I am happy to see this article out, but it is nothing that we in the 'alternative' childbirth field didn't already know and haven't already been saying for many, many years. 40 weeks is not a fail-safe date for all babies to be evicted. In fact, the average first time mom will gestate a baby for 41 weeks and 1 day. 

The fact is, a woman who is going to keep her baby in longer, usually does so because her baby is not ready to be born.  These babies who are forced out have higher incidences of neonatal issues normally associated with preterm births (duh).

Experts Discuss Importance of the Last Weeks of Pregnancy

NEW YORK, June 7, 2011 /PRNewswire-USNewswire/ -- Every week of pregnancy is crucial to a newborn's health, and today, the March of Dimes unveiled a new public education campaign to raise awareness about the important development that occurs during those last few weeks.

The campaign, called "Healthy Babies Are Worth the Wait," encourages women to allow labor to begin on its own if their pregnancy is healthy. It aims to dispel the myth that it's safe to schedule a delivery before 39 weeks of pregnancy without a medical need.
Babies born after 37 weeks of pregnancy are full-term. However, new research has shown that a baby's brain nearly doubles in weight in the last few weeks of pregnancy. Also, important lung and other organ development occur at this time. And, although the overall risk of death is small, it is double for infants born at 37 weeks of pregnancy, when compared to babies born at 40 weeks, for all races and ethnicities.

"Some women mistakenly think that the only thing a baby does during the last weeks of pregnancy is gain weight, making labor and delivery more difficult," said Judith Nolte, a member of the March of Dimes national Board of Trustees and former editor-in-chief of American Baby Magazine Group, who worked with the March of Dimes to develop the new awareness campaign. "When the moms in our focus groups learned about the important brain and organ development that occurs, they were more than willing to put up with their own discomfort so their baby could get a healthy start in life."

Only 25 percent of women know a full-term pregnancy should last at least 39 weeks, according to research published in the December 2009 issue of Obstetrics and Gynecology.
"Women may feel worried, anxious, or simply uncomfortable near the end of their pregnancy.  But unless there are medical complications, the healthiest and safest place for that developing infant is in the womb," said Eve M. Lackritz, M.D., chief of the Maternal and Infant Health Branch, Division of Reproductive Health, Centers for Disease Control and Prevention, who outlined the health consequences of an early birth. "Term labor and delivery are not just normal and natural – they're the healthiest alternative for both the mother and the infant."

Information about the new Healthy Babies Are Worth the Wait educational campaign can be found at marchofdimes.com/39weeks.

The March of Dimes is the leading nonprofit organization for pregnancy and baby health.  With chapters nationwide, the March of Dimes works to improve the health of babies by preventing birth defects, premature birth and infant mortality.  For the latest resources and information, visit marchofdimes.com or nacersano.org. For free access to national, state, county and city-level maternal and infant health data, visit PeriStats, at marchofdimes.com/PeriStats.

SOURCE March of Dimes
Back to top RELATED LINKS
http://www.marchofdimes.com/

- source 

Further information and reading:
On Pins and Needles - acupuncture for induction
Induction Increases Cesarean - the correlation between neonatal issues, induction, and cesareans
Avoiding the Pit - know the realities of Pitocin
An Australian post on Induction
Induction, Encouragement, Eviction

Induction, Encouragement, Eviction...

Induction, Encouragement, Eviction... these are all words that have been used in conjunction with artificially stimulating labor in order to get baby to come out.

Induction: to move by persuasion or influence: to call forth or bring about by influence or stimulation: effect, cause: to cause the formation of: to produce (as an electric current) by induction: to determine by induction; specifically: to infer from particulars

Encourage: to inspire with courage, spirit, or hope: hearten: to attempt to persuade: to urge: to give help or patronage to

Eviction: to recover (property) from a person by legal process: to put (a tenant) out by legal process: to force out: expel
- Merriam Webster Dictionary

Induction is the medical term used to encourage labor and birth of your baby. The term, induction, is misleading, though, as it infers something persuaded or 'influenced'.

Some people call it labor encouragement; I reserve this term for when a woman is choosing true encouragement techniques and they will not be influential unless the body is ready.

Some more jokingly refer to induction as an eviction. This is the closest term, in my opinion, when considering medical induction. Eviction is truly forcing baby out, one way or another.

For consistencies sake, though, we will call it induction.

Unfortunately, most first time mothers are faced with the dilemma ‘to induce or not to induce’. When you figure that the majority of obstetrical providers like to have mom deliver between 39-41 weeks, and you also consider that the average first-time mom will go into labor at 41.1 weeks, most women encounter this choice.

Remember, it is a choice in most instances and not necessity. In fact, we clearly know that induction increases risk to mom and baby.

