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Induction of Labor: Methods, Risks and Benefits 
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I am copying the chapter on induction out of The Thinking Woman's Guide to a Better Birth by Henci Goer as I feel this information might be useful in the community for those who do not own a copy of the book. Please read this information thoroughly if you or your caregiver are considering induction - you should be informed about the different methods, their risks, and their benefits so that you can make the best, most educated decision possible.

INDUCTION OF LABOR: MOTHER NATURE KNOWS BEST


Inducing labor is intrinsically ironic. It works best when least needed and often fails when needed most. It also causes the very problems it was intended to prevent.

Despite common perception, obstetricians can't just switch labor on at will. Starting and intensifying labor involves a complex cascade of feedback mechanisms that mutually reinforce and limit each other. It is an elegant and delicate interplay of hormones and other substances between the baby, who initiates and controls the process, and the mother. You can't simply dump in any of the substances involved and expect it to work unless labor was on the verge of starting on its own. Inducing labor when the mother isn't ready to labor often ends in a C-section. So why not wait?


WHY NOT WAIT?

One answer is that doctors wrongly believe that the development of agents to ripen the cervix has done away with the problem of induction failures. However, while undeniably effective at softening and effacing the cervix, these agents do little to reduce the cesarean rate. The gap in cesarean rates between induced and spontaneous labor has closed, mainly because cesarean rates have soared in spontaneous labors. For example, in one large trial, women one week past their due date were randomly assigned to await labor or to induction. Despite using a cervical ripening agent, 29 percent of first-time mothers in the induction group had cesareans, versus 33 percent--one-third--of the "await labor" group. Cervical ripening may have offered some slight benefit, but both percentages are appalling, especially considering that these women lacked almost every risk factor for cesarean in that they were healthy, their babies were mature, the babies weren't breech, and they weren't carrying twins.

A second answer is that doctors induce labor when they are concerned about the baby's condition, which brings us to the other irony: Induction causes the problems it was intended to prevent. Induced labors are much harder on the baby than natural labor. For one thing, it takes greater contraction pressures over a longer time to get a labor going and keep it going than generally are needed for spontaneous labor. (This is why oxytocin causes complications more often when used to start labor than when used to strengthen labor. You need higher doses, which increases the likelihood of problems.) For another, all of the conventional compounds used in labor inductions--namely, oxytocin (trade name Pitocin or "Pit"), prostaglandin E2 (also called dinoprostone, trade names Prepidil and Cervidil), misoprostol (also called prostaglandin E1, trade name Cytotec)--are notorious for causing contractions that are overly long, strong, and close together (uterine hyperstimulation). In addition, breaking the bag of waters, a usual practice with inductions, removes the cushioning effect of amniotic fluid, allowing contractions to squeeze the umbilical cord. In other words, a baby who has enough reserves to withstand the stresses of a natural labor might not be able to tolerate the rigors of an induced one.

A third answer, the one I will address in this chapter, is that even if the baby is fine, doctors believe the risks of continuing the pregnancy outweigh the risks of induction. Unfortunately, because obstetric philosophy emphasizes the perils of the natural process and minimizes the dangers of intervening in it, what obstetricians think justifies induction and what the research evidence supports are two different things. Here are some common rationales for inducting labor in healthy women carrying healthy babies and what's wrong with them.


CONVENIENCE INDUCTIONS

When you're feeling huge and uncomfortable and anxious, or worse yet, your doctor or midwife announces that he or she is leaving town, inducing labor can seem like a good idea. It isn't. When there is no reason to induce, you run the risks of induction--and those risks are not inconsequential--without any balancing benefit. Inducing merely for reasons of convenience has been disapproved by the FDA.


SUSPECTED LARGE BABY

The theory goes that if you are carrying a baby believed to weight 8 lbs., 13 oz. (4,000 grams) or more (macrosomia) or believed to weigh in the upper 10 percent of babies for that week of pregnancy ("large for gestational age"), inducing labor before the baby gets even bigger can spare you a cesarean section and the baby the possibility of shoulder dystocia (when the shoulders get stuck). The facts, however, are otherwise. To begin with, ultrasound weight estimates are so inaccurate that if your caregiver suspects a large baby, he or she could equally well flip a coin as order a sonogram. Moreover, studies comparing induced women with women allowed to begin labor on their own all show that induced women have more cesarean and equal numbers of shoulder dystocias. (Just so you know, planned cesarean is an even worse idea than induction.) It turns out that shoulder dystocia isn't very tightly tied to weight, and while it's a dangerous situation, handled properly it rarely results in permanent injury.


