In July, ACOG… the American College of Obstetrics and Gynecologists issued new/revised guidelines regarding the induction of labor for pregnant women. When I got word of this via email I was excited. I thought to myself, they are finally issuing a statement about the rising induction rate that is significantly tied to our rising cesarean rate and rising health care costs. I thought to myself, ACOG is going to finally tell its membership that the time has come to decrease the number of elective, unnecessary inductions taking place daily in this country. Yep I was excited…that is until I read the document.
I read the ACOG Practice Bulletin Number 107 published in the August edition of the Green Journal, only to discover that I was waaaayy off the mark. This document has no such information. It is merely a review of the current cervical ripening and induction methods being used today. It talks about misoprostol, the foley bulb, and PGE2 gel. It talks about membrane striping, Pitocin, and amniotomy. Yep it tells the membership of ACOG just what to do if they want to induce a woman’s labor.
This bulletin says nothing about the increasing health care costs and little about the cascade of interventions that follow along with induction. It does mention that during inductions “monitoring FHR and uterine contractions is recommended as for any high risk patient in active labor.” So even if you were not “high risk” during your pregnancy, once the induction starts you will be treated as “high risk” and this is how the cascade starts. Inductions mean IV fluids, continuous fetal monitoring, staying in the hospital bed, increase use of edpidual anesthesia… all sorts of things that prevent the normal natural progression of labor.
The practice bulletin does include a small area that talks about reasons and contraindications for inductions. It clearly states “studies are limited in evaluating the benefits of elective induction of labor,” yet it goes on to say labor can be “induced for logistic reasons, for example , risk of rapid labor, distance from hospital, or psychosocial indications.” So I suppose with the crystal ball that’s given out at the end of an OB/GYN residency program, a physician can magically tell if a patient is going to have a rapid labor. This is probably the same crystal ball method used to determine if a woman’s baby is too big to fit through her pelvis. This particular prediction results in many early inductions and scheduled cesarean sections based on suspected macrosomia (the medical term for a large baby) FACT: Induction for suspected macrosomia has NOT been shown in the research literature to result in better maternal or infant outcomes. FYI… ultrasounds are NOT good predictors of birth weight. And even if they were, birth weight is not a predictor of whether or not a woman can birth HER baby. I was once told by an older midwife/mentor… women will generally grow the baby their body is capable of birthing.
There is one statement in the bulletin about increased c/sections resulting from inductions… “nulliparous women undergoing induction of labor with unfavorable cervices should be counseled about a two-fold increased risk of cesarean delivery.” Strangely enough, this statement follows the statement about elective induction yet there is nothing included that would discourage the member of ACOG from doing elective inductions, even with nulliparous women (women having their first baby). It’s as if they are saying… as long as a woman has information regarding the increased risk of cesarean birth she can be induced for no particular reason?? It’s as if they are thinking… “It’s okay. It works half the time. Let’s go for it.” REALLY?? And the reality is… in 15 years of working in obstetrics, I have NEVER had a patient, who was being induced, tell me that she was counseled about the risks of operative delivery due to her induction. That part of the counseling seems to be frequently overlooked.
Providers rely on ACOG to give them the most up to date and accurate information with which to guide practice. Many of them don’t read journals, are not into research, and don’t keep up with new trends and information. I say this based on comments and conversations I have had with many physicians as I have worked in multiple facilities across the country. They look to things like updates in ACOG Practice Bulletins to give them the information they need to guide their practice.
According to the side bar/disclaimer on the first page of the practice bulletin, “the information is designed to aid practitioners in making decision about appropriate obstetric and gynecological care.” I find it interesting that a document meant to help them make decisions only provides half of the information. While the document does a good job of telling a provider how to induce a client, there is little in the document that speaks to the inherent risks of induction. How can a provider make an educated decision, and how can a provider help a woman make an informed and educated decision if they are only presented with half of the information. The answer… They CAN’T.
My suggestion… we should simply STOP doing elective, unnecessary inductions. That would mean all of us, women, families, and providers, would have to step aside and allow nature to take its course. WOW…. Imagine that? It would mean that we would begin to embrace the first of Lamaze International’s Healthy Birth Practices… allowing labor to start on its own. It would mean accepting the FACT that a normal pregnancy can last 42 weeks. It would mean having patience in the process, and a respect for the work that is done, as a mother’s pregnancy nutures her growing infant INSIDE her womb. It would mean having faith that a woman’s body and her baby will know when its time for birth.
