Labor induction is the initiation of the labor and delivery process by pharmaceutical means or by breaking the mother's "water," a process known as amniotomy. The pharmaceutical compounds used are either a prostaglandin gel preparation that is applied directly to the cervix, or a synthetic version of the natural hormone, oxytocin. Approximately 23.3 percent of all labors are induced today (Murphy 345.e1) a number that has doubled since 1989 (Moore, MD 698). The same methods can all be used to "augment" labor as well, when it has slowed or failed to progress quickly. Just like any other medical procedure, induction is not without risks and is associated with a multitude of problems. This calls for action to be taken to educate patients and discourage physicians from performing this procedure unnecessarily.
There are many reasons for inductions, which can be either medical or elective. Common medical reasons include hypertension, a pregnancy extending too far past its due date, and fetal macrosomia or abnormally large fetus. Non-medical or elective inductions are often scheduled out of convenience, either for the physician or for the mother and her family, or when a woman has grown anxious to get her pregnancy over with. Elective inductions make up approximately one half to two thirds of all inductions (Moore, MD 698) (Simpson 768). The rate of medically indicated inductions has risen more slowly than the rate of all inductions, indicating that elective inductions are rising at a much faster pace (Moore, MD 698).
The most common means to induce labor is with intravenous Pitocin, a synthetic version of oxytocin, which is a natural human hormone that causes labor to begin when it is present in high concentrations ("Elective Labor Induction..." 219). Prostaglandin gels work by "ripening" the cervix, causing it to soften, efface, and dilate. They often bring on contractions as well. Gels are popular because they are easily administered and relatively inexpensive (Wing, MD 828). Amniotomy, or rupturing of the membranes, is the mechanical breaking of the amniotic sac that surrounds the baby and contains the amniotic fluids, which can initiate contractions but not always. These means may be used individually or in any combination with each other; it is not uncommon for a physician to order all three. The same methods may also be used to augment active labor that may have begun spontaneously but has stalled or failed to gain momentum in a manner considered acceptable to the physician.
There are a few advantages to inducing labor. It can potentially save lives in circumstances where continuing a pregnancy would put the mother or baby at significant risk. Mothers who live in rural areas can avoid the problem of going into spontaneous labor while they are from away from medical care. Another perceived benefit is the ability to schedule deliveries around the mother's visiting family members, that may otherwise miss the event, or around the physician's schedule in order to avoid being called in on weekends.
While it may have a few advantages, there are many more drawbacks to labor inductions, including inherent risks that are directly associated with the methods themselves. The medications used can cause hyperstimulation of the uterus, which puts undue stress on the fetus and often leads to "nonreassuring fetal heart rates" (FHR) (Simpson 769). Hyperstimulation can happen naturally but happens much more often with induced labor (Simpson 774). Induction can often cause a longer labor, especially in cases where the cervix is not already ripe, meaning that it is still firm, thick, and not at all dilated (Simpson 768). If due dates are miscalculated, the baby can be delivered prematurely which could lead to admission into the neonatal intensive care unit (NICU), a longer hospital stay ("Eliminating the Overuse of Labor Induction" 4), future readmissions, and the costs associated with such issues. Additionally, there are more occurrences of respiratory illnesses in babies whose deliveries were induced ("Eliminating the Overuse of Labor Induction" 4). For the mother, there is an increased risk of hemorrhaging during or after the third stage of labor, when the placenta is expelled. This puts the mother at risk for hysterectomy, possibly needing a blood transfusion, a prolonged hospital stay or future readmissions, and even death ("Eliminating the Overuse of Labor Induction" 4).
One particularly troubling aspect is the significant association found between inductions of labor at term (38 to 40 weeks) and the occurrence of bilateral cerebral palsy (CP) with quadriplegia (Lund 4). Preterm infants have long been known to be at risk for this condition; however, as fetal monitoring technology has improved over the years, the number of preterm infants developing CP has gone down. Alternatively, the number of infants born at term with the condition has not changed. This contradiction suggests that at-term inductions may play a role in causing the disease in these children (Lund 4), possibly increasing the risk of this form of CP by four times (Lund 4).