PRELABOR RUPTURE OF MEMBRANES IN FULL-TERM PREGNANCY

In the 1960s, a flurry of papers on the danger of infection with prolonged rupture of the fetal membranes resulted in the twenty-four hour rule: Once membranes rupture, the baby must be born within twenty-four hours. This policy means inducing any woman who does not begin labor on her own within a few hours of membrane rupture, stimulating slowly progressing labors with oxytocin, and performing cesarean section on women who aren't close to giving birth by the twenty-four hour limit. In addition, it means babies born after or close to the limit are likely to be subjected to a series of tests for infection called a septic workup. Septic workups include drawing blood and often include a spinal tap. Many pediatricians confine the baby to the nursery and prescribe IV antibiotics until the baby's cultures come back negative. Even at the time the twenty-four hour rule was created, obstetricians expressed concern about raising cesarean section rates and observed that infections were rare when no vaginal exams were done. These hesitations were brushed aside on the grounds that high cesarean rates for failed induction or fetal distress were preferable to the deadly infections that would surely result from doing nothing. By the early 1970s, the twenty-four hour rule had become the standard of practice in full-term pregnancies.

The studies that sparked the rule had serious weaknesses. For example, many of them combined prelabor rupture of the membranes at full term with those occurring preterm. In many preterm cases, infection causes membrane rupture, not vice versa. Doctors also ignored the role they themselves played in precipitating infections. Studies show a clear connection between ruptured membranes, number of vaginal exams, use of internal monitoring devices, time, and infection. When membranes rupture, fluids wash out of the vagina, which means infective bacteria must migrate upstream, against the current, to enter the uterus. But, during a vaginal exam, the caregiver slides his or her fingers in, giving any organisms present a free ride up to and even into the cervix. Worse, internal electronic fetal monitoring and internal contraction-pressure monitoring create a pathway into the uterus itself. Waiting twenty-four hours or even more before inducing labor is safe as long as caregivers keep their fingers and internal monitoring devices out of the vagina--with one possible exception: women who are vaginally colonized by group B streptococci, also called group B strep, or GBS.


GROUP B STREPTOCOCCUS (GBS)

To give you some background, between one and three in every ten healthy women have GBS living in their vaginas (colonized). Before the widespread use of preventative antibiotics during labor, two to three of every hundred colonized women would have a baby who developed a serious infection. About 4 percent of infected babies died, making the odds of a colonized mother losing a child to GBS 4 to 8 per 10,000. A few survivors suffered permanent neurological damage. However, since 1 in 4 newborn infections are in premature babies, and 1 in 5 are not early-onset disease, the odds of preventable disease are reduced in full-term pregnancies. Also, prolonged ruptured membranes is a risk factor, which suggests that obstetric management plays a role.

The solution would seem to be to test for GBS early in pregnancy and give antibiotics when it is present, but this doesn't work. Once the course of antibiotics ends, GBS often reappears. For these reasons, the Centers for Disease Control recommend the following:

    * Screen all pregnant women at thirty-five to thirty-seven weeks of pregnancy. Give all colonized women IV antibiotics in labor. When GBS status at onset of labor is unknown, give IV antibiotics when risk factors are present, namely, preterm labor, ruptured membranes for eighteen hours or more, fever during labor, or prior baby with a GBS infection. Women testing negative for GBS do not need IV antibiotics even if they have risk factors except for those with a previous infected baby.

    * The baby of a GBS-positive mother needs no evaluation or antibiotic therapy provided the baby shows no signs of infection, is at least 35 weeks of gestational age, and the mother began antibiotic treatment at least four hours before birth. If the baby is younger that 35 weeks or was born less than four hours after antibiotic treatment, the baby should have blood cultures. If the mother received antibiotics because of suspected uterine infection or the baby shows signs of infection, the baby should have a full septic work-up, including a spinal tap, and antibiotic therapy.

Cases of newborn infection declined with the introduction of routine testing and treatment in the 1990s and currently stand at 0.5 cases per 1,000 births. There is, however, a downside. Cases of severe maternal allergic reactions have occurred, and while penicillin-resistant GBS strains have no yet appeared, GBS resistance to other antibiotics has. Even more concerning, the fall in GBS infections in preterm infants has been more than offset by a rise in deadly, penicillin-resistant E. coli infections.


"OVERDUE" PREGNANCY

A better term than overdue would be the medically correct post-dates. "Overdue" implies that going past your due date is a problem, rather like overbaking a cake. On the contrary, inducing for exceeding your due date is a textbook case of how mainstream obstetric care keeps narrowing the definition of normal until practically no one fits, which then creates the "need" for intervention. True, a small percentage of women don't begin labor when they are supposed to. And, yes, placentas are not made to last forever. Still, mainstream postdates management has little scientific basis.

Up to the late 1980s, conventional obstetric wisdom held that if pregnancy continued two weeks past the forty-week due date, either labor should be induced or some sort of periodic testing of fetal well-being should be done. Nonetheless, induction became the norm. This sounds reasonable, but as with so much of obstetric management, nothing is as it seems.

To begin with, there are problems with the due date itself. You may be surprised to learn that the conventional forty-week pregnancy length is completely arbitrary. It was established by a German obstetrician in the late 1800s. He simply declared that a pregnancy should last ten moon months, that is, ten months of four weeks each. However, when researchers in a 1990 study followed a group of healthy, white women, they discovered that pregnancy in first-time mothers averaged eight days longer than this, and the average was three days longer in women with prior births.

In addition, ultrasonography, the current standard for assigning due dates, does not reliably establish due dates. Even in the first trimester, the date is plus or minus five days. This means the actual due date falls within a ten-day window. Sonograms done later in pregnancy are even less accurate.

