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Labor Induction

Labor Induction

Without question, this page is the most visited page in the Birthsong website. You may have come upon this page searching for ways to "naturally" induce labor-- looking for ways to speed up the process and jump start Mother Nature. You may be tired of being pregnant, hate the uncertainty of not knowing when labor will start and are anxious to meet your new baby. You perhaps are looking for a non-pharmocological/non-medical method by which to do it. If this describes your reason for coming upon this page, allow me to share something you may not want to hear: there is no "natural" way to induce labor. The very term is paradoxical. You cannot force something to happen against its own timing and will and call that "natural." Enjoy your pregnancy. Be patient. Trust in your body to do what it needs to do exactly when it needs to do it. 99.9% of women will go into labor on their own without the aid of drugs, hormones or other invasive procedures. And, by letting your baby and your body decide when the time is right, you will be laboring in harmony with the perfect rhythm of nature and allowing for the most optimal birth possible. This is a time for meditation, reflection, and patient expectation. Prepare your mind, your heart, and your body for the new life which is to come forth. Live in the moment and don't worry about the future. Relish the eternal moment of now in which you live. Patience is a virtue that you will need to possess for motherhood and pregnancy is as good of a time as any to learn it and embrace it.

Nature provided a perfect process for birth. Yes, sometimes, as with all things, it does not go exactly according to plan. Sometimes there are difficulties and unexpected outcomes. But most of the time, it works out miraculously well. It is when we fail to trust in the ancient and sacred process of birth, in its perfect timing, that we fail ourselves. When your body is fully ready to open up and birth your baby, it will happen. Your baby will be perfectly prepared. Your body will be fully ready. The complex interplay of neurotransmitters and hormones will create a symphony within you that will echo forth your own unique and flawless birthsong.

The best way to experience labor and birth, as it was meant to be, is to open yourself up to the universe, surrender your will and with trust, honor the timeless and perfect process of birth.

~ Jennifer Ayers-Gould. BA LPN ICCE ~

The following articles go into more detail about labor induction:

Q: Any ideas, advice or recommendations on how to naturally induce labour? I am a midwife with a high percentage of first time mums overdue; they get fed up, and I have run out of tips.


A: According to the medical literature, human gestation ranges from 36 to 44 weeks. That is a two-month range, not the EDC plus or minus 2 weeks. The mean length of time plus or minus one standard deviation gives the 38-42 weeks range, with 40 weeks the average, or mean.

The mean has come to mean the right answer. Phooey! Here is an analogy: Few people actually have a 98.6 F temperature; that is an average. Some actually feel unwell if their temperature is 98.6 because their own body temperature is lower. Everyone has his or her own range. So it is with due dates.

Where I live, over 50% of births involve Pitocin, usually to induce, often because the practitioner wants the birth to be Monday through Friday, daylight hours. Sometimes it happens because the mother is complaining about the heaviness and pressure of late pregnancy and the provider takes that complaining seriously and tries to fix it. Sometimes it happens because the mother has dilated (even as far as 5 cm) or effaced a lot but isn't having contractions; the practitioner fears the baby will fall out (mothers wish that would happen!) and brings her in and induces. There is no respect for natural process. Even a birth center where I teach transfers 20% of women to the hospital most commonly because the women "need" Pitocin. How could the human race have survived if 20% of women couldn't give birth without drugs?

I hate the whole idea of "due date." It is only a guess that creates expectation. The woman often circles that date on her calendar so she won't schedule any other appointments for that day. Better to teach women that the misery of late pregnancy is a natural motivation to want to go into labor, which is a natural progression from the joy of showing the sweet little belly that occurs in the early months. Teach them how to pay attention to their babies to know if things are OK in there. Babies will still play and respond inside even at the very end.

Practitioners may want to see her every week, to listen to a heartbeat or check a blood pressure, to tell her how well she looks, to listen to her complain and suggest a warm bath and other comfort measures, and to communicate to her that pregnancy is a time of waiting.

As a cranio-sacral therapy practitioner, I appreciate the power of intention and belief. When the healthcare provider gets worried about the length of gestation, that worry communicates to the woman, who may delay the start of labor longer because her adrenalin level can go up. Worry and beliefs are contagious. And we all know that adrenalin is the enemy of oxytocin!