Having to deliver the baby surgically, commonly known as a cesarean section, is a significant risk. Overall, medically unnecessary, or elective, inductions cause a 67 percent increased risk for cesarean section delivery when compared to labors that begin naturally ("Unnecessary Induction of Labor..." 14). The incisions left by this surgery can lead to a host of other problems like infections, hysterectomy, and scarring. The internal scar tissue can cause the placenta to attach abnormally in future pregnancies. The healing process is painful and takes a long time, especially considering that even light physical activity, such as lifting one's baby, can cause the incision to reopen. Even after healing, many women will experience life-long abdominal pain ("Eliminating the Overuse of Labor Induction" 4). There is a higher rate of morbidity and mortality reported with cesarean sections and they increase the length of the hospital visit and healthcare costs associated with the stay, as well as with the procedure itself (Simpson 768). Typically speaking, cesarean sections that result from complications during inductions are likely to lead to further cesareans in each subsequent pregnancy (Simpson 770).
The medications and methods used to induce labor carry with them their own risks. There are many problems with the use of Pitocin, which is not even indicated for elective induction but is commonly used anyhow (Pitocin). The warnings listed by the manufacturer include anaphylactic reaction, postpartum hemorrhaging, arrhythmia (an irregular heartbeat), premature ventricular contractions (an extra, abnormal heartbeat), dangerously high blood pressure, hematomas (collections of blood) in the pelvic peritoneal area, bleeding in the brain leading to stroke, uterine ruptures and associated blood loss, and fatal afibrinogenemia - a condition of abnormal clotting due to decreased fibrin in the blood, which leads to prolonged bleeding (Pitocin). Even when administered properly, this drug can cause hypertonic contractions (Pitocin). The uterus is comprised of muscle tissue so labor contractions are just that, a muscle contracting. A hypertonic contraction happens when the uterus stays in a constant state of contraction, which is very painful for the mother and dangerous for the fetus. A further problem with Pitocin is its "intrinsic antidiuretic effect," meaning it causes the mother's body to retain water. This can lead to water intoxication and associated convulsions, coma, or death (Pitocin). Pitocin is not safe for the fetus either and, according to the manufacturer, at least a small amount probably reaches the baby's bloodstream (Pitocin). Common effects on the infant are low Apgar scores, jaundice, and retinal hemorrhage. The increased frequency and strength of the contractions can also cause a slow heartbeat, arrhythmia, premature ventricular contractions, permanent brain damage, central nervous system damage, seizures, and death (Pitocin). There is no information available as to whether it is a carcinogen or what effects, if any, it may have on fertility (Pitocin). Also somewhat troubling is that the manufacturer's sources for its claims, listed in the package insert, are all from 1982 to 1987 and none are specifically referenced in the body of the material provided so it is impossible to tell which source their specific information may have come from.
Prostaglandin gels don't appear to be any safer. One study attempted to compare the outcomes of inductions for mothers with previous cesareans when they were induced using one such gel, Misoprostal, versus Pitocin. The study was terminated early due to safety concerns when two mothers, both given the gel, experienced disruption of their prior uterine incisions. (Wing, MD 828). The authors noted that prostaglandin gels are known to alter the cervical tissue, both chemically and structurally speaking. They speculated that prior cesarean incisions may be exposed to the effects of the gel due to their close proximity to the cervix where the gel is applied, leading to deterioration of collagen fibrils in the scar tissue and eventual separation. This was likely exacerbated by the strain of the uterine contractions (Wing, MD 830). Even without incisions from previous cesareans, there are still reported cases of uterine rupture contributed to the use these prostaglandin gels (Wing, MD 828).
The drug-free choice, Amniotomy, may seem less risky than the use of pharmaceuticals but it is not without its complications. This procedure was once believed to shorten labor times and decrease the risk of cesarean sections; we now know that the opposite is true (Simpson 769). If the procedure is performed early on, as is the case when it is used to induce labor, it increases the risk of cesarean delivery (Simpson 769). If done with optimal timing, it may shorten, but at most only slightly (Simpson 769). Also, rupturing the membranes eliminates the cushion of fluid. This can cause injury to the fetus, severe variable decelerations in the fetal heart rate, or may result in the umbilical cord becoming trapped and compressed under the fetus, a condition known as cord prolapse. Each of these complications requires an emergency cesarean section (Simpson 769). It can also cause bleeding from undiagnosed vasa previa, which is a condition in which blood vessels are present close to the bottom of the cervix that are "free floating," or unsupported physically by the placenta or umbilical cord. Loss of the amniotic fluid that they were suspended in causes them to rupture under the pressure (Simpson 769). The membrane surrounding the amniotic fluid, when intact, creates a protective, physical barrier to the outside. Rupturing it leaves the fetus vulnerable to infection from exposure to bacteria, not only during the procedure itself, but also from each of the subsequent vaginal examinations that are performed quite frequently during labor (Simpson 769).