It gets worse. While even the forty-two-week limit isn't sound, in recent years, the "time's up" date has backed up to forty-one weeks, with some researchers recommending forty weeks. Based on the above study, first-time mothers are not only not "late" at forty-one weeks, they haven't even reached the average pregnancy length.

The earlier and earlier time limit has come about mainly through tests intended to evaluate the baby's well-being. All these tests have poor positive predictive values, meaning that when the test says the baby of a healthy mother is in jeopardy, it is probably wrong. However, faced with a worrisome test result, obstetricians quite properly induce labor or perform a cesarean. The baby turns out to be fine--it always was--but now the obstetric belief system takes over. Most obstetricians have an unfounded faith in the accuracy of tests. A healthy baby only reinforces the erroneous idea that timely intervention saved him. The policy of beginning routine testing at forty-two weeks resulted in many babies seeming to be at risk. Obstetricians concluded from this that if so many babies were in trouble at forty-two weeks, they should begin testing earlier. Again, because of the high false-positive rates, many babies looked as if they had problems earlier, and the vicious cycle continued.

Ironically, inducing labor also reinforces the belief that allowing pregnancy to continue is dangerous. Inductions increase the risk of fetal distress and the incidence of cesarean section, problems that are then attributed to the baby's condition rather than to their real cause--the induction. For example, one researcher found huge jumps in complication rates (6 to 20 percent) and cesarean rates (7 percent to more than 25 percent) at forty weeks, the women's due dates, at his hospital. Forty weeks was when women were automatically transferred to the high-risk clinic. The researcher concluded that risk increased earlier in pregnancy than previously thought, but any unbiased person would see the obvious culprit: management in the high-risk clinic.

Still, postdates pregnancy isn't a "one size fits all" issue. Routinely inducing at some arbitrary date is not the solution mainstream obstetricians believe it to be. Testing in order to determine which babies would benefit from induction runs the risk of acting on false-positive results. Letting nature take its course is generally best, although that is not risk-free either. No course of action (or inaction) guarantees good outcome.


TESTS OF FETAL WELL-BEING

    * Fetal movement counts. Starting the last few weeks before your due date, you pick a time every day when the baby is awake and count how long it takes for the baby to make ten distinct movements. If the time lengthens over successive days or there is a marked drop in the number of movements on a particular day, you report this to your caregiver, who should follow up with one of the following tests.

    * Nonstress test. Your caregiver uses external fetal monitoring to track the baby's heart rate when the baby moves or when you have a prelabor (Braxton Hicks) contraction. The heart rate should speed up. However, the most common reason it doesn't is that the baby is asleep.

    * Vibroacoustic stimulation. In this variation of the nonstress test, a buzzer is sounded against your belly. The baby's heart rate should speed up when he startles.

    * Contraction stress test or oxytocin challenge test. You are hooked up to an electronic fetal monitor and caregivers start an IV containing oxytocin to see how the baby's heart rate respond to simulated labor contractions. Alternately, and noninvasively, nipple stimulation can be done manually or with an electric breast pump. Nipple stimulation causes natural release of oxytocin.

    * Biophysical profile. In addition to a nonstress test, caregivers do an ultrasound scan to evaluate the placenta, the baby's movements, and how often the baby takes a practice breath (to conserve energy, babies in trouble stop moving around and stop practicing breathing). Caregivers give the baby an overall score on a scale of zero (worst) to ten (best).

    * Amniotic fluid volume measurement. Caregivers use ultrasound to estimate the amount of amniotic fluid. Too little fluid increases the probability of fetal distress in labor.



CERVICAL RIPENING AND INDUCTION PROCEDURES

    * Nipple stimulation. Stimulating the nipples causes oxytocin release. Low-tech stimulation can be through the application of warm, wet cloths, manual stimulation, or suckling by a baby or partner. To minimize the chance of overly strong contractions, begin by stimulating one nipple only. Stop the stimulation during contractions. If stimulating one nipple does not produce contractions, then stimulate both. High-tech techniques include stimulating the nipples with an electric breast pump or a TENS (transcutaneous electronic nerve stimulation) unit, a physical therapy device that painlessly delivers a low electric current through pads applied to the skin.

    * Sexual intercourse. If you didn't know how to do this, you wouldn't be reading this book.

    * Castor oil. Folk wisdom has long held that stimulating the digestive tract also stimulates labor contractions. Castor oil is often given with orange juice to disguise the taste and sometimes with vodka to reduce cramping.

    * Enema. Enemas, running liquid into the rectum, have been given on the same principle as castor oil.

    * Acupuncture or TENS. The acupuncturist places thin needles in particular points of the body and runs a low electric current through them to stimulate those points. Evidence in one study suggests that the same stimulation could effectively and noninvasively be given with a TENS unit.

    * Herbs. Several herbs are reputed to stimulate labor, but I could find no studies in the mainstream research literature. Herbs are usually drunk as teas.