So let's organize to keep pregnant ladies happy. Watch them with love and for heaven's sake, let the baby come when it wants.
-Nikki Lee

I think we shouldn't even consider doing anything to induce before 42 weeks unless there are definite concerns about the health of the baby. A mom is not post dates until she is past 42 weeks. Until then she is merely "due," not overdue.

I know some advocate induction near the due date because they think it will avoid problems with big babies, but the rate of fetal growth slows down near term. The average baby will gain no more than 4 to 8 ounces during that additional two week period. This quarter to half pound gain is hardly likely to significantly affect the birth outcome.
-Gail Hart

Four of my five babies born in hospitals were induced (the fifth baby was a section). I have had one Pitocin drip, two AROMs, and one Prostin plus AROM. I have also had my membranes stripped in numerous late dates pelvic exams.

These induced births were unpleasant for many reasons; for example, the Pitocin made my contractions agonizing, the AROMs made my babies go into terrible positions for birth, and the Prostin meant twelve hours of useless, tiring, constant contractions (not to mention it's just plain disgusting to now know there was pig semen in me). These babies were induced to "get things going," and all inductions made me believe I could never "get things going" all on my own.

Not once was I told of the terrible risks that accompany labor induction. Induction was always portrayed as safe, easy, expedient. But I now know that the drip made my baby more likely to have debilitating oxygen deprivation, the AROM put my babies at higher risk of death by cord prolapse, and the long-term effects of having the sperm of another species in me are not even known. The full hazards of induction are extensive and poorly researched. (And the idea of "natural induction" is illogical--any birth made to come before its time holds risk, and the words "natural" and "induction" together create a genuine oxymoron.)

With my sixth baby, I would certainly have been induced again if I had chosen to remain within medical confines to give birth. I went a full four weeks past my "best before" date, but I had wisely chosen the care of Gloria Lemay, the least interventionist birth attendant in my province. As the weeks went by, she reassured me of my body's innate birthing wisdom and of my baby's beautiful birth. It was difficult. I genuinely believed I couldn't give birth without artificial coercion, but I trusted her. And when the time was right I simply, easily, beautifully, and magnificently gave birth.

Any woman who is impatient to get her baby out or any attendant who is impatient for her, must know that inductions hurt terribly in many ways and have effects that are not even fathomable. Inductions undermine a woman's faith in her own body, and pilfer from her the most crucial rite of passage a woman can have. The birth attendant's job is to help women trust birth and be their strong anchor when fear, distrust and impatience threaten to overwhelm completely. It is the attendant's job to keep women and babies safe and mind the pregnant and birthing woman's body as the cathedral of life that it is, never to be desecrated by tubes, hooks, needles, animal semen, beef and hog pituitary gland extracts, or overeager fingers. Birth can be trusted, and is safe.
-Leilah McCracken

I read Phil Watters' comment about induction in the Dec. 3 issue and at first I was almost offended, but as I thought about it, I realized he is right! Midwives, we need to remember that one of the biggest reasons couples opt for homebirth is to *avoid* intervention. If we don't help protect them from that, we have done them a disservice.

Induction should never (in home or hospital) be done because mom is "antsy." One of the biggest reasons homebirth is a safe option is because nature is (or should be) allowed to do its own thing! Only in recent times has everyone started worrying about "due dates." Judging by the increasingly poor mortality rates in the U.S., all our "labor management" has not improved things much!

If I had not been a firm believer in this before I entered midwifery, I would have been after I spent time in a backwoods, doctorless maternity clinic in Bolivia. Those ladies had nothing going for them according to U.S. standards and they never worried about "due dates," yet their bodies gave birth very well to healthy babies, and I *never* saw a "deteriorating placenta!"

If mom gets impatient and uncomfortable, it is our responsibility to counsel her to be patient and help her understand the reasons why patience is still the safest option. A safer option than worrying about "due dates" would be to ensure that mom has an optimum diet so she and baby have optimum health when they go into labor.

