Let’s Talk Induction

Here is a very interesting study on the increase in cesarean sections stemming from the use of labor induction.  Labor induction has become a nearly ubiquitous labor intervention in recent years.  “According to the National Center for Health Statistics, 23.1% of all labors were induced in 2008 compared with 9.5% in 1990 – this is a more than twofold increase.”

Acta Obstet Gynecol Scand. 2011 Jun 17. Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Thorsell M, Lyrenäs S, Andolf E, Kaijser M.  PMID: 21679162

Source
Division of Obstetrics and Gynecology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden, and Clinical Epidemiology Unit, Department of Medicine at Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Abstract

OBJECTIVE:

To assess the risk for emergency cesarean section among women in whom labor was induced in gestational week ≥41 and to evaluate if parity and mode of induction affected this association.

DESIGN:

Hospital-based retrospective cohort study.

POPULATION:

Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden, during 2002-2006.

MATERIAL AND METHODS:

Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with a Bishop score of <7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients’ medical files. Results were adjusted for body mass index, age and the use of epidural analgesia.

RESULTS:

Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women and an almost twofold increase in risk for multiparous women.

CONCLUSIONS:

Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced, the high risk for emergency cesarean must be kept in mind.

So what does this mean?  Why do care providers induce? “Medical indications for induction are not always clear and straightforward, but the following situations comprise some of the reasons a care provider would consider induction:
  • If a woman’s water is broken for longer than a particular amount of time (which varies by care-giver)
  • If there is a uterine infection
  • If a women has preeclampsia (determined by significantly elevated blood pressure, protein in the urine, and swelling)
  • If the baby is not thriving
  • If the pregnancy has gone past a certain gestation (again, this varies among care providers) and the placenta shows signs of not being as effective”

This list does not include such guidelines as your, “baby is too big“, “done being pregnant“,   provider threats, or convenience.  There are many, many providers who respect and follow the appropriate guidelines, but some do not as evidenced by the huge increase in cesarean sections from elective inductions.  When faced with a possible induction, or a dilemma of any sort in discussing your medical care, it’s important to remember to put some BRAN in your conversations.  BRAN is an acronym to remind you ask your provider a series of questions: What are the BENEFITS of a procedure, What are the RISKS, What are the ALTERNATIVES, and What happens if we do NOTHING.  Another piece of knowledge that is valuable to have when discussing induction with your provider is your Bishop’s Score.  The Bishop’s score is a series of perimeters that can be used to determine if an induction is likely to succeed.  “Some sources indicate that only a score of 8 or greater is reliably predictive of a successful induction.”

Robert Bradley in “Husband-Coached Childbirth” once rhetorically asked, “‘When will that particular apple ripen?’ The appropriate answer is, ‘When it’s ripe.’  Good farmers wait for the fruit to ripen.  Good obstetricians do not ‘pick green apples.'”

Korfine, Lauren. (September 2011). Elective Induction: Current Research and Resources. Citizens for Midwifery.
Acta Obstet Gynecol Scand. 2011 Jun 17. Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Thorsell M, Lyrenäs S, Andolf E, Kaijser M.  PMID: 21679162