    * Stripping/sweeping the membranes. During a vaginal exam, the caregiver inserts a finger into the cervix and lifts the amniotic sac off the cervix. This minor irritation triggers the local release of prostaglandins, compounds that ripen the cervix and stimulate contractions.

    * Mechanical dilators. Inserted into the cervix, these materials absorb moisture and dilate the cervix as they gradually swell.

    * Prostaglandin ED (PGD2). This is currently the most popular technique for cervical ripening. The caregiver inserts a gel containing PGE2 (Prepidil) into the cervix. A newer formulation, Cervidil, packages PGE2 in an insert with a string, which allows it to be withdrawn should overly strong contractions occur and at the end of the ripening period. Contractions and the baby's heart rate must be carefully monitored for an hour or two because uterine hyperstimulation is a common side effect. Sometimes PGE2 is enough to start labor on its own, but usually IV oxytocin is needed as well.

    * Misoprostol (PGE1). Misoprostol (trade name Cytotec), like PGE2, is inserted vaginally. Contractions and the baby's heart rate must be carefully monitored because misoprostol is even more likely than PGE2 to cause uterine hyperstimulation and fetal distress.

    * Rupturing membranes (amniotomy). During a vaginal exam, the doctor or midwife snags the membranes with an amni-hook, which looks like a flat, plastic crochet hook except that it has a small, sharp tip under the curled-over tip. There will be a gush of warm liquid. The procedure can be uncomfortable for you but doesn't hurt the baby because there are no nerves in the membranes.

    * Oxytocin. The nurse starts an IV. The tubing is connected to two bags, one containing oxytocin (trade name: Pitocin, also called "Pit") and the other plain IV fluid. The medicated fluid is routed through a special machine that administers an adjustable number of drops per minute. The machine permits tight control over the dosage, a critical safety factor in administering this powerful drug. If contractions become too strong, the medication can be stopped while the plain IV is left running to keep the line open.



THE BOTTOM LINE ON LABOR INDUCTION GENERALLY: AVOIDING AN UNNECESSARY INDUCTION

Note: If this is your first baby, be especially leery of induction. You are at much greater risk of a cesarean. Induction may also pose a slightly greater risk of symptomatic scar separation in women with a prior separation.

* Choose a caregiver who:
    - has a low induction rate.
    - doesn't induce for suspected large baby.
    - at a minimum and in the absence of signs of infection, allows you twenty-four hours to begin labor on your own if membranes rupture.
    - doesn't consider you overdue until at least forty-two weeks of pregnancy.

* Refuse an elective induction, that is, induction for convenience.

* Refuse an ultrasound to estimate fetal weight. In a case of "what your doctor knows can hurt you," studies show that when an obstetrician thinks, based on a sonogram, that the baby will weigh over 8 lbs., 13 oz., the mother is more likely to have a cesarean than if the baby actually weighs this much or more, but the doctor doesn't suspect.

* Refuse an induction for suspected large baby.

* Don't permit your due date to be changed based on ultrasound scan (sonogram) unless it was done within the first thirteen weeks and the result is more than ten days earlier than your current due date. On the other hand, if you get a due date later than your current date, consider taking it. It may spare you hassle later over whether you should be induced for being postdates.

* If you know when you got pregnant--for example, if you did an early pregnancy test--refuse a sonogram for the purpose of estimating your due date.

* Consider refusing routine tests of fetal well-being. The American College of Obstetricians and Gynecologists (ACOG), the U.S. obstetricians' professional organization, acknowledges that there is no evidence that routine tests of well-being improve outcomes in postdates pregnancies. ACOG says to do them anyway because there is no evidence that testing has adverse effects, but there they are wrong. Because these tests have such high false-positive rates--30 percent or more--and because healthy women carrying full-term babies aren't very likely to have babies that are having difficulties, a positive result ("positive" means the test found a problem) is hugely more likely to be wrong than right. The consequences of a false-positive test are not trivial. For example, one study of amniotic fluid volume showed that having this test routinely done doubled the cesarean rate for fetal distress without improving newborn outcomes. Another study found that using one technique for extimating amniotic fluid volume (amniotic fluid index) resulted in much higher rates of abnormal findings than a different technique (maximum pool depth). The amniotic fluid index led to more inductions and C-sections with no improvement in newborn outcomes. Moreover, a negative result doesn't guarantee the baby is fine. While a negative test is generally reassuring, there can be false negatives, cases where either the baby's problem did not show up or something happened between tests.

* Make sure you have been drinking plenty of fluids in the hours before you have an ultrasound measurement of amniotic fluid volume. Drinking increases amniotic fluid volume, and even mild dehydration reduces it.

* If a test of fetal well-being is positive, insist on repeating the test or doing a different test before agreeing to an induction or cesarean section. Having two positive tests mathematically reduces the odds that the results are falsely positive.


PROS AND CONS OF TECHNIQUES FOR RIPENING THE CERVIX AND/OR INDUCING LABOR

MANUAL NIPPLE STIMULATION TO RIPEN THE CERVIX
    Pros: A natural and painless means of increasing circulating oxytocin levels, which ripens the cervix and can induce labor. It is noninvasive, costs nothing, and can be done at home.
    Cons: May require prolonged application to be effective--three one-hour sessions per day for three consecutive days in one study. May cause overly strong contractions.