Some reasons that your care provider might encourage induction:

• Postdate pregnancy (care providers vary on what is considered ‘overdue’, but it is thought that anything beyond 40 weeks is ‘overdue’ – see my handout on due dates)
• Premature rupture of the membranes (your water breaking without contractions)
• Pregnancy-induced hypertension (high blood pressure) or preeclampsia
• Chorioamnionitis (an infection of your amniotic fluid and/or the bag of waters)
• Intrauterine fetal growth retardation (IUGR – baby is not growing anymore – this can be because of placental decay)
• Large baby
• Oligohydramnios or polyhydramnios (too much or too little amniotic fluid)
• Significant maternal medical problems, such as diabetes mellitus with pregnancy at term

What are the risks of induction?
There are many risks to induction that should be weighed very carefully. In addition to the risks that normally occur with labor and delivery, induced labors tend to increase the incidence of pain medication use (which increases another set of risks), and the induction itself carries its own risks.

Some of the risks include: uterine hyperstimulation, fetal distress and a greater likelihood of postpartum hemorrhage.

As a result of the added risk, fetal heart rate (FHR) monitoring will be performed using a high-risk protocol, and a physician able to perform a cesarean section must be informed and available at all times. If you are considering an induction or your care provider has offered/requested an induction, evaluate the situation carefully; the risks of remaining pregnant should outweigh the risks of an induction before it is considered.

How do I know if an induction will work?
You don’t; in fact, no one does. You should ask your care provider about your Bishop’s Score (explained later). This is a system whereby you and your care provider can determine if your cervix and body are ready for labor. If your score is a 7 or over, you are a good candidate for a successful induction (meaning you won’t have a cesarean because your cervix didn’t dilate), but many of the other risks are still possibilities.

How can I tell if I am a good candidate?
As stated previously, a care provider can assess your likelihood to successfully dilate with an induction by something called a Bishop’s Score. If your score is 7 or over, you have a very good chance of dilating fully through induction. The table below is the adapted midwifery model, as it tends to be more accurate than the medical model.

If you would like to see the medical model, click here.

Keep this chart on hand and, in the event that induction is mentioned by your care provider, refer to this chart and be sure that your chances for successful dilation are in your favor.

Modifiers to this table include -
Add 1 point to score for:

• Preeclampsia
• Each prior vaginal delivery

Subtract 1 point from score for:

• Postdates pregnancy
• Nulliparity (never having birthed children)
• Premature or prolonged rupture of membranes

You can deduce your score by adding your points.

• If your score is 7 points or less, your chances of successfully and fully dilating without the assistance of a cervical ripener are not in your favor.
• If your score is 9 or more, your cervix is favorable to attempt to induce.
• If your score is 12 or more, your cervix is ready for labor (perhaps even in early labor), and a small amount of encouragement often gets things moving.

How are inductions done?
There are a few different types of inductions to consider. These include stripping your membranes, artificially rupturing your membranes (AROM – breaking your water for you), cervical ripening, and pitocin induction.

Types of induction:

• Stripping Your Membranes - When a care provider wishes to encourage labor to start but is not ready to commit mom wholeheartedly, they might suggest stripping your membranes. This will encourage labor to start by a) aggravating the uterus because of the weight of the amniotic sac sagging against the cervical opening as it is no longer held up by the mucosa, b) causing your body to release prostaglandins because of this irritation, and c) which might result in cervical softening and contractions.
• HOW IT’S DONE – the care provider completes a cervical exam. While they are near your cervix, your care provider inserts a finger into the cervical opening and sweeps their finger over the thin membranous mucosa that connects the amniotic sac to the wall of your uterus.
• WHAT YOU CAN EXPECT – vaginal exam with a gloved hand, possible intense cramping with bloody show, outpatient procedure.
• RISKS – risks that increase with stripping your membranes include: infection, PROM (premature rupture of membranes), bleeding.

• Artificially Rupturing The Membranes (i.e., artificially breaking your bag of water) – When your care provider is ready to commit mom to labor, the cervix is opened a few centimeters, and babies presenting part (usually head) is well applied to the cervix and low in the pelvis, they may suggest breaking your water to get labor started. This can work for many of the same reasons as stripping your membranes, plus there is the added irritation to the cervix of the sac being released, which causes more friction/pressure on the cervical opening.
• HOW IT’S DONE – the care provider completes a cervical exam. While they are near your cervix, they insert a plastic or metal device that looks very similar to a crochet hook (or they will wear a specially designed surgical glove with a hook on the end of one finger), snag the amniotic sac, and tear a small hole in it, releasing the waters.
• WHAT YOU CAN EXPECT – vaginal exam with a gloved hand, possible discomfort at onset, gush or small trickle of warm water, possible bloody show, many times fetal monitoring, inpatient procedure
• RISKS – In most practices, ROM puts mom on a 24 hour window to birth baby and the procedure possibly won’t create contractions or won’t create strong enough contractions, necessitating pitocin use. If mom does not have baby within the allotted time for ROM, she will be encouraged to have a cesarean. Increase risk of infection, fever, cord prolapse, internal cord prolapse, fetal distress, fetal heart decelerations, fetal malpresentation or malposition.

