Watch Your Step.... Avoiding the Pit

When it comes down to it, there is an average induction rate in the US of 22% (as of 2006), it may be even higher at this point, and induction carries quite a few risks. There are a few different methods of induction, although this post is specifically about Pitocin.

How is Pitocin administered and how does it work?
Pitocin is the brand name for a synthetic oxytocin administered through an IV port into the maternal blood stream and diluted with saline ringers.

Oxytocin is naturally produced by the hypothalamus and sent to the pituitary to be released. It stimulates contraction of the uterus as well as let down (milk) and release. It is released in spurts, causing rhythmic contractions of the smooth muscles of the uterus. Naturally occurring oxytocin also enter the brain and cause a euphoric high. When synthetic oxytocin is used (pitocin), it enters the blood stream and does not cross over to the brain, hence, mom and baby are deprived of the love hormone that causes the post-birth high.

Why do doctors recommend induction?
Post Date/Overdue:
We have talked before about Estimated Due Dates and what they actually mean. Some childbirth educators liken due dates to popcorn - that, just like when you pop corn, some kernels are ready and pop before the others, others pop later.

Likewise, we have talked about the error of our current obstetrical mode of determining date of 'dueness', as well as a more reliable means of establishing your estimated due date as well as how to know if you are a good candidate for a successful induction.

Big Baby:
Throughout history, women have birthed babies of all sizes with no issues, no complications. I know of many many women of different shapes and sizes who have birthed babies that were upper 9 and 10lbs with no issues. Late-term ultrasounds are known to be off by a pound either way, and there is no accurate way to determine how large a baby your hips can accommodate without a serious trial of labor.

Likewise, late in pregnancy, babies are gaining fat stores more than length and girth in bone structure. And the great news? Fat squishes. And, if nothing else can convince you, during a naturally occurring labor, hyaluronidase and relaxin help to loosen your joints and ligaments, including your pelvis, increasing the size of the outlet. These hormones are missing in an induced labor.

Old Placenta:
Also known as calcification of the placenta, this is when the placenta begins to show it's age by calcium deposits showing up as white spots on the surface of the placenta. This is very common toward the end of pregnancy and, in most instances, does not inhibit the safety and health of the baby. A care provider may monitor baby more closely to make sure that growth is not restricted as a result.

PROM (Premature Rupture of Membranes):
The rule of thumb is this: if your water breaks without contractions, you have a 12-24 hour window in which to deliver your baby before the risk of infection sets in. In reality, there is a large body of evidence to show that induction for this reason alone is not justification, as infection rates do not increase substantially enough during this window. In addition, there are a great number of women whose leaks reseal themselves or end up being 'surface leaks' and not true amnion breaking. Spontaneous labor occurs in 85% of women within 24 hours and in 95% of women within 72 hours.

To further decrease the risk, there are other steps a woman can take. These include: her GBS status (GBS negative, automatically there is a lowered risk for infection), vaginal exams (the less vaginal exams administered, the less risk of infection), and hydration (a woman who remains hydrated has less chance of having a 'dry birth' (although there is no such thing) and less chance of infection as amniotic continuously acts like a natural douche, pushing bacteria out of the vagina) to name a few. A great study on PROM and infection risk can be found here.

Infectious morbidity may be more influenced by the interval between vaginal examination and delivery rather than between rupture of membranes and delivery. “It would seem that the clock starts ticking after a vaginal exam,” she added.

Another issue is to consider this: a woman who has S/PROM at 30 weeks would be closely monitored for infection and given plenty of fluids... hoping to avoid infection and possibly even reseal the leak. The benefits outweigh the risks of induction at this point. Nothing changes 'at term' except that you are now 'at term'.

Other Conditions:
Other reasons commonly given for induction may include Gestational Diabetes, infection of the uterus, Pre-Eclampsia, diabetes, hypertension, or other conditions. When these complications present themselves, look into the risks and benefits of both an induction and the possible risks of waiting-and-seeing.. then make an educated decision for yourself.