Another problem with inductions is the increased interventions they lead to, which carry their own significant risks and drawbacks. These interventions are suspected to be highly unreported and are often deemed to be unwarranted and lacking in scientific evidence to support their use (Simpson 768). Interventions significantly increase the likelihood of illnesses or injuries that result from medical examinations or treatments (Simpson 768) to both mother and baby.
Labor inductions often necessitate delivery of medications and/or fluids intravenously (I.V.) and constant electronic fetal monitoring (EFM) (Simpson 769). EFM can either be external or internal and both can be very uncomfortable. External monitors use sensors, which are each strapped with an elastic belt around the mother's abdomen, and include one to monitor the fetal heart rate and another to monitor the strength of her contractions. They must be worn very tightly in order to be accurate and effective. Internal monitors are more accurate than external sensors but are also significantly more invasive as they must be inserted vaginally and require an amniotomy, which can lead to infection. To monitor the strength of contractions, a pressure-sensitive catheter is inserted through the cervix against the inside wall of the uterus. For FHR, a small electrode is inserted directly into the baby's scalp by puncturing the skin with a small metal coil that is then twisted to keep it in place. To monitor the mother's vital signs, automated blood pressure monitors and pulse oximeters are typically used and left constantly connected to free up the time nurses would otherwise have to spend taking these measurements by hand. For the laboring mother, this means confinement to bed with limited movement because she is connected to several devices at once.
Immobility can cause increased discomfort during labor and leaves the mother with no way to try different positions for pain relief. This, in turn, leads to the increased use of epidural anesthesia, which can lead to even more risks and interventions. Epidurals are painful to receive and lead to complications such as hypotension, fever, fetal heart rate decelerations, and chronic headaches for weeks after delivery (Simpson 770). They can also prevent mothers from feeling the urge to push, requiring the nurses to use "laboring-down" techniques in which the mother is directed when to push and her legs are held while her torso is pushed forward to create more outward pressure on the fetus. If this fails to produce sufficient results, the physician may have to resort to assisted delivery, or operative vaginal birth. For this procedure, a vacuum suction device or forceps are inserted into the vagina and suctioned to or clamped on the infant's head, enabling the doctor to physically pull the infant through the birth canal. Use of these devices necessitates an episiotomy (surgical cutting of the vaginal opening) which can cause third and fourth degree perineal tears, sometimes leading to anal sphincter injuries, further lacerations in subsequent births, infections, loss of blood, scars, pain, extended healing time, or sexual dysfunction and painful intercourse potentially lasting years (Simpson 770).
Some mothers also report problems with breastfeeding after epidurals and it is noted that breastfeeding issues commonly arise after inductions (Herrman) ("Eliminating the Overuse of Labor Induction" 4). Problems breastfeeding can inhibit maternal-child bonding ("Eliminating the Overuse of Labor Induction" 4). If breastfeeding is discontinued because of problems, the infant misses out on benefits like antibodies, lowered risk of obesity and other chronic illnesses, and increased IQ ("Eliminating the Overuse of Labor Induction" 4).
Inadequate staffing of nurses contributes to the problems associated with inductions. It is the nurses' responsibility to properly titrate the infusion of Pitocin but this can be problematic for a number of reasons (Simpson 771). Many aspects of the physiology of labor are still unknown so determining the optimal dose for individuals is difficult, if not impossible (Simpson 771). Furthermore, dosage adjustment protocols depend on a typical rate of increase as well as clinical criteria regarding the progress of labor, such as frequency and strength of contractions and how well the mother and fetus are tolerating them. The latter of these two requires close and frequent observation of patients, something nurses have little time to do, so they tend to focus more on the rate of increase portion of the protocol, without considering the actual progress of labor. This means that they may increase the dose at certain time intervals even if labor is progressing well enough that an increase is not warranted (Simpson 771). This increases the probability of overdose and the nurses' lack of immediate observation only compounds the problem. Busy nurses often record observations retrospectively, meaning they use the heart rate monitor strip and other device readouts to chart patients' vital signs, as they have already passed rather than as they occur. Consequently, an overdose of Pitocin, which should have been treated at the first sign of uterine hyperstimulation, may continue until it has gone so far as to cause fetal distress (Simpson 774).
