Many American hospitals and Obstetricians have put a “hard stop” on elective labor inductions. As a result many hospitals and physicians are seeing a significant drop in still births, NICU admissions, cesarean sections and post partum hemorrhage. Data presenting the effects of such hospital practice policies was presented at the American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting.
The United States has long been noted to have adverse birth outcomes that, in some instances, rival those of developing nations with far fewer resources. With the world’s eye upon us, many hospitals adopted a no elective labor before 39 weeks gestation policy. This means that under no circumstances is a mama to be induced before 39 weeks gestation unless it is absolutely medically necessary; there is danger to the life of mama or baby. Otherwise, Mamas and babies have to “tough it out” to term. Additionally, many hospitals are adopting strict policies against obstetricians who perform elective inductions in an effort to deter the practice.
The results of the policy has shown the following results according to researchers Nathaniel DeNicola, MD, from the University of Pennsylvania, in Philadelphia, Andrew Healy, MD, medical director of obstetrics at Baystate Medical Center, in Springfield, Massachusetts and Angela Silber, MD, director of maternal-fetal medicine at Summa Akron City Hospital, in Ohio:
Dr. DeNicola’s Study (A Survey Study)
- Many hospitals have adopted specific policies against elective induction
- Nearly two thirds of more than 2600 hospitals have “no elective induction” policies in place.
- 67% of hospitals have a formal policy against non-medically indicated labor induction, and among those without a formal policy, just over half said it was against their standard of care.
- 69% of formal hospital policies were hard-stop, meaning strictly enforced, as opposed to soft-stop or strongly discouraged.
Dr. Healy’s study
- Compared 9515 singleton births before the policy and 2641 singletons after the policy found a significant decrease of 5.9 hours in the median time to delivery (P = .002).
- The cesarean section rate for elective inductions also decreased from 16% before the policy to 7% after (P = .05).
- NICU admission rates decreased by a third. Before the policy, 3% of term babies got admitted to the NICU and after the policy that went down to 2%” (P = .02).
- No increase in the stillbirth rate
Dr. Silber’s pre- and post policy comparison
- Decrease in stillbirths and NICU admissions
- Comparing 9806 singleton deliveries before the policy and 6041 singletons after, the number of stillbirths decreased significantly from 16 to 3 ( P = .023), with a trend toward significance in the reduction of NICU admissions (from 867 to 587; P = .06).
- There was no significant difference in macrosomia (Large for gestational age) rates (P = .718)
Other data not fully analyzed shows a decrease in cesarean sections as well as postpartum hemorrhage.
As a result of these studies, many obstetricians and hospitals are really questioning the practice of induction and no longer performing inductions unless absolutely medically necessary. According to these researchers, this data may be what makes elective inductions history!
Summarized from MedScape News, OB/GYN & Women’s Health by Kate Johnson, May 23, 2013
A mama with gestational diabetes posed this question to the mama community on a pregnancy website:
Q: Hey all, do any of you have any tips for how I can make my labor and delivery more natural? I have always wanted a water home birth, but with each of my pregnancies (this is my third) I developed gestational diabetes. My first two labors and deliveries were very cold and sterile and highly mechanical. My doctor has already told me that I have to deliver in the hospital, have internal fetal monitoring and if the baby gets too big, that I’ll have to be induced. I called several midwives around town, but because I am on insulin (my blood sugars would soar in the early morning so I take a shot at bedtime).
I really want to avoid as much intervention as possible. I have hired a doula. What else can I do to make my delivery more natural and comforting?
The mamas on this particular website came up with some awesome ideas and I am going to share them here.
You Call the Shots! I was really heartened to hear the mamas in this community encouraging and empowering this mama to stand her ground for as natural a birth as possible. Many suggested that she find a midwife, but when “mama” shared her complicated course and her need for insulin, the mamas agreed that she should deliver in the hospital. However, they gave her sage advice to be very clear on her desires for her birth and to make sure that everyone knows what she wants and is on board to provide that care. One must always remember that the health care staff works for YOU! And while in our current paradigm health care providers often act as if they know what is best for us, in the end, we have the final say as to what treatments we receive.
Make sure that you understand each and every medication, treatment and procedure that is proposed. If you have questions, make sure they are answered to your satisfaction BEFORE you sign any consent form. (Truly make informed consent!)
Have an advocate. This mama was on this, she had already hired a doula. Having someone who knows what you want and who can express your desires if/when you cannot express them yourself is critical. Also, having someone there who is “all for you” is a tremendous emotional boost. This person has to be strong, knowledgeable, able to speak up to hospital personnel and yet someone who will first and foremost have your best health interest in mind, someone who may be able to help translate difficult information so you can make informed health care decisions if necessary. A doula is an excellent option if you don’t have a family member or friend who can take this stand for you, or if you prefer someone without the emotional ties and has some training in this area.
You Can Refuse to be Induced. Now this is a bit sticky. In Gestational Diabetes, there is always the risk of having a larger baby. However, if neither you nor the baby is in distress, there are no complications and you are not post dates, there really is no medically necessary reason to induce. You have the right to a trial of labor. Discuss this you situation with your OB and get the exact, specific reason he/she wants to induce your labor. If you have questions, you have the right to consult with another OB for a second opinion. Just be sure that an induction is truly indicated as it carries with it increased discomfort, the increased likelihood of an epidural, the increased likelihood of you having a c-section and an increased risk of your baby needing intensive care in the neonatal ICU (NICU).
