Thoughtful Discussions: Induction of Labor

One might wonder why on earth I feel this is an important topic for discussion. Well, I’ll tell you!

Once upon a time and not so very long ago, when things went wrong with a pregnancy, there wasn’t much recourse. You gritted your teeth, prayed for the best and prepared for the worst. Thankfully, today we have more options. The ability to induce a pregnant woman chemically, in a highly controlled environment, has undoubtedly saved the lives of millions of women and their babies. That said, the cesarean rates have shot through the roof and are double what the WHO says they should be. Many people have been postulating on what has caused our cesarean rates to skyrocket out of control and many are trying to understand how the nation that spends more money on health care than any other developed nation in the world could have such embarrassing maternal and fetal mortality statistics. The fact that the induction rates more than doubled between 1996 and 2006 seems to be in direct correlation with both of cesarean rates and our abysmal mat/fetal health stats. According to a survey done by Robbie Davis-Floyd, approx 81% of women will receive pitocen (synthetic oxitocyn) either to induce or augment labor. According to the CDC, up to 20% of women will have their labor induced. In fact, the induction rate has increased from 9% in 1990 to 22.1% in 2004. Despite these measures theoretically being taken with the best interest of mothers and babies at heart, we have not seen a corresponding decrease in neonatal and maternal mortality to match. Therefore, educating ourselves as consumers about induction and all of the pros and cons that come along with it seems a wise thing to do. In that vein, what follows is going to be a series of posts relating to this topic of discussion.

What are the common reasons for induction? In this post I’m going to talk about medically indicated reasons for induction.

There are many possible reasons for a woman to be induced. In fact, in our current birth culture, the list is long. What are truly cases for induction based on evidence? As mentioned above, induction most definitely saves lives. Here are some sterling examples:

Pre-eclampsia: Pre-e is a life-threatening condition that develops after the 20th week of pregnancy in some women (rarely it can present up to 6wks post partum). The disease is characterized by swelling in the hands and face, sudden weight-gain, blurry or spotty vision, terrible headaches, protein in the urine and in particularly bad cases, pain around the liver area (usually associated with HELLP). If left untreated the mother will develop Eclampsia. The only treatment for this disease is the prompt delivery of the baby.

HELLP: HELLP stands for the abbreviation of the main findings of the disease- Hemolytic anemia, Elevated Liver enzymes and Low Platelet count. From what I’ve been reading, this appears to be considered a variant of Pre-eclampsia, however it was determined to be a distinct clinical entity (as opposed to just severe pre-e) in 1982. Symptoms include a marked increase and severity in headaches as well as vomiting, “band-pain” around the upper abdomen, and arterial hypertension (though it may be mild). There is more but these are the presenting symptoms. If seizures or coma are present, it has already progressed into full-blown Eclampsia. Around 8% of the cases of this disease don’t appear until after the pregnancy but in most cases, delivering the baby will cure the condition and in fact, it’s the only cure for the disease that is known.

Pre-eclampsia and HELLP are referred to together as Hypertensive Disorder of Pregnancy and Toxemia of Pregnancy

Eclampsia: This is what happens when the above two diseases are not treated. It is marked by the above mentioned symptoms along with seizures or coma. Renal failure is possible, as well as pulmonary edema, liver failure and oliguria (lack of urine). Eclampsia is deadly and the only cure is delivery of the baby. Well actually, the only cure is the delivery of the *placenta* but obviously, in order for that to be possible, the baby must be born as well.

Intra-Uterine Growth Retardation: This complication is usually referred to as IUGR. Sometimes, for various reasons, the baby isn’t growing well or thriving in the womb and when this occurs, the baby may have a better chance of survival if delivered early.

Cholestasis of Pregnancy: This is a disease involving decreased liver function caused by the slow-down or cessation of the flow of bile from the gall-bladder to the liver. Characteristics of this disease are itching on the palms of the hands and feet (often the only symptom for many women), dark-colored urine, light coloring of bowel movements, fatigue or exhaustion, lack of appetite and depression. Severe and less common symptoms are jaundice, upper-right quadrant pain and nausea. I actually thought this was a rare disorder as I’ve rarely come across it but in fact, it affects 1 or 2 women out of every thousand. So it’s not terribly rare, though not terribly common, either. This disease can have negative consequences for both mother and baby and as such the pair must be monitored closely. The baby depends on mom’s liver to cleanse out the impurities of its blood so her body not being able to do so can cause stress for the baby. Cholestasis may increase the risk of fetal distress, preterm birth or stillbirth. Once again, the only cure for this disease is delivery of the baby though from what I’m finding induction isn’t always indicated and depends upon the severity of disease and how it is affecting mom’s liver. I have known two women to have this disease. One of them needed an induction and the other didn’t.

Various Pre-existing conditions in the mother: These may include certain cancers, heart conditions and other unique issues that make a controlled, induced delivery necessary. These conditions can range widely, from severe illness (such as pneumonia) to congenital heart problems. The difficulty in some cases is that the pregnancy puts an extra stress on the body, complicating the pre-existing condition or conversely, the pre-existing condition is complicating the pregnancy. I have known of several mothers with various heart conditions or severe respiratory disorders who have had to deliver early and others with similar conditions that have not. I even know of one woman who had a congenital heart condition as well as Type 1 diabetes that had to deliver early for one pregnancy and not for another! These conditions are definitely a case by case decision to be carefully made between Mom and her doctor.

The next “Thoughtful Discussion” post will pick up with common reasons given for induction that are not evidence-based or necessarily in mom and baby’s best interest. Do you have a topic to discus? Comment with your ideas!