Changing the current system should be encouraged through education and policy change. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) encourages doctors and mothers alike not to choose induction of labor unless it is medically necessary ("Eliminating the Overuse of Labor Induction" 4). Such a procedure should only be recommended when the benefits outweigh not only the risks associated with the induction but also those associated with continuing the pregnancy. Holding the decision to such high standards would eliminate the use of induction for reasons that are merely convenient or social.
A public campaign to educate mothers about the risks of labor induction might make it less acceptable and desirable. Many women have a positive attitude towards induction and its promise to shorten the length of their pregnancies and speed up the process of labor and delivery (Herrman) (Simpson 770). They also do not typically object to the use of most interventions, so long as they have access to epidural pain management (Simpson 770). Given this perception, it is unlikely that they are being provided with a thorough explanation of the risks that come with induction or the interventions that commonly follow it. ACOG and the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) advise medical practitioners to inform mothers of the acceptable reasons for inducing labor, the methods and medications used, the possibility of complications, and any alternatives that may be available to them. It is believed that most mothers, if they are being told of these issues at all, are not made aware of them until they have already arrived at the hospital for induction and are being prepped for the procedure, at which point it is likely too late for them to make any other choice (Simpson 770).
Policies should also be put in place to decrease the liberal recommendation and use of labor induction. AWHONN has urged insurance companies to adopt payment plans that would make it less financially favorable for physicians to perform labor inductions and augmentations for elective or marginally medical reasons. Such a policy could go a long way in encouraging physicians to allow normal pregnancies to continue until labor begins naturally and could encourage hospitals to be more stringent when it comes to allowing admissions for inductions. This might also motivate physicians and institutions to discourage patients from seeking inductions for social reasons and educate them as to why it is best to wait for nature to take its course ("Eliminating the Overuse of Labor Induction" 4).
The bottom line is that the safest births are those that take place at or near term and happen spontaneously ("Unnecessary Induction of Labor..." 14). Mothers need to wait for their babies to decide when they are ready to come into the world. "Prospective studies are limited or non-existent to recommend induction of labor for elective or marginal indications" (Moore, MD 698). Additionally, physicians need to stop recommending inductions electively or for reason that are not absolutely warranted for the safety of mother and child. Even in cases where a previous cesarean has left a potentially hazardous incision and scar tissue, allowing labor to begin spontaneously and delivering vaginally is not only considered safe, but is recommended. However, inducing labor under these circumstances is highly problematic (Wing, MD 828). Suspicion of fetal macrosomia is cited as a common reason for recommending induction, but there is no scientific evidence showing that maternal or fetal outcomes are improved in these cases and the American Congress of Obstetricians and Gynecologists (ACOG) does not consider it a reasonable indication (Simpson 768). Public campaigns should be initiated to educate mothers of the risks of inductions and when it is appropriate to have one. Furthermore, policies should be put in place to encourage physicians and hospitals to lower the number of unnecessary inductions that are performed.
At first glance, it may seem beneficial to be able to plan the delivery of a baby as easily as one can schedule any other appointment in their calendar. However, when consideration is made for the increased interventions, higher rates of complications, prolonged hospital stays, significantly higher financial costs, and potential litigation that all may result from such a decision, it becomes clear that mothers should exercise much more caution when considering whether to undergo the procedure and physicians should reevaluate their current practices of excessively recommending it. Childbirth is a natural process that has had plenty of time to be perfected by nature. It is not a disease to be cured or even treated. "Surely God and/or Mother Nature have not failed U.S. childbearing women, to the extent that 1 out of 4 women requires abdominal surgery to give birth, 1 out of 4 requires artificial rupture of their membranes to initiate or stimulate labor, 1 out of 2 requires exogenous oxytocin to achieve normal labor progress, and 1 out of 3 requires an episiotomy, forceps, and/or vacuum to give birth" (Simpson 768-69).
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