The Logic in Rising Induction Rates

     I’m a seasoned doula with an innate faith in childbirth as a normal, natural function. When I hear that one-third of American women are given chemicals to start labor, I have to either conclude that women have somehow lost the ability to give birth or that we are witnessing a societal change. If women are being induced for the legitimate reasons of health and safety, then mortality and morbidity statistics should be improving. Yet the statistics are quite flat. We see little change in US statistics, except for in the category of tiny, preterm babies. An induction and augmentation rate of over 35% has not seemed to improve the health of mothers or babies. It has, however, strongly impacted the cesarean rate and—subsequently—the rate of VBAC and uterine rupture after prior cesarean section.

    Induction is so common that many people are unaware of the risks. Even a “simple,” uncomplicated induction can begin an avalanche of interventions. It often starts with a cervical stretch and sweep to “ripen” the cervix, IV Pitocin, electronic fetal monitoring (EFM) and amniotomy; then, perhaps, it’s on to an intrauterine pressure catheter, amnioinfusion for unusual fetal heart tones, an epidural for the pain of Pitocin-induced contractions and malrotation or poor descent because of the epidural; then maybe a vacuum extraction or cesarean is performed for “failure to progress.” It goes on and on. The mother ends up with lifelong injury to her uterus. Her baby may be stressed and separated from the family. A normal birth may turn into a nightmare. And that’s if all goes well! If there are complications or a surgical emergency then the nightmare really begins.

   Induction is a minefield, a setup for complications. An induced labor forces the baby out before the body is ready, before the complex hormone interaction has primed the cervix and often before the baby has reached his full intrauterine maturity. We have drugs now that can produce contractions and soften the cervix but this is only a small part of the complicated process of labor. We can make a woman have contractions but we don’t always succeed in forcing her body to release the baby and give birth. If we start a labor with chemicals, we may very well have to finish the labor with the surgeon’s scalpel.

   In some studies, induction raises the risk of cesarean by 800%. EFM must be used in all chemical induction methods because of the risk of hypertonic contractions and fetal distress. Electronic fetal monitoring alone increases the risk of cesarean and of vacuum extraction or forceps. Amniotomy increases the risk again. Cesarean for fetal distress is even more common—whether the distress is real or a result of EFM artifact—since non-reassuring fetal heart tones are frequently observed. Meconium staining, meconium aspiration syndrome and even shoulder dystocia are directly associated with inductions. The rise in induction closely mirrors the rise in cesarean delivery, as does the rising incidence of post-cesarean rupture. A woman with a prior cesarean is unlikely to suffer a uterine rupture (odds are usually given under 1 %). But if she is induced, her risk may rise to 2–4 %.

    If the data shows that induction is a risky procedure, and we see little statistical benefit, then why are we inducing so often? Doctors and midwives will express many reasons for induction, but many of those reasons are colored by a misunderstanding of the risks involved. The risks created by induction are sometimes ignored—induction seems simple and easy. Any complications or problems are seen as simple chance—the “normal risk” of birth—caused by the situation that prompts the induction.

— Gail Hart
Excerpted from “Induction and Circular Logic” in Midwifery Today’s The Postdates and Postmaturity Handbook