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Monday
Aug022010

Time for a Change? Induction of Labor Increases Odds of Cesarean Delivery

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By Jill—Unnecesarean

 

Time.com posted an article today titled “Are C-Sections Overused? Rethinking Induced Labor.”

The rate of C-sections has reached more than 31% in the U.S., a historical high, according to 2007 data from the American College of Obstetricians and Gynecologists (ACOG). The reasons for the increase are many and have been widely discussed: the rising rate of multiple births, more obesity in pregnant women, the older age of women giving birth. In fact, C-sections have become so common that many women may have an inflated sense of safety about them. “For the most part, moms and babies go through the process healthy and come out healthy, so maybe there’s this sense that we’re invincible,” says Dr. Caroline Signore of the Eunice Kennedy Shriver National Institute for Child Health and Human Development.

The article focuses extensively on the study, Labor Induction and the Risk of a Cesarean Delivery Among Nulliparous Women at Term, which appeared in the July 2010 Green Journal. From the discussion of this study:

We studied cesarean delivery for a cohort of nearly 8,000 nulliparous women presenting with a vertex singleton pregnancy at term using data derived from hospital obstetric records. Women in the cohort represented 85% of the births in the region and received obstetric care provided by a mix of both hospital staff and community providers. Consistent with earlier studies, the odds of a cesarean delivery was influenced by obstetric management, sociodemographic factors, maternal comorbidities, pregnancy complications, and neonatal factors.6,17–21 The risk factors with the greatest contribution to cesarean delivery in this population, based on the strength of their association and their prevalence, were the use of labor induction and the presence of maternal prepregnancy obesity. Neither of these factors is reliably reported in vital statistics data and neither has been included in explorations of temporal changes in cesarean delivery.7

Labor induction was associated with a twofold increase in the odds of a cesarean delivery after adjustment for confounders. The effect was somewhat larger among a low-risk group of women without major complications that might lead to the indication for labor induction or cesarean delivery. The population attributable fraction reflecting the contribution of labor induction to the rate of cesarean delivery in this population was estimated to be 20%. We also found that the obesity-related risk remained independently associated with odds of cesarean delivery after adjusting for maternal demographic factors as well as obesity-related complications including gestational diabetes, gestational hypertension, excess maternal weight gain, or neonatal birth weight of 4,000 g or more. The odds of cesarean delivery increased with increasing maternal BMI in the overweight range and continued to rise with each BMI category.

 

The article also discusses Magee Women’s Hospital, which was awarded in 2008 for lowering the number of induced births. The hospital’s 2008 cesarean rate was 27.2%.

 See all Pennsylvania 2008 cesarean rates by hospital

 

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Reader Comments (8)

While participating in a huge mainstream birth community ("birth board"), I realized I could find almost zero women who go into labor spontaneously anymore. If a woman does not go into labor by about 39 weeks, chances appear incredibly high that her provider will schedule a pitocin/prostaglandin induction. This is true even if she is nulliparous and has an unfavorable cervix. It seems to be a combination of the mothers wishing to end an uncomfortable part of their pregnancy and providers wanting the convenience of scheduling delivery for the day(s) that they are in the hospital. Many providers are now saying that there is no point to waiting beyond the due date for delivery, as the babies "just get bigger" and "bad things can happen".

As a long gestator myself, and as someone who believes the medical research literature demonstrating that the range of normal pregnancy does indeed go up to 42 weeks (and that the percentage of complications even beyond 42 weeks is small), I get incredibly angry about this phenomenon. Women are encouraged to have their labors induced and often not told of the increased risk of Cesarean for fetal distress or failure to progress. Then, in the next pregnancy, they are told not to attempt a VBAC because clearly, their body could not birth a baby the first time around (when it wasn't ready).

It is almost radical to decline an elective induction offer.

August 2, 2010 | Unregistered CommenterKK

KK, it does seem to have crossed over into a dominant cultural belief. Forty weeks and one minute is considered "overdue" and it's very common for a pregnant woman to be asked when they are going to induce her.

Elective induction is offered almost routinely by many docs in my area. One friend heard right before hitting 37 weeks, "OK, once you hit 37 weeks, we can talk induction."

Weird phenomenon, but not surprising when we consider all of the context about making medical care fast and efficient to increase profitability. Or the perception *something* has to be performed to buffer a physician/hospital in a lawsuit.

August 2, 2010 | Registered CommenterJill

I used the induction stats to illustrate to my mother how different giving birth has become since she had her children, and used our own family as an example. My dad's side being from good Irish Catholic stock, there's a huge range in the grandchildren/great-grandchildren, not to mention a good number. The first pack was born roughly 1970-1988 (9 kids). Then there was a gap of about five years with no babies, and then the next set started to be born (10 so far). I don't think a single birth was induced in the first set (including my brother born at 41+3). Of the second set, at least 5 were induced, and one was a planned c-section for transverse lie (where my cousin was pressured to schedule early because the baby was "big" by ultrasound, yet came out at less than 6 lbs.) The last four in a row were induction, planned c-section, induction, induction. The cultural change is so evident.

I sometimes see "IOL for postdates" written on the files of women on the postpartum floor. I take a little subversive pleasure in charting "IOL for 'postdates' " in my LC notes when it says that and she was induced at something like 40+3.

August 2, 2010 | Unregistered CommenterRebecca

Magee augments a very high number of women. There is a bag of pitocin in every labor room I've attended a birth in... and most CPs do not tolerate deviation from Friedman's curve very well.

Yes, the are technically not scheduling inductions anymore, but there are OBs there that will come up with a whole host of reasons to induce and then do a cesarean because the mom gets stuck at 5-6cm. I know that I'm only one person, but I have seen it played out at more than half of the births I have attended there.

August 2, 2010 | Unregistered CommenterVanessa Manz

Here's a link to an article that reads like a campfire ghost story, but could be historically accurate. It includes the definition of a new word to me. Burking: Murder for hire for the purposes of medical research.
http://www.guardian.co.uk/uk/2010/feb/07/british-obstetrics-founders-murders-claim

August 2, 2010 | Unregistered CommenterPriss

I've thought about this a lot. If, for example, my baby would have gestated naturally to 42 weeks, and we did an elective induction even at 38 weeks, that would be a whole month of development thwarted by early induction. If I had a baby naturally a month premature, it would be considered a medical emergency. Yet, purposefully inducing babies (perhaps) two to four weeks early is thought nothing of. Why is that?

August 3, 2010 | Unregistered CommenterAugusta

Augusta, I wonder how many times I've heard physicians declare with complete and total confidence that there is no benefit to staying in the womb past ________ (x number of weeks). The March of Dimes has spent a lot of time, money and effort pleading the case against elective inductions and cesareans because of the rise in late preterm births and prematurity. Ultrasounds are not accurate enough to measure gestational age beyond a shadow of a doubt and the result of a 38 week induction or cesarean might well be a baby that's actually only 35.5 weeks old.

August 3, 2010 | Registered CommenterJill

Augusta - beautifully said. My babies seem to come ~2 weeks early, but upon exam they are "term" (wrinkling of scrotum, lines on feet, muscle tone and strength, among other things) rather than "early". I'm certain that many babies born at 41-43 weeks would also measure "term" rather than "late" if we used these measures instead of a somewhat arbitrary calendar or US. And who is so naive as to think that every baby needs the exact same amount of time in the womb? Babies crawl/walk/talk at vastly different ages, why shouldn't it be equally normal to be born over a 5-week range of gestation.

August 5, 2010 | Unregistered CommenterLarissa
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