NIPPLE STIMULATION BY BREAST PUMP OR TENS TO INDUCE LABOR
    Pros: Safe and effective. Studies are few and small, but because stimulation is readily controlled, it is unlikely to pose any more hazard than prostaglandins or oxytocin and probably imposes less.
    Cons: Some women induced with a breast pump complained of sore nipples.


SEXUAL INTERCOURSE
Because of the risk of infection, never engage in sexual intercourse with ruptured membranes.
    Pros: Natural and pleasurable means of increasing prostaglandin levels. It costs nothing and can be done at home.
    Cons: Effectiveness unknown.


CASTOR OIL
    Pros: Reduces the need for oxytocin. Does not require hospitalization.
    Cons: Causes diarrhea. Its effects cannot be halted once administered. Not enough data to determine whether there are adverse effects.


ENEMA
No data on either effectiveness or adverse effects.

ACUPUNCTURE OR TENS
    Pros: Small studies have shown acupuncture to be effective at inducing labor, and TENS used at acupuncture points has been shown to increase the frequency of labor-strength contractions. Both acupuncture and TENS can be stopped should there be adverse effects. TENS is noninvasive and painless.
    Cons: No adverse effects known of either, but studies have been small. The TENS study only looked at use over a few hours. While this caused contractions, it isn't known whether longer use would induce progressive labor.


HERBS
    Pros: Anecdotal data suggests that herbs may be effective and freer of adverse effects than conventional treatments. Inexpensive, painless home-based treatment.
    Cons: No rigorous research into effectiveness or possible adverse effects. Cannot be stopped once administered.


STRIPPING/SWEEPING THE MEMBRANES
    Pros: Slightly decreases the number of oxytocin inductions by reducing the number of postdates pregnancies. However, routine induction for postdates pregnancy has questionable value.
    Cons: Potential of rupturing membranes, instigating infection, or causing hemorrhage if the placenta is overlaying the cervix (placenta previa). Does not decrease C-section rates.


MECHANICAL DILATION
    Pros: Cheaper than prostaglandins.
    Cons: They may increase the odds of infection.


PROSTAGLANDIN ED (PGE2; Cervidil or Prepidil)
    Pros: Somewhat reduces the cesarean rate compared with straight oxytocin inductions with an unripe cervix. Cervidil can be removed if it causes problems.
    Cons: Can cause uterine hyperstimulation and fetal distress. In some cases, fetal distress can lead to cesarean section. Prepidil cannot be removed once administered.


MISOPROSTOL (Cytotec)
    Pros: It may be more effective at ripening the cervix and inducing labor than PGE2 or oxytocin alone. Some studies show that its use reduces the cesarean rate compared with other induction methods. Much cheaper than PGE2.
    Cons: It increases the odds of both uterine hyperstimulation compared with PGE2 and abnormal fetal heart rate resulting from uterine hyperstimulation. Uterine rupture has been reported. Once administered, its effects cannot be stopped. Studies have not established a safe, effective dose. Misoprostol was not formulated for use in inducing labor, and has not been approved by the FDA for this purpose.


RUPTURING MEMBRANES (Amniotomy)
    Pros: In a woman on the verge of beginning labor, rupturing membranes may be enough to trigger labor.
    Cons: Can precipitate umbilical cord prolapse. Increases the odds of episodes of abnormal fetal heart rate and cesarean section for fetal distress. Since the interval between rupture and birth may be long with an induction, it increases the risk of infection in women who subsequently have vaginal exams and women colonized with group B strep.


OXYTOCIN (Pitocin)
    Pros: Effective agent for inducing labor. Can be stopped if it is producing adverse effects.
    Cons: Labor is more painful. Requires an IV and electronic fetal monitoring, which have their own potential adverse effects. Often causes uterine hyperstimulation, which can lead to fetal distress. Doubles the odds of the baby being born in poor condition. Also causes increased postpartum blood loss and newborn jaundice. Blood loss and jaundice may relate to direct effects of oxytocin; increased use of IV fluids, especially IV fluids that don't contain salts; or both. Increases the risk of C-section, which also has grave potential adverse effects.


RUPTURING MEMBRANES AND OXYTOCIN
    Pros: One study where women were assigned to oxytocin alone or oxytocin with amniotomy concluded that doing both was the more effective option. However, a statistical analysis of that study concluded that participating obstetricians had almost certainly sabotaged the random assignment process because of their preconceived belief that amniotomy was also needed.
    Cons: Another trial that randomly assigned women to induction with early or late amniotomy found that early amniotomy was associated with increased likelihood of fetal distress and maternal infection but had no effect on cesarean rate. Three-fourths of the early-amniotomy cesareans for fetal distress were for abnormal fetal heart rate patterns typical of umbilical cord compression due to lack of amniotic fluid.



GENERAL ADVICE ON INDUCTION

* If cervical ripening is necessary, ask for Cervidil because it comes enclosed in a net and attached to a string. Unlike the gel formation, it can be removed should uterine hyperstimulation occur.

