system, producing the social phobias of autism. When he administered oxytocin to autistic patients, it made them four times more talkative, and according to the patients themselves, twice as happy, although not all patients responded.29
In 1978, the FDA advisory committee removed its approval of Pitocin for the elective induction of labor. (The drug has never been approved by the FDA for the use of augmenting labor.) The current Physicians' Desk Reference clearly states that "Pitocin is not indicated for elective induction of labor." An innovative New York , section 2503, passed in 1978, requires physicians and midwives to provide full, informed consent to laboring mothers regarding the use of drugs during labor and delivery.
Today, despite the problematic nature of inducing labor and the lack of hard data supporting these protocols from carefully designed controlled trials, the routine elective induction of labor in both normal and gray-area pregnancies (ones not yet showing clear medical indication, just possibilities) is still common.
Why Induce Labor?
According to ACOG, "Induction of labor is indicated when the benefits to either the mother or fetus outweigh those of continuing the pregnancy."30 A very small number of babies (a typical estimate would be less than Caldeyo-Barcia's 3 percent, mentioned above) actually need to be induced for medical reasons. Another 3 to 12 percent seem to want to drive their mothers crazy and hang out inside that wonderful, warm, loving womb. No one knows why these suspected "postmature" babies choose not to make an appearance exactly when those of us on the outside want them to.31
Actually, the percentage of babies born exactly on their predicted due date is so small it's a wonder we bother with due dates at all. It's perfectly normal for 80 percent of healthy babies to have anywhere from a 38- to 42-week gestation.32 Several generations ago, a physician might tell an expectant mother that she was due "sometime in late October or early November"; today, women are given a "precise" due date, often determined by ultrasound testing. Many instances of so-called postmaturity result from nothing more than an inaccurate due date.
Robert Mittendord of the University of Chicago Medical Center has isolated 16 factors that can influence the accuracy of a predicted due date. Ethnicity may play a role; African-American women, for instance, often have pregnancies that are, on average, three to eight days shorter than those of other women. First-time mothers can almost be counted on to deliver ten days or more after their due date. The length of gestation seems to peak for babies of mothers who are around 29 years of age, so maternal age may be a factor. Caffeine consumption makes pregnancies shorter. Taking The Pill up to two months before conception can cause havoc with due dates. Finally, because biologic variation in fetal size increases throughout gestation, ultrasound dating can be deemed somewhat reliable only in the first trimester.33
The gestational age of an unborn baby is best determined by looking at a number of different factors. If you combine an accurate date of the last menstrual period with a first-trimester pelvic exam, fundal measurement (from the pubic bone to the top of the uterus), date of "quickening," and a fetal heart tone, then confirm these findings with a first-trimester ultrasound, you'll end up with a due date that is still only 85 percent accurate, plus or minus 14 days. Second-trimester ultrasounds tend to be inaccurate by plus or minus 8 days, and third-trimester ultrasounds by a whopping 22 days.
It's probably best to stick with the "late November, early December" method unless you are fortunate enough to know the exact date of conception, another way to attempt to pinpoint a due date. Medical science recognizes in vitro or artificial insemination as the only accurate means of determining conceptual age. However, if a woman was using an ovulation predictor test correctly, or her husband was home between business trips only once after her period ended (and she actually wrote this date down on a calendar), she could nail down her due date by counting forward ten lunar months from conception. Even so, she might end up with a baby who stubbornly decides to belong to that 10 percent who go beyond 40 weeks. Despite all of these calculations, an induced baby may turn out to be premature rather than postmature.
<!--pagebreak-->What Exactly Is Postmaturity?
ACOG defines a post-term pregnancy as one that lasts beyond 42 weeks of confirmed gestational age. The need to diagnose postmaturity accurately is important because , the risk of fetal distress, and the need for C-sections double by 42 weeks.34-38 Risks of true postmaturity include stillbirth, meconium aspiration, and "dysmaturity syndrome," found in some babies adversely affected by being in a declining uterine environment. Robert Hamilton, assistant clinical professor of pediatrics at UCLA, says that in all his years as a pediatrician, he has seen actual postdate babies less than 5 percent of the time. Moreover, the vast majority of post-date babies overcome problems after birth and are ultimately healthy.39, 40 AGOC estimates that 95 percent of post-term babies are born safely between 42 and 44 weeks.41-45 (Perhaps these babies were meant to "ripen" a bit later than their "average" counterparts.)