• Prostaglandins – prostaglandins are the hormones that ripen and soften your cervix, making it nice and pliable for dilation. To better the chances of a successful vaginal induction, the cervix must be ‘favorable’, meaning that it should be soft and more ready to dilate. When a care provider encourages induction and the cervix is not favorable or ripe, they might recommend a cervical ripener. There are two main types of cervical ripeners, Prostaglandin gels (Cervidil, Prepidil, etc..) and a pill called Cytotec (Misoprostol). For information on Cytotec, see the special section on Cytotec.
• HOW IT’S DONE - The prostaglandin gels are applied directly to the cervix via a tampon like applicator. Once contractions are established, or the prescribed amount of time has passed to see if this mode of induction is successful, they will remove the device. Cytotec, on the other hand, is inserted in pill form into the external os of the cervix (cervical opening).
• WHAT YOU CAN EXPECT – intermittent to continuous fetal monitoring usually is completed, mom is often required to remain in bed, inpatient procedure. Cramping, bleeding, possible loose bowels, general discomfort. If contractions are not established within an allotted amount of time, and if your water has not broken during this time, there is the very good chance your care provider may send you home. If your cervix does become more favorable during this time, but contractions have not become established, they may recommend pitocin.
• RISKS – increased risk of infection, uterine rupture, ,uterine hyper-stimulation, fetal bradycardia, when uterine rupture does occur, fetal death rate is 25% 
• see here for more information or here for more information

• Pitocin – pitocin is a synthetic oxytocin. Oxytocin is the hormone that produces contractions. When a medical induction is indicated or suggested, this is the most aggressive means of inducing. Pitocin works by stimulating and simulating contractions.
• HOW IT’S DONE – the care provider or nurse will administer the synthetic hormone through an IV drip in your wrist, hand, or arm. Along with the hormone, you will be given IV fluids. The dosage is usually started at a low drip and then increased every 30 minutes or so until your contractions reach a regular and productive pattern.
• WHAT YOU CAN EXPECT – IV pole, IV fluid bags, IV catheter in your hand/wrist or arm, continuous fetal monitoring, inpatient procedure, discomfort, increased pain because of an unnatural labor pattern (seemingly more intense), possible SROM, spotting and cramping from dilation, possible blood pressure increase, loose bowels, possible nausea.
• RISKS – increased risk of titanic contractions (contractions that last too long), double peaking contractions, increased risk of uterine rupture, postpartum hemorrhage, increased risk of fetal malpresentation or malposition, increased risk of using pain medication, increased risk of cesarean for failure to progress, shoulder dystocia (baby), and fetal distress. Increased risk of fetal bradycardia.
• We now know that there is a correlation between pitocin use and the incidence of ADHD. See here for more information on pitocin.

• **Cytotec is becoming more popular as a means of induction. It has been shown to start labor faster and result in faster labors than pitocin. It is a small pill that is inserted (whole or in pieces) into the vagina near the cervix, where it dissolves. There is no standard dosage for this medication as it was not intended for induction. Once it is administered, unlike prostaglandin gel or pitocin, it cannot be removed, even in the case of maternal or fetal distress. There are many risks, and a high incidence of them. 
• Risks include: increased chance of uterine hyperstimulation, uterine rupture, no safe/effective dose, not approved by the FDA for this use, fetal malpresentation, fetal malpositioning, fetal distress, postpartum hemorrhage, fetal bradycardia, and, when uterine rupture occurs, the fetal death rate is 25%. 
• For more information, please see here or here.

What about alternative method of labor induction?
I will start by saying that, if you are interested in homeopathic means of encouraging labor, you should consult a midwife, herbalist, acupuncturist, homeopathic practitioner, chiropractor, etc... The information below is to provide information on these alternatives, but are not to be used as a suggestion or prescription.

That said, just like with any other intervention, there is always added risk when we tamper with nature. The positive aspect of homeopathic or alternative methods of induction is that, if your body isn’t ready, it won’t work. That is why I prefer to call these alternative labor encouragers.