* You can go home during the ripening process. THe American College of Obstetricians and Gynecologists recommends and observation period between thirty minutes and two hours before going home to make sure uterine hyperstimulation is not occurring.

* Start oxytocin at night. Although there are no data on timing of induction, the uterus is most sensitive to oxytocin at night, which is why labor usually starts at night.

* Although this should be standard practice, make sure the IV fluid contains salts. Salt-free fluids, especially in combination with oxytocin, one of whose effects is fluid retention, can cause serious blood-chemistry imbalances.

* Have continuous electronic fetal monitoring. It reduces the risk of newborn seizures.

* Insist on a low-dose oxytocin regimen that allows at least thirty minutes between dose increases, because high-dose regimens increase the risk of adverse effects. The chance of developing adverse effects goes up with the total amount of oxytocin given and the peak dose. High-dose regimens greatly increase both.

* Once you are actively dilating, try turning off the oxytocin. Sometimes, once labor kicks in, it will continue on its own without extra oxytocin. This will be much more comfortable for you and easier on your baby. As long as the IV line is kept open, the nurse can always restart the oxytocin if needed. Low-dose, long-interval protocols increase the odds of being able to turn the oxytocin drip down or off in active labor.

* Avoid or at least hold off on an epidural. Epidurals slow labor and, with prolonged use, cause fever. A fever in labor indicates a possible infection in mother or baby, and you and the baby will be treated accordingly.

* Refuse rupture of membranes until 5 centimeters' dilation or more. For one thing, you can back out if the induction doesn't work. For another, you eliminate the risk of infection and avoid IV antibiotics and septic workups should labor be slow to start.

* Limit vaginal exams once membranes are ruptured. There is a clear relationship between length of time since rupture, number of vaginal exams, and infection.

* Refuse internal contraction-pressure monitoring. It requires rupture of membranes, increases the odds of infection, introduces risks of its own, and doesn't improve outcomes.


THE BOTTOM LINE ON LABOR WITH A LARGE BABY

STRATEGIES TO AVOID UNNECESSARY INTERVENTION

* Have a caregiver with a low cesarean rate. Obstetricians with low cesarean rates are less likely to opt for C-sections when they suspect a large baby.

* Avoid an epidural. Epidurals interfere with effective pushing and prevent you from doing the activities and assuming the positions that will maximize your chances of birthing a large baby. Avoiding an epidural will also help you...

* Avoid a low or outlet forceps delivery. These are deliveries done when the baby's head has passed through the pelvis, which means they are mostly unnecessary except in cases of sudden fetal distress. Evidence suggests that low and outlet forceps deliveries are more likely to injure a large baby than spontaneous delivery.

* Preplan with your caregiver to use the all-fours maneuver should there be problems birthing the baby's shoulders. Assuming an all-fours position seems to be the best and safest technique for releasing the shoulders. The potential need for this maneuver is another reason to avoid an epidural, although with coordinated assistance, even a mother with an epidural could be quickly helped into this position.


THE BOTTOM LINE ON INDUCTION FOR PRELABOR RUPTURE OF MEMBRANES

GENERAL ADVICE

* If membranes rupture, have someone listen to the baby's heart. It should tick along at two beats per second or more (120-160 beats per minute). If it is much slower than this, or if you are having contractions and it slows down drastically during a contraction, go to a hospital immediately. The umbilical cord may have slipped down ahead of the baby, which can pinch it between the baby's head and your pelvis.

* Refuse vaginal exams before active labor. The main reason to do one is to determine whether the umbilical cord has come down into the vagina, but this can be ruled out simply by listening to the baby's heartbeat.

* Limit vaginal exams even after labor kicks in.

* If you and your caregiver aren't sure membranes actually ruptured, consider refusing induction. The common tests for membrane rupture will incorrectly diagnose ruptured membranes in equivocal cases in one-quarter or more women.

* Refuse internal contraction-pressure monitoring. It increases the risk of infection and it does no better than external contraction monitoring for determining oxytocin dose.

* Avoid having an epidural early in labor. Epidurals cause fevers, especially with prolonged use. Epidural-induced fever can lead caregivers to mistakenly conclude you have an infection.

[Omitted chart: Compare and Contrast Three Approaches to Prelabor Rupture of Membranes]

Note: Many doctors want you in the hospital once membranes rupture, but you can just as well and much more comfortably await labor at home. A large study that randomly assigned women to induction versus awaiting labor found that women preferred induction. However, this preference applied only to women admitted to the hospital while awaiting labor. Women allowed to go home like expectant management just fine.


POINTS FOR GBS-POSITIVE WOMEN TO CONSIDER

GBS migrates into the vaginal outlet from the colon. It is rarely found in the upper vagina, but almost all newborn GBS infections arise from the bacterium invading the uterus. This suggests that conventional obstetric management could cause infection by transferring GBS to the cervix or opening a pathway into the uterus via prenatal cervical checks, vaginal exams in labor--especially after membranes rupture, rupturing membranes, and internal fetal heart rate or contraction monitoring. The effect cannot be measured because we have no unexposed GBS-positive comparison group. Still, infection in general is associated with ruptured membranes, number of vaginal exams, use of internal monitoring devices, and time. You may wish to refuse potentially contributory practices since none of them have offsetting benefits. Wiping from front to back might also keep GBS from getting into the vagina.