The most accurate current criterion for diagnosing postmaturity is the mother's amniotic fluid volume. As placental function decreases in a true postmature pregnancy, blood flow and blood pressure in fetal organs decreases. The result is lower levels of amniotic fluid, as measured by an amniotic fluid index. Fluid levels of less than 5 centimeters are considered low and greatly increase the risk of . A normal level is 8 centimeters or more; 5 to 8 centimeters is borderline. (Borderline fluid levels can be caused by something as simple as dehydration, so a woman should be sure to drink plenty of water throughout her pregnancy.)
It is not known whether the increased risk to the baby is caused by the postmature pregnancy itself, or if some babies who are inherently at greater risk are more likely to be overdue. Therefore, it is difficult to determine via research if the timely induction of labor decreases the risk in post-term pregnancies. The ' 1996 Assessment of Post-Term Pregnancies concludes that whether there is any "fetal testing modality that will provide the most accurate prediction of a healthy fetus is debatable."46
How Does Labor Begin Naturally?
Up until recently very little was known about how natural labors actually begin. Scientists knew that the release of oxytocin resulted in both uterine contractions and milk production. Pioneering research by scientists at Cornell University, the University of Pittsburgh School of Medicine, and the University of Auckland, New Zealand, suggests that it's the baby's brain that initiates birth.47
These researchers discovered a pea-sized region of the fetal sheep brain called the , which actually serves as a biosensor designed to trigger the events leading to a birth. Two hormones, corticol and adrenocorticotropic hormone (ACTH), reach peak levels in the fetal bloodstream just before birth. Peter W. Nathaniels of Cornell University suggests that the "fetal brain may act as a tiny monitor, tracking its own development."48 When the baby is ready for birth, the paraventricular nucleus signals the fetal pituitary gland to increase ACTH secretion. The pituitary, in turn, tells the fetal adrenal gland to secrete more cortisol. These hormonal increases cause changes in the mother's hormones, including the release of oxytocin, which lead to uterine contractions. Because scientists speculate that a malfunction of the fetal biosensor may account for early or late births, this research may prove helpful in the future, both to stop premature labor or to effectively induce a truly postmature pregnancy.
All of the currently available methods of inducing labor bypass this important first step of fetal paraventricular nucleus biosensor interaction between the hormonal systems of both mother and baby.
Protecting Our Unborn Babies
Labor should be induced only when medically necessary, never simply for convenience or because a woman is sick of being pregnant. The risks in these situations far outweigh the perceived benefits. Determining postmaturity or a woman's readiness to give birth are complex processes. We are just beginning to understand the long-term effects on the fetal brain of drugs such as Pitocin, and the exact long-term effects of inducing or augmenting labor are unknown. Pregnant woman wanting information on the safety of a drug can consult the Physicians' Desk Reference or call the product safety officer at the pharmaceutical company where it is manufactured.
Not all babies appear to be harmed by the inducing or augmenting of labor, but these procedures do carry risks. According to Doris Haire, "The fact that Pitocin can shorten the normal oxygenating intervals that occur between contractions is a threat to the integrity of the fetal brain and can have lifelong consequences for the affected baby."49
Pregnant women owe it to themselves and their unborn babies to do everything they can to stay healthy and thereby minimize or prevent the need for medical induction. Babies born from natural, spontaneous labors have the best overall outcomes, and their mothers experience easier labors and quicker postpartum recoveries.
Natural Methods for Inducing Labor
Suggestions for the natural induction of labor have ranged from taking castor oil to having sex. Before turning to a few techniques that might actually work, let's take a look at some of the "old wives' tales" that have made the rounds.