Methods for alternatively encouraging labor:

• Relaxation/Visualization/Meditation – when a mom is in labor, she moves into this place where the world cannot worry her anymore. Oftentimes, stress, workloads, worries, fears, marital issues, etc…, can all cause upsets in naturally occurring labor. It is no surprise, then, when these same things can inhibit labor from starting at all. The great thing about this particular encourager is that it can be easily paired with a medical induction to increase the chances of it working. 
• HOW IT’S DONE – you would remove yourself from noise and disturbances, a place where you can relax and let your mind go blank. You could use hypnosis techniques (if you are a student of Hypnobabies, they have a Baby Come Out CD), visualization (picture your baby pressing down on your cervix, your cervix nice and soft and open, your uterus pressing in on your baby), meditation (positive affirmations about your body and baby). This destressing can be done with a warm bath, candles, incense, your partner.. anything.
• WHAT YOU CAN EXPECT – a sense of peace, lowered blood pressure, perhaps gentle tightening. Some women report a pop when their waters spontaneously break, slight cramping, mild abdominal discomfort, spotting.. or you might expect no signs of labor, but a clear mind, a positive outlook, and the fortitude to wait a little longer.
• RISKS – you may not be so anxious to have the baby, you may begin to enjoy having baby inside.

• Prostaglandins – Semen is a great natural source of prostaglandins. Having intercourse regularly throughout the last trimester will keep your cervix coated in prostaglandins, which will encourage a favorable cervix.
• HOW IT’S DONE – Well, it is done however you would normally have intercourse with your partner. Your odds will increase in effectiveness if your hips are elevated for awhile after intercourse to increase the saturation of semen on your cervix.
• WHAT YOU CAN EXPECT – feeling closer to your partner, a sense of euphoria, relaxation, sleepiness.
• RISKS – possible cramping and bleeding, possible SROM if your cervix is open quite a bit and you are very aggressive.
• Intercourse – likewise, intercourse itself is a great uterine stimulant as orgasms (by the mom) produce oxytocin. The combination of semen and orgasm can cause a great environment to encourage cervical ripening and regular contractions.
• HOW IT’S DONE – the same as above. Additionally, taking special attention to the woman achieving orgasm, as well as the man.
• WHAT YOU CAN EXPECT – feeling closer to your partner, a sense of euphoria, relaxation, sleepiness.
• RISKS – possible cramping and bleeding, possible SROM if your cervix is open quite a bit and you are very aggressive.

• Evening Primrose Oil – unlike popular belief, Evening Primrose Oil (EPO) does not cause contractions. It only prepares and softens the cervix. For this reason, many women choose to start taking EPO around 36 weeks. This will encourage your body to produce its own prostaglandins. 
• HOW IT’S DONE – You would purchase 500mg gel caps. Starting around 36-37 weeks, you would take 2 of them in the morning. Then, roughly a week after starting that regime, you would begin also inserting 2-4 vaginally at night. During the night, the gel caps will be dissolved by the damp environment of your vagina.
• WHAT YOU CAN EXPECT – possible softer stools, more discharge in the morning when the oil runs out of your vagina, softer perineal tissues, softer labia, some women report it increases their sex drive by feeling the increase lubrication.
• RISKS – it can be messy, some women report nausea from orally consuming too many, some women report loose stools from orally consuming too many.

• Nipple Stimulation - nipple stimulation, like orgasm, releases oxytocin, which contracts the uterus. Midwives have been using nipple stimulation for induction of labor for many centuries.
• HOW IT’S DONE – there are a number of ways: manual stimulation, artificial stimulation, or hydrostimulation. For manual stimulation, you or your partner would find a dark, relaxing place to tweak and gently manipulate your nipples for about 15 minutes. Take a break for about 2-3 hours, then start again. For artificial stimulation, you would do the same as previously explained, but you would use a breastpump instead. For hydrostimulation, you would run a warm shower and then, while in the shower, place a washcloth over your breasts. Allow the showerhead to stimulate your nipples through the washcloth for the same time regime.
• WHAT YOU CAN EXPECT – mild to moderately irritated nipples, possible arousal, possible cramping or spotting, 
• RISKS – possible sore nipples, possible abdominal cramping with no labor, possible hyperstimulation when not using a safe protocol.

• Acupressure/Massage - there is a stimulation point on your calf called the Spleen 6 which can cause oxytocin productions. Additionally there are pressure points in your lower back, upper neck region, and pad of your foot which can also cause uterine stimulation or oxytocin production.
• HOW IT’S DONE – you would ask your doula, midwife, massage therapist, or reflexologist to assist you or teach you this practice. 
• WHAT YOU CAN EXPECT – mild discomfort at pressure point (similar to other deep tissue massage), afterward relaxation and better circulation. 
• RISKS – possible dehydration as your body moves toxins through your body and stimulates hormone production – be sure to stay hydrated, possible abdominal cramping with no labor.