You should know that inducing labor for ruptured membranes is not a Centers for Disease Control recommendation. If you agree to induction, know that using prostaglandin E2 quadrupled the incidence of infection in GBS-positive women compared with oxytocin alone. None of the women, though, had IV antibiotics in labor. Know too that the CDC guidelines specifically state that colonization is not a reason for scheduled cesarean section. Finally, GBS positive status doesn't rule out home birth. IV antibiotics could be administered and the baby observed or a blood sample taken if warranted.

[Omitted chart: Induction for Postdates Pregnancy: Compare and Contrast Three Postdates Options]


GLEANINGS FROM THE MEDICAL LITERATURE

* Nipple stimulation, castor oil, acupuncture, and TENS stimulation have all been found effective at ripening the cervix and/or inducing contractions, and sexual intercourse increases the local concentration of prostaglandins involved in initiating labor.

* Oxytocin, especially in the quantities required for induction of labor, has risks.

* Physiological oxytocin-induction regimens offer advantages over high-dose regimens.

* Prostaglandins have not solved the problem of induction leading to more cesareans.

* Inducing labor for reasons of convenience or other nonmedical reasons (elective induction) increases the risk of cesarean and fetal distress.

* Ultrasound weight estimates followed by induction for suspected large baby increases the risk of cesarean without improving outcomes.

* Waiting for labor onset for at least twenty-four hours after membranes rupture is safe, provided there are no symptoms of infection, the mother tests negative for group B strep, and no vaginal exams are done.

* Inducing with oxytocin shortly after membrane rupture may greatly increase the odds of C-section compared with awaiting labor.

* Inducing with PGE2 shortly after membrane rupture results in similar cesarean rates to those for awaiting labor, but it doesn't decrease infection rates.

* The obstetric powers that be have decided that labor should be routinely induced at forty-one weeks, but the situation is not nearly as clear-cut as it seems.

* The all-fours position is a rapid, safe, and effective technique for relieving stuck shoulders.

Goer, H. (1999). The Thinking Woman's Guide to a Better Birth. New York, New York: The Berkley Publishing Group.
Comments 
30th-Aug-2006 06:13 pm (UTC)
Wow - thanks a lot for this! I am adding this to my memories :]
I haven't even thought of induction and my OB hasn't brought it up but it is still a really nice thing to read.

And when you said copying it out of the book - you mean you wrote all that out?!
30th-Aug-2006 06:17 pm (UTC)
Haha yeah, it took a long, long time. I worked on it off and on all day yesterday and today. ;)

I'm glad you find it interesting! It's a good thing to read about "before the fact", just so that you are prepared and know what your options are if it should ever come down to a decision you need to make, you know?
30th-Aug-2006 06:45 pm (UTC)
Wow! That was seriously such an awesome thing to do :]
I don't think I would have had the patience haha.

I agree - definitely something that would be good to know before it got brought up/suggested. :]
30th-Aug-2006 06:15 pm (UTC)
Wow. Awesomely informative. Thank you for this post!!
30th-Aug-2006 06:21 pm (UTC)
For the record, I think this is going to be very helpful. Hopefully it'll sway some of the on-the-fencers back to the right side of the fence. I had an induced labor with my daughter at 39 weeks and I really regret it now. So I really hope this has a good affect on all of the ladies in here... especially the ones who may be considering induction. Knowledge is power :)
30th-Aug-2006 06:22 pm (UTC)
Thank you! I plan on getting a copy of that book when I finish Ina May's Guide to Childbirth. I was a B&N the other day and they didn't have Henci Goer's book :(
30th-Aug-2006 07:27 pm (UTC)
for what it's worth (and this coming from a former "die-hard" B&N customer) I've found that the prices on Amazon are cheaper than B&N, even with shipping, and even with B&N member discount.

'course, ordering the book doesn't have the same same-day gratification as purchasing in-store.

:)
30th-Aug-2006 07:31 pm (UTC)
Thanks for the advice :)

I suppose I can wait a few extra days. I'm not quite finished with Ina May's book anyway :)
30th-Aug-2006 06:24 pm (UTC)
wow I cant believe you typed all that out!
I read that book and passed it on, it really was a good read.
30th-Aug-2006 06:34 pm (UTC) - <<<<< only copyright icon, proving i'm a bitch on the internets everyday
i think you should put this in a locked post since its technically copyright infringement to post publicly, right?
but thank you! i'm very impressed you typed it out and shared with everyone :)
30th-Aug-2006 06:43 pm (UTC) - Re: <<<<< only copyright icon, proving i'm a bitch on the internets everyday
Is it? I wondered about that, considering the fact that it is cited? Of course, if you were going to use this book as a resource in, say, a paper you were writing - you wouldn't copy the entire chapter ;)

I'll friends-lock it just to be safe!! :)
30th-Aug-2006 06:51 pm (UTC) - Re: <<<<< only copyright icon, proving i'm a bitch on the internets everyday
not that the publishers would go after a blog like this, but I know that its very tricky. cited or no, its still distributing a large bit of something they want you to pay for ;) i know we can't post chapters of books without express permission from the publisher on our library websites for class, and genereally we have to pay something
30th-Aug-2006 11:58 pm (UTC) - Copyright Infringement/Fair Use
Atually, you are allowed to use a limited portion of a work for education purposes (such as this). This falls under Fair Use laws.