A 280 day pregnancy is an *average* based on a 28 day cycle. To create an average, there must be those on either extreme. On the other hand, I know midwives will sometimes induce labor simply due to pressure from the medical community to conform to their standards. A case in point: A former client of mine has had seven healthy babies. The first two were medically induced, knock-em-down, drag-em-out, hospital horror stories. The next five were born in the comfort of her own home, and all were beautiful, uncomplicated, healthy births. Only one of her babies was born close to due date. She has gone 43-46 weeks every other time! All her babies weighed 10-11 lbs and she pushed them out with 2-5 pushes. No, she is not diabetic, and her mother had big babies, too. Except for birth weight, when assessing her babies according to gestational age charts, her babies always appear to be 39-week babies. If this lady were induced because her "dates" were "right" or because her baby was "big enough to be born," or when she got antsy and uncomfortable, she would always have had premature babies. For this lady, 43-46 weeks is normal, (she is one of those who helps create the averages) and induction would be harmful. She is the only mom I have ever "induced" (with herbs) and she and I both agreed to do this only because of pressure from the medical community. We knew that if we would have to transport her at that stage of "overdue" pregnancy, the flack could be pretty devastating, so we chose herbal induction as a safer option than chemical induction and hospital birth.

Phil Watters is right! Consumers often pressure their doctors to do things for convenience and comfort (if you can call medical induction comfortable!) and on the other hand, sometimes midwives do things because of pressure from the medical community. It's a two-way street, and either way we are doing couples a disservice, first for not seeing to it that they are educated well enough so that they don't want induction, and second for giving in to what we know is not wise or safe.
-Elaine

Reprinted from Midwifery Today E-News (Vol 1 Issue 50, Dec 10, 1999)
To subscribe to the E-News write: enews@midwiferytoday.com
For all other matters contact Midwifery Today:
PO Box 2672-940, Eugene OR 97402
541-344-7438, midwifery@aol.com, Midwifery Today

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Let the Baby Decide: The Case Against Inducing Labor
Mothering Magazine, March-April 2001, by Nancy Griffin

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 tetanic contractions 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, neonatal jaundice, 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 Mount Sinai Medical Center 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 Public Health Law, 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.

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 perinatal mortality, 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 cord prolapse. 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 American Academy of Family Physicians' 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 paraventricular nucleus, 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.

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.

Medical indications for inducing labor may include, but are not limited to, the following conditions in either mother or baby:

High blood pressure
Premature rupture of the membranes
Maternal infection or medical problems, such as diabetes mellitus, kidney disease, or chronic pulmonary disease
Suspected fetal jeopardy
Fetal death
Severe blood incompatibility
Severe pre-eclampsia or toxemia
Postdate pregnancy, where there is a proven danger to the baby

Source: American College of Obstetricians and Gynecologists

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," American College of Obstetricians and Gynecologists Technical Bulletin 217 (December 1995).
4. "Induction of Labor in Postterm Pregnancy," ICEA Review 12, no. 1 (February 1988).
5. See Note 2.
6. "Expectant Management 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.
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
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
American College of Obstetricians and Gynecologists (ACOG). 409 12th Street, SW, Washington, DC 20024-2188. 202-863-2518 (Resource center). www.ACOG.org
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
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.

Big baby: Is induction of labor necessary?
by Henci Goer

What’s involved in inducing labor?

Many obstetricians and some midwives recommend inducing labor if you are near or at full-term, and they think the baby is larger than average -- macrosomia, literally, “big body.” Typically, they use an estimation that the baby weighs or will soon weigh 4,000 grams (8 lbs. 13 oz.) as the threshold. Inducing labor usually involves the following:

  • Prostaglandin treatment if the cervix is still long, firm, and thick: Prostaglandins are a family of compounds, two of which are known to soften a cervix that isn’t ready for labor. These same two can also stimulate contractions. Prostaglandin E2 is inserted into the vagina either in gel form (Prepidil) or in a tampon (Cervidil). Prostaglandin E1 (Cytotec) comes only as a pill because it is not formulated for the purpose of inducing labor. A piece of the pill may be inserted vaginally or the pill may be given orally.
  • Breaking the bag of waters (amniotomy or artificial rupture of membranes): During a vaginal exam, the birth attendant snags and tears the membranes using an instrument that resembles a crochet hook with a small sharp tooth under the curled tip.
  • Oxytocin (Pitocin or “Pit”): Pitocin is given intravenously via a pump that controls the dose.

Why would practitioners want to induce labor for suspected big baby?