• Castor Oil – castor oil is a stimulant; it irritates the bowels and, as such, can irritate or stimulate the uterus as well. The result is, most often, diarrhea, and sometimes, labor.
• HOW IT’S DONE – you would procure castor oil from a local pharmacy or food store. It can be consumed in apple or orange juice, in scrambled eggs, in milk shakes, or with baking soda. Most commonly, the dosage is around 3-4 teaspoons. Some women have simply taken a few spoonfuls of castor oil, but most women cannot get past the gag reflex. Many midwives recommend not eating anything afterward for at least 2 hours to maximize the effect.
• WHAT YOU CAN EXPECT – oily dosage, difficulty swallowing it, possible cramps and show within 3 hours of taking it. possible mild to moderate nausea, possible vomiting, most probably diarrhea.
• RISKS – possible mild to moderate dehydration from diarrhea, be sure to drink plenty of water, possible severe diarrhea, possible severe vomiting, possible severe abdominal cramping with no labor, possible meconium staining from the castor oil use, which can increase the risk of meconium aspiration.

• Consumables – Spicy food, pineapple, basil and eggplant have all been recommended as ways to encourage labor throughout the centuries. Purportedly, spicy food works because it irritates the bowels, which, in turn, irritate the uterus, similar to castor oil. Pineapple might encourage labor because it contains bromelain, and Basil and Eggplant because, well, I am not honestly sure where those came from.
• HOW IT’S DONE – prepare any of these foods in your favorite way and enjoy a wonderful meal.
• WHAT YOU CAN EXPECT – hopefully you will enjoy eating a good meal and feel full. There is limited research done on the validity of these claims.
• RISKS – spicy food and pineapple could produce heartburn, eggplant and spicy foods could produce loose stools, indigestion could occur as well.

• Chiropractic Adjustment – when your spine is misaligned, it might produced on and off again labor (start and stop, or prodromal labors). Having an adjustment by a chiropractic skilled in prenatal chiropractic care may be what your body needs to be able to start things on their own. Additionally, oftentimes, chiropractic adjustments can touch on the pressure points for induction of labor, unless the chiropractor is going out of their way not to touch those trigger points. Chiropractors also routinely place mom in a position that facilitates something called a pelvic floor release, which can ‘unwind’ tense pelvic floor muscles and allow baby to sink lower in your pelvis, potentially stimulating contractions and causing dilation from gravity.
• HOW IT’S DONE – schedule an appointment with your chiropractor, letting them know that you are looking to encourage labor and would also like to have a pelvic floor release performed.
• WHAT YOU CAN EXPECT – if you have never been to a chiropractor before, they will manipulate your muscles and joints through changing your positions on either a bed with a drop out section for your belly or on a specially designed chair for pregnant women. You may experience popping as they manipulate these joints and you may experience a slight humming or brief warming where it occurs.
• RISKS – dehydration may occur from the release of these joints and muscles. Drink plenty of water afterward.

• Blue/Black Cohosh, Cotton Bark, Squawvine, or Goldenseal – These herbal tinctures do carry some medical risk, it is best to take these only under the close eye of a holistic practitioner. These tinctures can cause stimulation of the uterus and are rather reliable. They are considered the most aggressive alternative labor encouragement method of all.
• HOW IT’S DONE – According to Anne Frye, (Holistic Midwifery Volume II ) you would take 10 drops of both Blue and Black Cohosh four times a day, or as often as every hour, depending on how aggressive you would like to be and your bodies tolerance to the protocols. 

“For induction, Cotton Root Bark tincture is perhaps the most effective of all labor-inducing herbal remedies.” After using the Cohosh tinctures as directed therein, if it has little to no effect, Anne Frye recommends,” First, you can give a dropper of blue cohosh tincture at 30 minute intervals for 1 to 2 doses. Then switch to cotton root bark tincture in dropper doses spaced as often as every 15 minutes the for next 3 to 6 hours.”

• WHAT YOU CAN EXPECT – the tinctures taste very herb-like and, if you have chosen an alcohol based one, may have a residual after burn in your mouth for short term. Cramping, spotting, increased discharge, possible heart palpations, possible strong contractions, possible loose stools.
• RISKS – contraindications include: history of anemia, history of postpartum bleeding, high blood pressure, or history of clotting disorders. Cohosh can cause blood pressure drop, so be sure to drink lots of water. Cohosh can also cause nausea or fetal heart rate fluctuations.

• Various other methods – Additionally, there are the options of going curb walking, blowing up balloons, walking through a pool with weighted ankles.. all of these are entertaining options, but the available validity of these claims are very sketchy.

In conclusion
Did you know that you can worry yourself right out of labor? I have encountered woman after woman who asks how to encourage her body to go into labor naturally. The best way to encourage your body to go into labor naturally is to relax and let it go into labor naturally!