Castor oil simply causes the person taking it to empty her bowels quickly and efficiently. Because the uterus is so tightly wedged against the intestines, movement in the bowel can sometimes trigger uterine activity. Castor oil looks like a pretty silly remedy when one realizes the complex interaction between the brain chemistry of the mother and the baby leading to labor. Take castor oil only under the supervision of a midwife or a doctor. Balsamic vinegar and senna tea have similar but much weaker effects on the intestines.
<!--pagebreak-->Uterine-stimulating herbs, such as black cohosh (Caulophyllum), blue cohosh (Cimificugua), achyranthes root, goldenseal, motherwort, wild ginger, and red raspberry leaf, have been used to induce labor. No long-term follow-up study has ever been carried out to show that the use of herbal remedies is safe for inducing labor. All drugs, including medicinal herbs, reach the baby, and any dosage that has an effect on the mother is going to have an overdosing effect on the baby simply because the mother's body weight is about 20 times greater. A pregnant woman, therefore, should never self-prescribe any medicinal herb. Anyone who must be induced for a medical reason, and who wishes to use alternative induction methods, should be guided by a knowledgeable herbalist, acupuncturist, or aromatherapist.
Essential fats and oils such as pennyroyal and safflower have historically been used to treat all manner of female complaints and are considered to be alternatives to cervical gel (artificial prostaglandins applied directly to the cervix to "ripen" it). Safflower is simply a safe cooking oil, but pennyroyal is known to have potential abortive effects.
Acupressure is considered by some American practitioners as potentially effective in jogging a late labor, but traditional Oriental practitioners almost never use acupuncture on women at any time during pregnancy. Traditionalists believe in trusting Mother Nature.
Aromatherapists advocate the use of the oils of lemon, clarysage, and fennel, which are massaged into the abdomen and inhaled by the expectant mother. Anything inhaled by a pregnant woman, however, is also inhaled by her baby, and cannot therefore be deemed safe.
Sex is an age-old method of induction that seems to be effective. Prolonged and continuous nipple stimulation results in the natural release of oxytocin and is a proven nonmedical method for inducing labor.50, 51, 52 The release of semen onto the cervix during intercourse can promote cervical ripening because semen contains prostaglandin, a hormone partially responsible for cervical softening.
Finally, relaxation--mental, physical, and emotional--prevents the pregnant woman from releasing adrenaline, a hormone that stops labor so that the expectant mother can find safety first before her baby is born.
All of these things, together with a healthy lifestyle, good nutrition, and a healthy pregnancy, combine to produce healthy babies who show up on time--the exact moment when nature intended.
Notes
1. Diana Korte and Roberta Scaer, A Good Birth, A Safe Birth (New York: Bantam, 1984).
2. JAMA Statistical Bulletin (January 21, 1998).
3. "Induction of Labor," Technical Bulletin 217 (December 1995).
4. "Induction of Labor in Postterm Pregnancy," ICEA Review 12, no. 1 (February 1988).
5. See Note 2.
6. " While Waiting for Spontaneous Labor Compared to Immediate Induction Following PROM," New England Journal of Medicine (1996).
7. Assessment of the Postterm Pregnancy, American Academy of Family Physicians, 1996.
8. "A Critical Review of the Recent Literature on Postterm Pregnancy and a Look at Women's Experiences," Birth (1985).
9. "Elective Induction v. Spontaneous Labor: A Retrospective Study of Complications and Outcomes," American Journal of Obstetrics and Gynecology (1992).
10. "Postdate Pregnancy, Part 1 and 2," Journal of Nurse-Midwifery (1985).
11. "Postmaturity: Much Ado about Nothing?," British Journal of Obstetrics and Gynecology (1986).
12. "Prolonged Pregnancy: The Management Debate," British Medical Journal (1986).
13. "Elective Induction of Labor," The Lancet (May 1975).
14. Henci Goer, Obstetrical Myths v. Research Realities (Westport, CT: Bergin and Garvey, 1995).
15. See Note 1.
16. Sally Inch, Birth Rights (New York: Pantheon, 1984).
17. "Care in Normal Birth," The World Health Organization.