The theory goes that inducing labor will prevent:

  • Cesareans, due to the baby growing too large to fit through the pelvis.
  • Shoulder dystocia, a situation where the head is born, but the shoulders hang up behind the pubic bone.
  • Birth injuries, namely, broken collar bone, or injury to a complex of nerves controlling the shoulder and arm (brachial plexus injury). Birth injuries often, though not necessarily, occur in conjunction with shoulder dystocia.

However, studies consistently show that inducing labor for suspected big baby accomplishes none of the above (2-3,5,7,9-10,15-16). These studies include two trials, randomly assigning women thought to have big babies either to induction or to await spontaneous labor (7,15). Random assignment trials produce the strongest evidence because they eliminate bias by ensuring that the two groups are truly similar.

Why doesn’t inducing labor help?

Whether a woman carrying a big baby has a cesarean depends largely on her caregiver’s management, not her pelvis. In proof of this, the cesarean rate for babies weighing 4,000 grams or more was three percent in 1958 in Great Britain (4). These days, U.S. obstetricians may perform cesareans on as many as half of women with babies of this size (11,16).

The practitioner’s belief that women cannot safely birth big babies vaginally, or cannot birth them vaginally at all, will lead to cesarean sections. Several studies illustrate this factor at work. Studies have found that:

C-section rates for mothers having big babies can vary enormously among individual practitioners. One study reported that having a private obstetrician tripled the odds of cesarean compared with having a resident or a midwife (2). Another found rates among obstetricians ranging from less than five percent to one-third (14).

Doctors may be likely to order planned cesareans for women suspected of carrying big babies. This was true for one-third of the women in one study (3).

When obstetricians believe that women are carrying a big baby, far more of them may have cesareans than when doctors don’t think the baby is that big, but it actually is. A study reported that half the women whose babies had estimated birth weights of 4,000 grams or more had cesareans versus less than one-third of women with lower estimated birth weights but whose babies were just as big (16).

The reverse is also true. When ultrasound predicts a big baby, women may be just as likely to have a cesarean when the ultrasound is wrong than when it is right. In yet another study, roughly half the women predicted to have babies with birth weights in the top ten percent had cesareans regardless of whether their babies actually weighed in this range (11).

Doctors may not give women a fair chance to labor when they think the baby is big. A study found that when obstetricians thought the baby would weigh 4,200 grams (9 lbs. 4 oz.) or more, half the cesareans for poor progress were performed in early labor (16). When they didn’t think the baby was that big, although it was, they performed cesareans for poor progress in early labor less than twenty percent of the time.

Inducing labor for a suspected big baby increases the odds of c-section compared with starting labor on your own. Most, though not all, studies conclude this (2,5,9-10,16). This could be the belief that women can’t, or shouldn’t, birth big babies vaginally coming into play. It could also be the fact that labor induction, even with pretreatment to prepare the cervix, is more likely to end in a cesarean in first-time mothers than starting labor spontaneously.

While shoulder dystocia and birth injuries are more likely in bigger babies, they occur in non-macrosomic babies and occur rarely even in big babies. For this reason, a policy of induction could have little effect on outcomes even if it reduced the incidence of these problems. To give you an idea of the numbers, an analysis of nearly 15,000 births reported shoulder dystocia rates of twelve percent in non-diabetic mothers of babies weighing 4,000 grams or more and one percent in babies weighing less than this. A similar analysis of birth injuries in nearly 20,000 babies found that less than two percent of babies weighing 4,000 grams or more experienced a birth injury as did less than half a percent of smaller babies (8).

Further diminishing any potential benefit, few cases of shoulder dystocia result in injury. In one study, of 825 cases of shoulder dystocia in infants weighing 4,000 grams or more, only thirty-six, four percent, experienced five minute Apgar scores less than 7, a broken bone, or a brachial plexus injury. Of these thirty-six complications, eight were a broken bone. Breaking a bone is not serious because bones heal. Subtracting the eight instances of fracture, only three percent of babies with shoulder dystocia were at risk for long-term consequences. Even so, more than nine out of ten babies with brachial plexus injuries will completely recover as will eighty-eight percent of infants with five minute Apgars of 7 or less (12-13).

What are the potential problems with inducing labor?