Your body knows how long to grow your baby, what size of baby to grow, and how to start labor. I highly encourage women to know their options, but only act on them when the risks of baby remaining inside outweigh the risks of forcing nature’s hand at the act of induction.

Whenever we tamper with natures design, we introduce unnecessary risk, emotional, mental, and physical stress - none of which are good for labor and birth. Trusting the process and only interfering when there is a true medical indication for it will ensure the safest, healthiest, most satisfying outcome for all involved.

For Additional Reading:
On Pins and Needles - acupuncture for induction
Induction Increases Cesarean - the correlation between neonatal issues, induction, and cesareans
What A Difference A Week Makes - avoiding premature babies 'at term'
Avoiding the Pit - know the realities of Pitocin
An Australian post on Induction


References:

• Gülmezoglu AM, Crowther CA, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2.
• Dodd JM, Crowther CA. Elective repeat caesarean section versus induction of labour for women with a previous caesarean birth. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004906. DOI: 10.1002/14651858.CD004906.pub2.
• Irion O, Boulvain M. Induction of labour for suspected fetal macrosomia. Cochrane Database of Systematic Reviews 1998, Issue 2. Art. No.: CD000938. DOI: 10.1002/14651858.CD000938.
• Harman & Kim. "Current Trends in Cervical Ripening and Labor Induction" American Family Physician 1999; 60:477-84. 
• Pregnancy, Childbirth and the Newborn by Simkin et al.,
• TheThinking Woman’s Guide to a Better Birth by Henci Goer
• Romney S et al, editors: Gynecology and Obstetrics: The Health Care of Women, ed 2, New York, 1981, McGraw-Hill.
• Holistic Midwifery Volume II, Anne Frye, Labrys Press
• Wise Woman’s Herbal
• Naturally Healthy Pregnancy
• http://www.mother-care.ca/induction_meth.htm
• http://www.gentlebirth.org/archives/natinduc.html#castor
• http://www.mothercare.ca/bishop.htm
• http://www.cdc.gov

Induction Increases the Risk of C-Section and C-Section increases Newborn Infection

Labor Induction and the Risk of a Cesarean Delivery Among Nulliparous Women at Term, a recent study published with the American College of Obstetrics & Gynecology (July 2010 - Volume 116 - Issue 1 - pp 35-42) gave the following conclusion:

Labor induction is significantly associated with a cesarean delivery among nulliparous women at term for those with and without medical or obstetric complications. Reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population.

This makes for even more worrisome fodder, as the study also includes this information:

Labor induction was used in 43.6% of cases, 39.9% of which were elective.

Inductions for 43.6% of cases?! How many inductions are too many?? And, based on the information given just previously, how many of those resulted in maternal or newborn risk?

Another study printed with the National Academy of Sciences researched what microbiota habitat a newborn at birth... depending on their mode of birth. The small study found that:

those born vaginally tended to get colonized by bacteria such as Lactobacillus from the mother's vaginal canal. C-section babies, however, got more Staphylococcus, a type of microbe usually found on the skin and one that sometimes causes nasty infections. - "Babies' First Germs Depend On Type Of Birth", Chao Deng, NPR

So, in conclusion, to lower cesarean rates and increased risk of newborn strep infections, we should stop inducing for mundane reasons. To lower strep infections, lower the risk for newborn death, respiratory distress, incidences of autism and other SENs, and modestly lowered IQ scores, we need to stop inducing so much.

This is only the tip of the iceberg, people. Oh, the tangled web we weave.

What A Difference A Week (or two) Makes

With the rate of inductions being so high in the United States, the question is raised of, beyond maternal and birth risk, what additional risks are there for babies immediately after birth and long-term?

Babies Born at 37-39 weeks gestation are at an increased risk of autism or an SEN (Special Education Need). It was already known that children born very premature were at increased risk for this, but, until just now, no research had been done on closer-to-term infants. The findings report that these babies, babies born between 37-39 weeks gestation, are 1.16 times more likely than truly full-term babies to develop autism or another SEN.

Additionally, children born earlier are at an increased risk for newborn death, respiratory distress, and modestly lower IQ scores.

An interesting bunny trail regarding this particular article is that, although the article points out many risks for babies born prematurely, as well as Dr. Michael S. Kramer pointing out that

..... both obstetricians and women should be aware that labor induction at the 37th or 38th week is not without risks. And studies should continue to examine the potential public-health impact of the rising labor induction rate.

He is careful to include the comment that:

"I'm not saying we're at the point that we're doing too many labor inductions," Kramer said. But if the rate continues to increase, he added, "eventually, we may get to the point where we do more harm than good."

hmm... so, even though the induction rate is at or above 22%, and...