There are a few reasons when a labor induction is medically necessary. During these situations, it is critical that women seek out the information they need to make informed decisions. In addition to the Lamaze International document mentioned above, you can also get information about avoiding inductions and understanding when induction may be necessary by checking out this short 3 minute video.
An unecessary induction can certainly have an impact on your birthing experience. It is imperative that women ask questions and demand the TRUTH!! As always, your birthing experience depends on it.
In Birth and Love
Nicole
My friend’s doctor told her that sometimes a womans timer is broken and she needs induced! She has never had labor start on its own for her four children.
Unfortunately women are told that about many things including rupturing of their water bag and episiotomies. Womens are often lead to believe their water bag won’t break unless their provider breaks it and I have even heard a woman say “Doctor please cut an episiotomy” and when I asked her about it she told me “oh I need one. I had to get one with all of my babies” OMG!! so sad and unfortunate!
[...] wrote my original submission, as a critique of the newest ACOG Induction Practice Bulletin. I updated it a bit for submission to the carnival and today Amy put together a post that [...]
[...] Bulletin on Induction of Labor. Nicole at It’s Your Birth Right points out the bulletin’s doublespeak about elective induction – acknowledging the serious risks of elective induction but failing to advise against the [...]
Oh, ACOG. If only they’d get some practical input from AWHONN before taking some of these positions. I’m so tired of OBs practicing as though no woman can have an effective labor or successful delivery without good ole “Vitamin P (aka Pitocin).” My second labor was induced at 38 weeks (incidentally, this was before I worked L&D) because I was suffering from severe hyperemesis. While I was glad to have the pregnancy over and my digestive tract functioning normally again, I would never go through another induction. That was the worst kind of hard labor. I wish more pregnant women would make use of their Internet resources, learn about the risks of induction, and advocate for themselves to allow nature to take its course. God did design the process and it does work!
The thing about many of the MD’s practicing today (and you know this as an L/D nurse) some of them REALLY do think they are doing women a favor by inducing them lol. Its a sad scenario!. I wish more women took the initiative to get more info instead of believing “doctor knows best” that is such a slippery slope. Sometimes they do know best and many times in spite of what is best they do something different!! “smh”
***What I meant was that after I had my baby who was 8 1/2 lbs my former doctor said she’d c-sect/induce my NEXT baby. I’m pregnant with the “next” baby and not planning on an early delivery.
So sad and unfortunate! My doctor has ACOG and ACOOG after his name, so I’m assuming he’s a “member” or whatever you want to term him.
My former doctor wanted to c-sect/induce me 2 weeks early after I had an 8 lb 8 ounce baby whose collarbone snapped during delivery (even though I have a nice, wide pelvis- it was probably just her position and the fact the doctor was yanking on her).
When I told him that he said he’d leave the decision up to me to induce early if I felt baby was getting big. And I told him that wouldn’t be necessary. Inductions, after everything I’ve read, scare the crap out of me. I’ve given birth 2 times already without induction and I’d like to keep it that way!
“The day of doctor knows best has LOOOONG been over.” While I totally agree with this, there’s still a culture of blindly trusting the doctor here in the U.S. It is changing, but not quickly enough. I was just discussing with a friend about how our mutual friend’s doctor was pushing her to induce (which she has refused), and she said, “Well, that doctor came highly recommended. I’m sure if he thinks it’s a good idea, he’s not suggesting it without reason.” I had to be careful to disagree as kindly but as firmly as possible, but even then… I could tell she did not agree with my alarm at the doctor’s actions (telling her to schedule an induction when she already had refused, doing a manual dilation w/o informed consent, lying to her about his availability — saying, “We have to induce Friday because I’m going out of town,” and then saying later that he’s not actually leaving until Monday…). This goes back to your previous post, where, indeed, so much of L&D is now centered around convenience — usually the doctor’s convenience — and “maximum reimbursement,” and NOT on what’s best for the mother.
You are absolutely right Karen. Many people still say “Well if they doctor said it … ” It often breaks my heart. That’s why we are here. We gotta keep telling the truth on blogs, in workshops, at lunch with friends, in books, at seminars etc…etc…etc.