18. Robbie Davis-Floyd, Birth as an American Rite of Passage (Berkeley: University of California Press, 1992).
19. See Note 17.
<!--pagebreak-->20. "Life in a Parallel World: A Bold New Approach to the Mystery of Autism," Newsweek, May 13, 1996.
21. See Note 18.
22. See Note 16.
23. See Note 14.
24. Ibid.
25. See Note 1.
26. The Physicians' Desk Reference, 52nd ed. (Montrale, NJ: Medical Economics Co., 1998).
27. See Note 10.
28. "Neonatal Morbidity and Mortality and Long-Term Outcome of Postdate Infants," Clinical OB-Gyn (1989).
29. See Note 20.
30. See Note 3.
31. See Note 7.
32. Ibid.
33. Ibid.
34. See Note 4.
35. See Note 7.
36. See Note 8.
37. See Note 10.
38. See Note 11.
39. See Note 4.
40. See Note 7.
41. See Note 4.
42. See Note 7.
43. See Note 8.
44. See Note 10.
45. See Note 11.
46. See Note 7.
47. "Fetus Tells Mother It's Time for Labor," Science News.
48. Ibid.
49. Personal interview, Doris Haire, September 23, 1998.
50. Jacques Gelis, History of Childbirth (Boston: Northeastern University Press, 1991).
51. Richard Wertz, Lying-In: A History of Childbirth in America (New Haven, CT: Yale University Press, 1989).
52. See Note 18.
Resources
The Bradley Method. The American Academy of Husband-Coached Childbirth. 91413-5224 PO Box 5224, Sherman Oaks, CA 91413. 800-4-A-BIRTH (800-423-2397) www.bradleybirth.com [2]
The American Foundation for Maternal and Child Health. 439 E. 51st Street, New York, NY 10022. 212-759-5510
International Childbirth Educators Association. PO Box 20048, Minneapolis, MN 55420. 612-854-8660. www.icea.org [3]
American College of Obstetricians and Gynecologists (ACOG). 409 12th Street, SW, Washington, DC 20024-2188. 202-863-2518 (Resource center). www.ACOG.org [4]
National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPSAC). Rt. 4, Box 646, Marble Hill, MI 63764. 573-238-2010.
Internet Resources (available by subscription or at libraries)
Infotrac, Medical Lexus, Medline, Elsevier
<!--pagebreak-->Science Books
Brackbill, Yvonne. The Birth Trap. C. V. Mosby, 1984.
Bradley, Robert. Husband-Coached Childbirth. Bantam Books, 1996.
David-Floyd, Robbie. Birth as an American Rite of Passage. University of California Press, 1992.
Dick-Read, Grantley. Childbirth without Fear. 5th ed. Harper & Row, 1984.
Edwards, Margot, and Mary Waldorf. Reclaiming Birth. The Crossing Press, 1984.
Elkins, Valmai Howe. The Rights of the Pregnant Parent. Shocken Books, 1980.
Goer, Henci. Obstetric Myths versus Research Realities. Bergin and Garvey, 1995.
Inch, Sally. Birth Rights. Pantheon Books, 1984.
Korte, Diana, and Robert Scaer. A Good Birth, A Safe Birth. Bantam, 1984.
McCutcheon, Susan. Natural Childbirth the Bradley Way. E. P. Dutton, 1984.
Mitford, Jessica. The American Way of Birth. Penguin Books, 1992.
Romalis, Shelly. Childbirth: Alternatives to Medical Control. University of Texas Press, 1981.
Rothman, Barbara. In Labor: Women and Power in the Birthplace. W. W. Norton, 1982.
Nancy Griffin, MA, AAHCC, is the mother of a 16-year-old daughter and owner of the Mommy Care Mothering Center in Los Angeles. She is a Bradley Method childbirth teacher at St. John's Hospital, a lactation educator, and an expert in pregnancy and postpartum exercise. Nancy would like to thank Haire for her invaluable assistance with this article.