Labor Induction
To Induce or Not to Induce
A study recently printed in The American Journal of Obstetrics and Gynecology suggests that using medications to start labor should be reserved for situations where continuing the pregnancy presents a clear health risk to either mother or baby.
The study, conducted in Belgium, compared over 15,000 births occurring over one year (1996-7) in first-time mothers. All women had healthy, uncomplicated pregnancies. At their request, half had labor induced artificially shortly before their due dates. The other half went into labor naturally. The women with induced labors used significantly more pain medication and had more cesarean births due to both fetal distress and stalled labors. That group also had more forceps and vacuum births and had more babies admitted to intensive care.
Using medications to artificially start or induce labor has long been practiced when pregnancy is complicated by illness. High blood pressure, diabetes, and extremely overdue pregnancies are clearly understood to jeopardize health. Continuing an unhealthy pregnancy can sometimes be more dangerous than delivering the baby early, even if the induction process itself carries some risk.
Using these same techniques to induce labor for non-medical reasons has tantalized both the public and care providers for years. Indeed, the pressure to schedule births for reasons of convenience—both of patients and their providers—has resulted in growing numbers of non-medical inductions. Known as "elective induction," this has become one of the most commonly performed medical procedures in the United States. According to the National Center for Health Statistics, about one in five labors is begun artificially, and the percentage has been rising yearly for as long as data has been collected.
Sorting out the apparent risks of inducing labor has been a vexing problem for decades. Professional organizations, such as the American College of Obstetricians and Gynecologists and the American College of Nurse Midwives, have long discouraged elective inductions. So have virtually all textbooks and the bulk of research. In spite of this, numbers rise.
Research dating back to the 1980s and earlier has consistently shown induced labors more often end in cesarean section, forceps deliveries, serious infections, and greater complications for both mother and baby. Still, many physicians have not been convinced. Earlier studies left open the question of whether birth complications resulted from the pregnancy disorders necessitating the induction or from the induction process itself. Uncertainty about the safety of induction in otherwise healthy pregnancies feeds hope of controlling one of nature's most capricious and unpredictable agendas: birth.
This most recent Belgian study is but one of several in the last five years which have attempted to address these questions by studying only clinically similar, uncomplicated pregnancies. Most have found strikingly similar results.
Induced labors generally require stricter bed rest, omission of food and even fluids, more time on fetal monitors, and more frequent monitoring of maternal vital signs. Labors are often longer. Since the medications most commonly used are administered by IV pump, induction usually requires being tethered to that equipment as well. Because the effectiveness of the medications can be difficult to assess, especially in the long early phase of labor, vaginally placed internal monitors are often used, further restricting mobility. Women get epidural anesthesia more frequently when labor is induced, indicating that induced labors may be more painful. Perhaps the most common and disappointing complication is outright failure. Inductions simply don't always work, and plans must be scuttled.
None of the studies advocate a passive approach to medically complicated pregnancies. But they do help to define the seriousness and risk of the induction procedure and suggest a more cautious approach to its use.
Perhaps some new drug or technique is just around the corner that will prove equal in safety and effectiveness to Mother Nature's design. Until then, there are compelling reasons to respect her whims, at least in pregnancies uncomplicated by disease.