Risks of Induction
One of the most comical, but accurate, media representations of these risks can be found on the Business of Being Born, and seen below:



Some of the risks they touch on in this excerpt:

• Contraction intensity - synthetically produced contractions do not slowly build in intensity, length, and duration, as natural labor does, which results in more intense labors. Also, prematurely sending a body into labor means that the body has not had the chance to produce the cocktail of hormones that help labor to be more effective, resulting in longer labors, on average. In some instances, the contractions become tetanic. Additionally, women who are induced are refused nourishment, because the risk for cesarean increases.
  
• Fetal distress/bradycardia - the more intense, longer, stronger contractions of induced labor increase the risk of a baby being deprived of oxygen or experiencing distress because of the intensity of labor.
• Severe allergic reactions including itching, swelling, difficulty breathing.
  
• Additional interventions necessary - induction automatically necessitates the use of an IV for administration of fluids as well as the medication. It also requires that mom be on continuous fetal monitoring, in the event that any of the numerous risks do occur to mom or baby, including bradycardia or abnormal uterine activity as discussed above. There is an increase risk of internal fetal monitoring being used as well for the same reasons above.
  
• Bed confinement - because of the increased use of interventions (the difficulty keeping a baby continuously on the monitor when a woman is active laboring), many times a woman is confined to bed or just beside the bed (on the birth ball or chair), further increasing her discomfort, the chance of malpresentation, and the below risk.
  
• Increase chance of pain medication use - because of the increased intensity, increase in duration of labor, and the increase risk of being 'bed ridden' pain medication is used more often, which carries it's own list of risks.
  
• Increase chance of cesarean (because of either iatrogenic complication or failed induction).

And additional risks that the video didn't touch on:

• Increase risk of fetal malpresentation - because baby has not had a chance to naturally move down into the optimal position for birth and trigger labor on it's own, a baby may be in a less-than-optimal position for birth, and be forced further into the birth canal in that position, because of the synthetic contractions of an induced labor. This means more incidences of posterior babies, shoulder dystocia, asynclitic positioning, or flexation issues.
  
• Increased risk of vacuum or forceps - because of the aforementioned issue.
  
• Increased risk of infection and postpartum hemorrhage - because of the aforementioned issue, blood clotting issues, as well as the risk mentioned below.
  
• Premature separation of the placenta/placental abruption - the unnatural contractions caused by induced labor can lead to the placenta detaching from the uterine wall before baby is born.
• And, for first time laborers, the risk for cesarean increases by two to three times
  
• Uterine rupture - hyperstimulation of the uterus can cause preexisting weak spots or scarring in the uterus to rupture/tear.
  
• Higher rates of neonatal resuscitation due to fetal hypoxia or asphyxiation
• Increase NICU risk - with the risk of epidural use being increased (which has the added risk of maternal fever), and the risk of premature labor being increased (baby has not yet sent signals to mom's body to start labor, indicating that they are most likely not yet completely ready for life outside the womb), there is an increased risk that baby will be born prematurely. An induction baby may also be more likely to suffer from jaundice. A baby born even a week or two too early can result in he/she being a near term or late term preterm infant. This means that they are more likely to have troubles breathing, eating, and maintaining their core temperature.

Women "buy" a package of intervention when they ask for induction. Make sure that you know what that package is and carefully weigh the benefits and the risks.

So, now that we know the how, the why, and the risks.. how do we avoid the pit?

Education and rights. Know your rights and your risks. Know your Bishop's Score to make a more informed choice whether you are truly ready to birth your baby or not. What reasons are your care providers giving for induction?

• Big baby? Late term ultrasounds are notoriously off on weight estimates. Even if your baby is big, fat (which is what your baby is gaining the most in the last weeks) squishes. Trusting that your body will not grow a baby too big for your body. The average baby will weigh 7lbs and 14oz.. And many many women of all different shapes and sizes have birthed babies that are double digits with no problems.
  