Precisely why labor inductions rose between 1992 and 2003 is not known; Kramer's team had no information on the medical reasons for individual women's inductions...

... he is sure to point out that he is not saying that they are at the point that they are doing too many inductions! Even though those inductions carry obvious risk and the rates are still climbing. Hmm...

I digress... So, all of this to say that there is a great wealth of supporting information and studies to show that we are, indeed, introducing unnecessary risk when we induce women without valid medical reason: when benefits CLEARLY and COMPLETELY outweigh the risks.

I cannot stress this enough. You would not believe the number of women who succumb to an induction because they were 'told they had to if they wanted a chance at a vaginal birth', were 'told their baby was due and now we were risking things by allowing baby to stay in past (supposed) 41 weeks', or were 'told that the baby was getting too big for a vaginal birth unless we have them now'. And on and on...

When we cannot truly know when a baby is truly due based on the gestation wheel alone, and we cannot meddle in nature without increasing risk to begin with, the question is raised, "WHY do we continue to allow early inductions without valid reason?"

A Good Reason is NOT:

• big baby
• supposed due date
• slightly elevated BP close to the due date
• edema close to the due date
• schedule conflicts
• low fluid levels close to the due date
• family in town
• convenience

A good reason is when the medically sound benefits of getting baby out of the womb OUTWEIGH the risks of a possible early induction (again, because we cannot know beyond a shadow of a doubt how 'due' a baby truly is until they are born) combined with the risks associated with induction (regardless of when it is performed).

I think it is high time that we start to really consider how much faith we put in human interference versus nature's design.

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.

All About Inductions: Do Due Dates Mean Your Baby is Due?

I'm sure you know, from my past posts, the answer to that question: Most likely, no.

I abhor the term 'due date'; this term means a day of collectibility. Once you reach that estimated day of collectibility, suddenly you are considered "late". Late carries the burden (no pun intended) of being defunct, dysfunctional, or errant. "Overdue" infers something that is spoiled, going bad, or rotting (i.e. milk). Did I mention that I abhor that term?

Unfortunately, the Estimated Due Date (EDD) commonly used by health professionals is not nearly as accurate, and thus the majority of inductions are not nearly as pressing, as they claim.

Pregnancy is assumed to last 10 lunar months or 40 weeks (280 days). People often use this formula to calculate the EDD: The first day of your last menstrual period, minus 3 months, plus 7 days.

An example of using this formula:

First day of my last period was December 13th.

December 13th minus 3 months = September 13th

September 13th plus 7 days = an EDD of September 20th

This is a relatively easy formula. The problem is, it is only somewhat accurate - and then only when a woman has a regular cycle of 28 days, a luteal phase of 14 days, and did not take any oral contraceptives... uh oh, I just saw 95% of hands in the room go down.

How did we come up with this majority-inaccurate formula? Dr. Franz Naegele came up with it, which puts all women on a bell-curve for convenience and estimations' sake. It is a good guide to help estimate age, but should not be considered rule.

Carol Wood Nichols, previous Assistant Professor at Yale University School of Nursing, Maternal-Newborn Nursing/ Nurse-Midwifery Program, and Director of the Yale Nurse-Midwifery Practice, developed a calculation that takes variations in cycle length as well as previous childbearing into account.

Nichols' calculator, as cited in Anne Frye's "Holistic Midwifery Vol 1" states:

For first time moms who have true 28 day cycles: LMP (last menstrual period) plus 12 months - 2 months,14 days = EDD

Example: For December 13th, the EDD is then September 30th

For women who have different cycles or who have already had other children (multiparas), add or subtract the number of days her cycle varies from 28 days... for a full list of formulas using this rule, see below:

1. 1st-time mothers with 28-day cycles: LMP + 12 months - 2 months, 14 days = EDD
2. Multiparas with 28-day cycles: LMP + 12 months - 2 months, 18 days = EDD
3. For cycles longer than 28 days: EDD + (actual length of cycle - 28 days) = EDD
4. For cycles shorter than 28 days: EDD - (28 days - actual length of cycle) = EDD

Let's use me as an example... I don't have a normal 28 day cycle, I cycle regularly around 31 days. Using the same example as previous, I was a grandmultipara by the time I was pregnant with my son.

Hint: the EDD given by my caregiver of September 20th was grossly inaccurate. My EDD was somewhat more accurate based on the 1st-time mothers with 28-day cycles formula from Nichols, resulting in an EDD of Sept 30th...

Let's go a step further though; following Nichols' rule for cycles longer than 28 days (line 3.):

Dec. 13th plus 12 months - 2 months,14 days = Sept 30th.
Sept 30th + (31-28) = Oct. 3rd.

My son was born on October 6th.