You don’t have to have an epidural. You don’t have to have an epidural. Again, if every thing is progressing without complications or distress, and you feel comfortable and competent to manage your pain, you are well within your right to refuse an epidural.
You don’t have to have an episiotomy. An episiotomy, a surgical cut in the perineum is not necessary. Many OB’s perform this to “prevent tearing”. However, there are methods of perineal massage that allow for natural stretching of the tissue in this area. Most Midwives know these techniques and most OB’s do not. Ask a midwife or doula if they can share methods of perineum softening/stretching to ease delivery.
Make Friends with the L & D staff. If you can, visit the Labor and Delivery floor at the hospital at which you intend to deliver. Chat with the staff. If you can, get a feel for how the nurses care for the patients. The more you know up front, in terms of how the floor is laid out, how the nurses work with the patients and the nurses themselves, the better will be your experience.
Bring things from home to make your surrounds more comfortable and “homey”. Most of the mamas advised that mama bring her own gowns, robes and slippers, candles, music, pillows-anything that she finds soothing and that will make her surroundings feel more like home and less like a hospital room.
Labor induction is always controversial. There are times when induction of labor is completely appropriate; when mamas are in crisis with pre-eclampsia or other obstetrical complications, when the baby is struggling or when progression of the pregnancy will put the life of the mother and/or baby at risk. But many mamas are induced for what seems like “convenience”; Mamas are tired, their OB’s want to schedule the delivery so that mama is not delivered by a partner, etc… While many obstetricians advocate for induction as a way to “prevent” adverse outcomes, we can’t ignore the fact that labor induction carries with it an increased risk of intervention in the birth process and adverse outcomes for mama and baby.
Recently in the British Medical Journal, researchers looked at elective inductions to see if they had any benefit on birth outcomes when compared to allowing labor to progress naturally. Sarah J. Stock, PhD, from the MRC Centre for Reproductive Health, University of Edinburgh in the United Kingdom was the lead researcher for the study.
Using Scottish birth and death records, they analyzed data for more than 1.2 million women with single pregnancies who gave birth after 37 weeks’ gestation between 1981 and 2007.
What Stock and her colleagues found is that
There was no significant difference in spontaneous vertex (normal head down) delivery rates between elective induction of labor and the expectant management groups (normal labor progression) for weeks 37, 38, and 39. However, a primary analysis showed an association of elective induction of labor with a reduction in spontaneous vertex delivery rates compared with the expectant management group at weeks 40 and 41. This difference was maintained for week 41, but not week 40, during secondary analysis. (so did more induced mamas have c-sections?? This is what previous data have stated.)
The authors estimate that for every 1040 women having elective induction of labor at 40 weeks, 1 newborn death may be prevented. This would result, however, in 7 more admissions to a special care baby unit (NICU).
The authors conclude that although residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery.
There are a couple of issues that I have with this study. First, while the sample size is definitely adequate, there was no way to control for confounding variables such as maternal size, number of pregnancies, pregnancy complications (i.e bed rest), prenatal state, etc… Additionally, the data has been run through a couple of multivariate analyses which controlled for possible confounding variables. I always wonder, if those “confounders” are incorporated into the data, how do they change the results and conclusions?
The authors conclude that elective induction of labour at term gestation can reduce perinatal mortality in developed countries. Is this reduction in mamas, babies or both? This was not clear to me.
The authors also state that they did not see any increase in operative deliveries.This is very interesting in that the United States has some of the highest c-section rates worldwide and the probability of having a c-section goes up with labor induction. Were these some of the variables removed a confounders?
Finally, the authors estimate that for every 1040 babies born, 1 would be saved from death while 7 would end up in the NICU. Now these aren’t huge numbers, but if you are the mama with the one baby who died, this number is significant. Likewise, it’s not good if your baby ends up in the NICU.
While the authors state that the intention of induction is to reduce perinatal morbidity and mortality in developing countries (and the United States certainly has some of the worst statistics for maternal and infant morbidity and mortality, i.e. maternal and infant complications and deaths, in the developed world) I don’t agree that induction is the way around these potential problems.
Induction of labor initiates a cascade of events that more times than not are not ready to begin. There is a delicate, yet complex interaction between the baby and mama that goes on as the baby begins to enter this world. Both mama and baby’s bodies have to transition from interdependence to independence and for the baby especially, there are several physiological mechanisms that must occur to prepare the fetus (inside baby) to become a neonate (outside baby). Induction speeds up these transitions and in some cases, certain transitions don’t occur (hence the NICU admissions for babies). While some may argue that babies may spend “just a few days” in the NICU, these babies have experienced a traumatic birth, their bodies have not had time to adjust to life on the outside and everyone involved (mama, dad and baby) are all traumatized. Is it really worth it? Further, we can only “guesstimate” gestational age. We really don’t know when the sperm fertilized the egg nor when the embryo embedded in the uterine wall. So a woman we may think is 40 weeks may really be 39 or even 38 weeks. Hence the induction is more of an intrusion. What if she is in fact 42 weeks?
I don’t know what the authors intend to do or recommend with this data, but I hope that they don’t use this data as a way to recommend elective induction as standard of care-especially in low risk uncomplicated pregnancies. I believe that human gestation is intended to be 40 weeks for a reason and that as much as possible, human babies should be allowed to gestate for those 40 weeks. If a baby comes at 38 or 39 weeks, so be it. But if the baby stays in until 40 weeks, are we to assume that there is something wrong or that something will go wrong and intervene? I believe that babies should be left alone to gestate for a long as they need, and only in the situation of maternal/baby distress or markedly being post dates (say 42 weeks or more) should induction even be an option.