• Overdue? How was your due date determined? Are you solidly sure that your body and baby are truly overdue or is your care provider determining your date of due-ness by a standardized formula? Throughout history babies came when they were ready, induction has not improved the rates of prematurity and maternal/fetal morbidity and mortality.
• PROM? Remember that there is no guarantee that you will ever get an infection. Remember the ways to minimize this risk. Remember that, if you were 32 weeks, they would be ensuring close monitoring vs delivering a premature baby.
  
• Other conditions? Understand and research your diagnosed condition. Then carefully weigh the benefits and risks of induction vs. the wait-and-see approach.
• Antsy family/mom? If you have to, turn your phone off or change your VM to tell family and friends that, unless they have gotten a phone call stating you are in labor, then you are NOT in labor and baby is NOT here. Ask your SO and other supportive people in your life to spread the news to family and friends that you only want supportive comments, not discouraging ones, about your continued pregnancy. Remind yourself that you are doing a great job of growing your baby, your baby will start labor when he/she is ready, and that you can do anything for 1 more month.

Be prepared to assume the risks and benefits of an induction by pitocin.

Prepare your body for naturally occurring labor and birth before the last trimester by remaining active throughout your pregnancy, eating a healthy, balanced, and whole foods diet, reducing chemical interference and salting your food to taste. Educate yourself to the benefits of using Evening Primrose Oil for cervical ripening and Red Raspberry Leaf Tea for uterine tone.

I give this information not to condemn the choice of induction, but to fully inform and educate so that women (and partners) can make the best choices for their situations. There is to flippant an attitude in our obstetrical model of care to the risks and implications of forcing nature's hand. Be educated.

For further reading:
OBGYN.com
Childbirth.org
Drugs.com

References:
March of Dimes. (2006). If you’re pregnant: Induction by request. Retrieved September 21, 2007, from http://www.marchofdimes.com/prematurity/21239_20203.asp
March of Dimes. (2006). Late preterm birth: Every week matters. Retrieved September 21, 2007, from http://www.marchofdimes.com/files/MP_Late_Preterm_Birth-Every_Week_Matters_3-24-06.pdf American College of Obstetricians and Gynecologists [ACOG]. (2004). ACOG Practice Bulletin No. 55: Management of postterm pregnancy. Obstetrics and Gynecology, 104(3), 639-646.
Ben-Haroush, A., Yogev, Y., Bar, J., Glickman, J., Kaplan, H., & Hod, M. (2004). Indicated labor induction with vaginal prostaglandin E2 increases the risk of cesarean section even in multiparous women with no previous cesarean section. Journal of Perinatal Medicine, 32(1), 31-36.
Condon, J. C., Jeyasuria, P., Faust, J. M., & Mendelson, C. R. (2004). Surfactant protein secreted by the maturing mouse fetal lung acts as a hormone that signals the initiation of parturition. Proceedings of the National Academy of Sciences of the United States of America, 101(14), 4978-4983.
Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Gilstrap, L. C., & Wenstrom, K. D. (2005). Williams obstetrics. (22nd ed.). New York : McGraw-Hill.
Glantz, J. C. (2005). Elective induction vs. spontaneous labor associations and outcomes. Journal of Reproductive Medicine, 50(4), 235-240.
Goer, H., Leslie, M. S., & Romano, A. M. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. Journal of Perinatal Education, 16(Suppl. 1), 32S-64S.
Kramer, M. S., Demissie, K., Yang, H., Platt, R. W., Sauve, R., & Liston, R. (2000). The contribution of mild and moderate preterm birth to infant mortality. Journal of the American Medical Association, 284(7), 843-849.
Tanner, L., & Associated Press. (2000, August 16). Death risk higher for preemies: Study reassesses danger for those born just a few weeks early. Dallas Morning News.
Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstetrics & Gynecology, 105(4), 698-704.
Wang, M. L., Dorer, D. J., Fleming, M. P., & Catlin, E. A. (2004). Clinical outcomes of near-term infants. Pediatrics, 114(2), 372-376.
And all linked sources throughout this article.