In addition to all of this fun calculating (BTW, did I fail to mention that I had to take calculus 3 times before I passed?), there was a study performed by Mittendorf, which results showed that the average length of pregnancy is longer than usually calculated, especially for European first-time mothers. And those of us in the childbirth field can attest to the fact that most of the first-time mothers we work with deliver after their EDD as calculated by Naegele's gestational wheel. First pregnancies are often longer than subsequent pregnancies.

So, all of this to say that the EDD given by your care provider is simply to give you an idea of your baby's birth date. Don't use 40 weeks as an expiration date, but simply as a guesstimate.

When asked when your baby is due, consider telling people more vague answers to keep from prying questions (are you still pregnant?) and bothersome phone calls (have you had the baby yet?). A vague answer could very well consist of "I'm due early October".

Remember that pregnancy, on average, lasts 38 to 42 weeks, this means you have a due month, not a due day.

How do you broach this subject with your doctor? It truly helps to have a chart of your MP to prove cycle length, and gives you better bargaining chips for setting EDDs in your chart. Remember, though, you don't need to consent to an induction if your knowledge of your body conflicts with their policies.

I know that it is becoming fairly common for doctors to 'always' induce between 39 and 41 weeks. But, there is no medical justification for an induction simply for 'expiring' your EDD as determined by the Naegele Wheel. As this post just explained, it is perfectly normal and natural to go over this date. Induction for 'expiration' alone is not justified. For your and your care provider's peace of mind, though, you can start a kick chart around your EDD.

To begin a kick chart, choose a time of the day (1 hour in duration) when your baby is usually very active. For consistencies sake, try to do your kick counting at this same time every day. Relax (lie or sit down) so that you can pay attention to your baby and are not distracted by TV, work, or the computer (or you may miss the smaller movements - which you have become accustomed to over the last 32 weeks or more).

You can drink a glass of cold water to perk baby up even more right at this time if you would like. During that 1 hour count baby’s movements (this includes kicks, punches, turns, rolls, hiccups, etc..). You should be able to count around 10 or more in one hour. On the chart I linked above, when you reach 10, put an X in the window that marks the duration of time you had to wait to reach that count.

If you feel less movement than normal at that time of day and cold water does not wake him up, try for another hour after eating a small snack to give baby and you a boost in blood sugar. If baby is still less active than usual, consider consulting your caregiver.

In closing, remember, it is your choice to consent to an induction or not. An induction may sometimes be necessary, but the majority of inductions are not. Millions of healthy babies have been born after their EDD and, depending on your true estimated due date, without a medical reason for it, an induction can cause more complications and necessitate more interventions if mom's body and baby are not ready.

Considering Induction? Refer to Your Bishop...

In the mid 1960s, the Bishop Scoring (Bishop, E. Pelvic scoring for elective induction. Obstetrics and Gynecology 24(2), 266-268) method was introduced as a means of evaluating the cervix in relationship to successful induction. This scoring system attempts to predict success of induction by assessing five factors: position of the cervix in relation to the vagina, cervical consistency, dilation, effacement and station of the presenting part. The higher the score, the higher rate of success of the induction. A score less than five indicates an unfavorable cervix for induction. Some texts also reference the Burnett Scale* which assesses approximately the same factors.

A score of 5 or less suggests that labor is unlikely to start without induction. A score of 9 or more indicates that labor will most likely commence spontaneously. A low Bishop's score often indicates that induction is unlikely to be successful. Some sources indicate that only a score of 8 or greater is reliably predictive of a successful induction.

Although some care providers will attempt to improve scoring through cervical ripening agents (Cervadil, Cytotec, or Foley Catheters) before induction (Pitocin, AROM, etc…), that will only improve ONE of the many assessing factors.

Below, you will find the Bishop Scoring chart.

Something to keep in mind; if you are attempting to see how favorable your body is for successful induction, I would recommend NOT asking your doc for your Bishop score, but ask, instead, for your dilation, effacement, station of baby, position of baby, and consistency of your cervix - so that later you can assess your OWN Bishop's Score. Many doctors will give a skewed score or refuse to give it outright. This will alleviate that issue.

Once you add up your points, this is how to interpret your score:

• 0-4 points = 45-50% failure to induce successfully
• 5-9 points = 10% failures rate
• 10-13 points = 1% failure rate

* Here is a great link for the 'revised chart'. Just one more way to be informed and make informed decisions on your health care.

At Your Cervix

I just happened upon a great blog excerpt from the blogspot, At Your Cervix. She has posted a great wealth of information on induction and risks.

I cannot say it enough: educate yourself! If you are at all concerned about your newborns wellbeing and your own, EDUCATE yourself and make informed and responsible decisions regarding your healthcare. I encourage all women to read this.