How much of someone else's work can I use without getting permission?
Under the fair use doctrine of the U.S. copyright statute, it is permissible to use limited portions of a work including quotes, for purposes such as commentary, criticism, news reporting, and scholarly reports. There are no legal rules permitting the use of a specific number of words, a certain number of musical notes, or percentage of a work. Whether a particular use qualifies as fair use depends on all the circumstances. See FL 102, Fair Use, and Circular 21, Reproductions of Copyrighted Works by Educators and Librarians.


The 1961 Report of the Register of Copyrights on the General Revision of the U.S. Copyright Law cites examples of activities that courts have regarded as fair use: “quotation of excerpts in a review or criticism for purposes of illustration or comment; quotation of short passages in a scholarly or technical work, for illustration or clarification of the author's observations; use in a parody of some of the content of the work parodied; summary of an address or article, with brief quotations, in a news report; reproduction by a library of a portion of a work to replace part of a damaged copy; reproduction by a teacher or student of a small part of a work to illustrate a lesson; reproduction of a work in legislative or judicial proceedings or reports; incidental and fortuitous reproduction, in a newsreel or broadcast, of a work located in the scene of an event being reported.”

http://www.copyright.gov/help/faq/
31st-Aug-2006 12:31 am (UTC) - Re: Copyright Infringement/Fair Use
Hey, thanks! I'm glad it's OK - I thought this would be quite helpful in this forum :)
31st-Aug-2006 12:33 am (UTC)
As long as you aren't trying to make money off this community, it's instructional, so you're golden.
30th-Aug-2006 07:29 pm (UTC)
Ms. Goer's book should be required reading for anyone involved with giving birth (ie: expectant moms, dads, doulas, health-care-providers.)

(It's very rare that I'll borrow a book from a library and then purchase my own copy.)
30th-Aug-2006 07:30 pm (UTC) - a question
Thanks for posting this! I ran across a question while I read it, not sure if you know the answer, though. I'm mostly just wondering.

This was under the "Tests for Fetal Well-Being" section:

* Amniotic fluid volume measurement. Caregivers use ultrasound to estimate the amount of amniotic fluid. Too little fluid increases the probability of fetal distress in labor.

If your water breaks before going into labor, why would low amniotic fluid levels cause fetal distress in labor? Wouldn't the fluids be gone already?
30th-Aug-2006 07:35 pm (UTC) - Re: a question
Good question, but not one I'm sure I know the answer to.

I know there is the possibility of cord compression when amniotic fluid levels are low, but as you mentioned - some women have ruptured waters before they even begin having contractions and that is not, in and of itself, a concern.

I guess I'm kind of at a loss for what to say! If only we could email Henci Goer directly!
30th-Aug-2006 07:38 pm (UTC) - Re: a question
Wouldn't that be nice?

Thanks for giving it a try. :o)
31st-Aug-2006 12:00 am (UTC) - Henci's email
Contact email from her website: goersitemail@aol.com

31st-Aug-2006 12:32 am (UTC) - Re: Henci's email
Hahaha, I wonder if she'd respond if I told her I used her entire chapter on induction to help inform an online community of pregnant women and there were some questions...!
31st-Aug-2006 12:34 am (UTC)
She probably would, especially since you are encouraging them to read her book.
30th-Aug-2006 08:59 pm (UTC) - Re: a question
I can't recall where I read this (thus can't vouch for reliability) but I think that even after your water breaks, there is still some fluid in there - it doesn't all necessarily come out before baby. In that case, I suppose starting out with less fluid would mean more likely to have even less fluid left in during labor - hence increased possibility for cord compression?

Just a guess (and I'm in no way a medical professional or birth expert. :)
30th-Aug-2006 08:53 pm (UTC)
Glad you posted this. Thanks!
30th-Aug-2006 11:44 pm (UTC)
LOVE LOVE LOVE this book.....fantastic idea to post this especially now it seems!
31st-Aug-2006 12:32 am (UTC)
I'm going to just send this link as a response when someone is pondering induction :)

This book is amazing. Anyone who finds this chapter helpful should definitely check out this book from their local library (and then they'll probably want to buy it!)
8th-Feb-2007 06:23 am (UTC)
Thanks for typing this all out. I am getting impatient at almost 40 weeks and this is just what I needed to read tonight.
8th-Feb-2007 05:22 pm (UTC)
Oh, I'm so glad it helped :) Congrats - it'll be any day now for you!
1st-Mar-2008 05:52 am (UTC)
This was incredibly informative, thank you!!!
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