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Entries from November 1, 2008 - November 30, 2008

Monday
Nov242008

Article: Unnecessary Inductions- Trends, Studies and Guidelines

While doing some research, I came across an article that appeared last year in the LA Times. All non-italicized quotes are from the article “All in good time” by Shari Roan published on August 13, 2007 in the Los Angeles Times.

 

 

What if all of the women who trusted their doctor enough to submit to completely unnecessary obstetric management procedures got really angry and did something about it? Misa Hayashi was told that her baby would be too big. Spoiler Alert: He only weighed 7 pounds, 10 ounces.

 

Her first baby wasn’t due for four days, but Misa Hayashi was advised by her obstetrician during a routine exam to check into the hospital that day.

 

“The doctor said the baby was too big for me to push out and we should go ahead and induce labor,” says the Alhambra woman, 24. “I didn’t really question it. Induction sounds so common. We went home and packed a bag and checked in at the hospital.”

 

Once there, however, Hayashi’s plans for an uncomplicated birth faltered. After receiving the drug Pitocin to trigger contractions, she labored for 20 hours. The pain was so intense she needed medication to ease it – something she had hoped to avoid –and eventually the baby became distressed, requiring constant monitoring of his heart rate.

 

Finally, almost a day after Hayashi entered the hospital, her son was born. Although he was healthy at 7 pounds, 10 ounces, Hayashi was left questioning the wisdom of labor induction.

 

Hayashi turned to Lisa Sherwood, a CNM/NP to attend her second baby’s birth:

…after she was informed – in the first trimester – that she would be induced again.

 

“I think these doctors kind of play bully. They give you the better of two horrible options and say your body can’t do it.”

 

Her second son was born two weeks after her due date following a spontaneous, four-hour labor.

 

A good collection of statistics on induction:

Fewer than 10% of women underwent induction in 1990, but more than 21% did so in 2004, according to federal government statistics. No one knows how many of those inductions were prompted by legitimate medical concerns. But various studies have put the number of inductions for convenience at 15% to 55% of the total number.

 

At the same time, rates of caesarean sections increased to more than 29% in 2004, up from 23% in 1990, with many women requesting elective C-sections – surgical births without any medical justification. That trend too has generated debate about whether patients are undertaking unnecessary risks.

 

The famous “cascade of interventions”:

But some experts say the practice creates unnecessary risks and costs. It can lead to more interventions, such as caesarean sections, and increased use of forceps and vacuum devices to assist in delivery, research has shown. A 2005 study in the journal Obstetrics & Gynecology found that C-sections occurred 12% of the time among women having spontaneous labor compared with 23.4% for women having medically necessary labor induction and 23.8% for women having elective labor induction.

 

Other studies have found that, compared with spontaneous labor, elective induction leads to longer hospital stays and higher costs. Induced labor also may be more painful because some of the drugs administered to trigger labor can cause more intense contractions.

 

Often held up as a model for limiting medically or financially unjustifiable practices in birth, Intermountain Healthcare implemented “strict guidelines on elective labor induction” eight years ago in the 21 hospitals that it operates in Utah and Idaho.

 

The chain, which delivers 53% of all babies in Utah, told its doctors they must seek permission from a supervisor before inducing labor prior to 39 weeks. Doctors must also make sure the cervix is favorable for delivery.

 

When the cervix is optimal (it must be opened and thinned out enough to allow the baby’s head to pass through the vagina), labor averages about nine hours in a first-time pregnancy, according to Intermountain. If the cervix is not ready, however, an average labor is about 22 hours. The guidelines have reduced rates of elective labor inductions performed before 39 weeks gestation from 28% in1999 to 3.4% in 2006. The percentage of first-time moms with an elective induction has fallen from 15% in 2003 to 4.7%.

 

Hospital administrators no longer see sudden spikes in deliveries before major holidays, three-day weekends and Jazz basketball playoff games.

 

The program has resulted in plunging C-section rates, fewer newborns in intensive care and fewer medical interventions in delivery. Length of labor has decreased by an average of two hours per patient. That’s important, Wilson says, because length of labor is linked to a higher risk of dehydration and infection.

 

“We feel pretty confident that it does make a difference,”she says.

 

 

Yes, let’s please get that baby out before it gets HUGE. Ask Misa Hayashi (above) about her gigantic 7 pound, 10 ounce baby.

Not everyone thinks elective labor induction is harmful. A study published July 31 in the Annals of Family Medicine suggested that “preventive labor induction” may produce the best safety outcomes, including lower C-section rates.

 

Doctors practicing in a rural Connecticut hospital found that the approach, which includes the use of a mild-acting prostaglandin gel to ripen the cervix before inducing labor, significantly lowered C-section rates compared with women receiving traditional care. Specific criteria were used to determine the “optimal time” for the patient to undergo the preventive induction.

 

The idea is to perform an induction before the baby gets too big and the placenta can no longer fully support a healthy pregnancy.

 

Here’s the final paragraph from the discussion section of the study referenced in the article:

At a time when national cesarean delivery rates have surpassed 30%,6,7when preventive primary cesarean delivery is being offered as an unproven means of preventing intrapartum perineal trauma,31 and when the short- and long-term complications of cesarean delivery are still not completely understood,28,29,32,33we hope that practitioners might consider the potential benefits of an apparently safe alternative method of maternity care that is associated with high rates of successful vaginal delivery. The AMOR-IPAT approach uses accurate pregnancy dating and risk scoring to estimate an optimal time of delivery for each woman.11If spontaneous labor has not occurred before the upper limit of optimal time of delivery, then preventive labor induction, with cervical ripening if needed, is used to increase the likelihood that labor occurs before the fetus has grown too large for the maternal pelvis and/or before the placenta has grown too old to support the fetus during labor. Adequately powered prospective randomized trials of AMOR-IPAT are warranted to assess its impact on rates of cesarean delivery and other birth outcomes.34,35 [Emphasis mine]

 

 

Dr. Michael C. Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, wrote an editorial in the Annals of Family Medicine calling the study’s conclusions into question.

“Childbirth is complex,” says Klein, who has studied birth outcomes. “What they are doing is complex, but they are not acknowledging it.”

 

Klein says the lower C-section rates may be due to the especially attentive and intense care the laboring women in the study received – not because they were induced at an optimal time.

 

“This is another study saying to women, ‘You can’t survive without us making things better; nature is completely off-track,’ ”says Klein. “And there is a huge reservoir of practitioners out there who want to hear this message.”

 

A few words from a Lisa Sherwood, CNM/NP in San Clemente, CA:

Doctors who want the convenience to schedule daytime deliveries may be the biggest force for elective labor induction, says Lisa Sherwood, a certified nurse midwife and women’s health care nurse-practitioner based in San Clemente. Women who “haven’t slept well in weeks, have swollen ankles and sore backs” are vulnerable to the suggestion of elective induction. “People look at the doctor as the expert and will do whatever he or she suggests.”

 

But, she says, “once you do an intervention, it begets more interventions, and many women feel they are led down a road they didn’t understand. Women tell me, ‘I didn’t know it was going to end up like this.’ Women need to be given all the information on what they are signing up for, not just told, ‘You’re going to have your baby today.’”