While conferring no benefits, inducing labor increases the likelihood of overly strong contractions, fetal distress and, as documented above, probably cesarean section (6).

How might having an induced labor affect your birth experience and postpartum recovery?

Having labor induced will medicalize your experience, in that you will need an IV and continuous electronic fetal monitoring. You will likely be confined to bed for most or all of the labor. Contractions will probably be more painful, so if you wanted to avoid pain medication, this will make it more difficult to achieve that goal. An epidural will help eliminate the pain, but introduces a long list of potential problems of its own. You may run a additional risk of the labor ending in a cesarean, with all that entails in complications, pain, and recovery time.


References

Acker DB, Sachs BP, and Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol 1985;66:762-8.
Combs CA, Singh NB, and Khoury JC. Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Obstet Gynecol 1993;81(4):492-6.
Delpapa EH and Mueller-Heubach E. Pregnancy outcome following ultrasound diagnosis of macrosomia. Obstet Gynecol 1991;78(3):340-3.
Francome C and Savage W. Caesarean section in Britain and the United States 12% or 24%: is either the right rate? Soc Sci Med 1993;37(10):1199-218.
Friesen CD, Miller AM, and Rayburn WF. Influence of spontaneous or induced labor on delivering the macrosomic fetus. Am J Perinatol 1995;12(1):63-6.
Goer H. The Thinking Woman’s Guide to a Better Birth. New York: Perigee Books, 1999.
Gonen O et al. Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol 1997;89(6):913-7.
Kolderup LB, Laros RK, and Musci TJ. Incidence of persistent birth injury in macrosomic infants: Am J Obstet Gynecol 1997;177(1):37-41.
Larsen JS, Pedersen OD, and Ipsen L. Induction of labor when a large fetus is suspected. Ugeskr Laeger 1991;153(3):181-3.
Leaphart WL, Meyer MC, and Capeless EL. Labor induction with a prenatal diagnosis of fetal macrosomia. J Matern Fetal Med 1997;6(2):99-102.
Levine AB et al. Sonographic diagnosis of the large for gestational age fetus at term: does it make a difference? Obstet Gynecol 1992;79(1):55-8.
Rouse DJ et al. The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA 1996;276(18):1480-6.
Ruth VJ and Raivio KO. Perinatal brain damage: predictive value of metabolic acidosis and the Apgar score. Br Med J 1988;297:24-7.
Sandmire HF and DeMott RK. The Green Bay cesarean section study. IV. The physician factor as a determinant of cesarean birth rates for the large fetus. Am J Obstet Gynecol 1996;174(5):1557-64.
Tey A, Eriksen NL, and Blanco JD. A prospective randomized trial of induction versus expectant management in nondiabetic pregnancies with fetal macrosomia. Am J Obstet Gynecol 1995;172(1 Pt 2):293.
Weeks JW, Pitman T, and Spinnato JA 2nd. Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome? Am J Obstet Gynecol 1995;173(4):1215-9.


More Information about Labor Induction:

Induced Labor and Infomed Consent in Canada
http://www.ican-online.org/resources/white_papers/wp_induction.htm

Induction of Labor
http://www.childbirth.org/articles/labor/induction.html

The Tatia Oden French Memorial Foundation *
Dedicated to Saving The Lives of Those Giving Life to Others
http://www.tatia.org/

* History: In Dec. 2001, Tatia Oden French entered a well-known and well-respected hospital to deliver her first child. She was 32 years old, in perfect health, and looking forward to a natural, unassisted childbirth. There were no problems during the pregnancy. According to her doctor's calculations, she was a little under 2 weeks overdue. She was given the drug Cytotec to induce her labor. Cytotec, also known as Misoprostol, is a drug manufactured to treat ulcers. It is NOT approved by the FDA, or the drug company, to induce labor. Ten hours after being administered Cytotec, Tatia suffered hyper-stimulation of her uterus. Her uterus ruptured, forcing an emergency C-Section. Both Tatia and her baby Zorah died in the operating room. The Tatia Oden French Memorial Foundation, a non-profit corporation, was formed in March 2003 to give ALL women of childbearing age complete information concerning medical interventions and drugs which are administered during childbirth. We do this hoping that women may then be able to make FULLY informed decisions regarding the birth of their children.

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