On-demand deliveries: Some fear misuse of labor inducement

By Judy Foreman, Globe Staff, 9/25/2001

You're 39 weeks pregnant, not quite full term. You're still working, of course - after all, you're a modern mom - and you've got everything under control. Except the obvious.

If you knew exactly when the baby was coming, you could tell your boss when to start the maternity leave clock ticking. You could tell your mother when to take time off from her job to come take care of your older child. Your obstetrician wouldn't exactly mind knowing the precise ETA of your baby, either - after all, she's got kids of her own and would much rather deliver babies between 9 and 5 on weekdays than pull all-nighters on weekends.

So, why not do the modern, high-tech thing and get your doctor to induce labor so that you, not Mother Nature, can decide when the baby will come?

Actually, there are lots of compelling reasons why not, and we'll get to them in a minute. But more and more busy mothers-to-be, used to being in control of most things in their lives, are flat-out demanding that childbirth be as easy to schedule into their Palm Pilots as a corporate meeting. And many obstetricians are only too happy to oblige.

Between 1989 and 1999, the number of labor inductions - in which doctors hurry childbirth along with drugs to dilate the cervix and stimulate uterine contractions - has soared to 775,245, according to the National Center for Health Statistics. That's a whopping 19.6 percent of live births, up from 8.2 percent in 1989.

In many cases, the induction of labor is done for legitimate medical reasons such as toxemia (high blood pressure and other symptoms), gestational diabetes, or a birth that's a week or two overdue (which means the placenta, the organ that supplies the fetus with oxygen and nutrients, may start to break down).

But increasingly, induction of labor is done for elective reasons - that is, pure convenience. And while some obstetricians hail this move, noting that it cuts down on weekend deliveries, many obstetricians and nurse-midwives worry that the trend may lead to a cavalcade of problems: more Caesarean sections if induction fails; more respiratory problems in babies born with not-quite-mature lungs; and more chance of uterine ruptures triggered by labor-inducing drugs such as prostaglandins and Pitocin.

The Center for Health Statistics does not keep track of how many labor inductions are done for medical reasons, how many for convenience, and how many for a combination of the two, such as a woman with a track record of short labors who lives far from the hospital.

But Dr. Lewis Rosenberg, an obstetrician-gynecologist at New Island Hospital in Bethpage, N.Y., believes elective inductions now constitute 40 percent of all inductions.

The trend toward scheduling childbirth, he adds, is also propelled by managed care and the need for doctors who work as solo practitioners or in small groups to maximize their own efficiency. ''If you're going to be seeing a large number of patients in one day, the worst thing is to have a patient in labor - you have to reschedule a lot of people,'' says Rosenberg.

A recent online survey by Americanbaby.com, a parenting Web site, found that 36 percent of 827 respondents said they would consider scheduling induced labor and another third said that, while they wouldn't do it themselves, they didn't object to other women doing so.

And that probably underestimates the actual number of requests for elective inductions.

''Almost everyone who walks through the door to my office wants a scheduled childbirth,'' says Dr. Laura E. Riley, 41, a maternal-fetal medicine specialist at Massachusetts General Hospital who counsels against it, from both professional and personal experience.

Five years ago, shortly before Christmas, Riley begged her obstetrician to induce labor. She was 39 weeks pregnant. ''I didn't want to deliver at Christmas,'' she says. ''I wanted the baby beforehand so I could be home with my 2-year old.''

So the week before Christmas, Riley's doctor admitted her to the hospital, ''started the Pitocin and cranked it up to the highest number,'' recalls Riley. ''I went from having cramps to the most unbelievable labor out of nowhere because there was no ramp-up time. It was awful.''

On top of that, the painkilling drugs - given by injection epidurally (into the space around the spinal cord) didn't work. ''It was a fast labor, only two hours,'' says Riley. ''But it was so intense I thought I would go out of my mind. Fortunately, I was fine and the baby was fine. But, in retrospect, it was silly.''

Just how silly, however, is a matter of contentious debate.

The American College of Nurse-Midwives takes a dim view of elective inductions. The American College of Obstetricians and Gynecologists does, too, although that group says labor may be induced for ''psychosocial'' reasons. But the group has a warning for obstetricians who induce labor in a woman who is not quite full term: Be very sure that the fetal lungs are mature or that other tests show the fetus is developed enough to be born.

Generally, this means that the woman should be at least 39 weeks pregnant and that her cervix be ripened; that is, already soft, flat, and at least partially open.

The chief argument against elective induction of labor is that nature does a brilliant job of orchestrating the delicate dance of chemical signals that cause the cervix to ripen and the uterus to begin contractions. It's tough for mere mortals to do nearly as well.

One theory is that when the fetal brain is mature, notes Joyce Roberts, a nurse-midwife at Ohio State University, it sends signals to the fetal adrenal glands to secrete cortisol, a stress hormone. That may trigger a shift in the placental metabolism of the two key hormones of pregnancy, estrogen and progesterone, so that estrogen begins to dominate. That, in turn, may make the uterus more capable of contracting.

Meanwhile, scientists believe, the fetal lungs secrete chemicals signalling that they are mature, along with enzymes that trigger the release of prostaglandins, which in turn tell the cervix to ripen and the uterus to contract. Oxytocin, made in the mother's body, triggers further uterine contracts. (It is the natural hormone of labor upon which Pitocin is modeled.)

''To push those mechanisms is foolish,'' Roberts says. ''There's an optimal timing'' in nature's method ''and most of the time, it works out amazingly well.'' When labor is induced ''for no good reason, the fetus may not be optimally mature and the mothers uterus may not be capable of good labor contractions.''

But some obstetricians argue that, when done carefully in the right patients, elective induction of labor is safe.

''Personally, I think if the patient is well worked up in terms of the baby's maturity and if the cervix is ripe, I don't think there's anything wrong with it,'' says Dr. Alan DeCherney, chairman of obstetrics and gynecology at the UCLA School of Medicine. ''But you have to do it in the right people.''

Rosenberg, of New Island Hospital, agrees. ''You have to make sure there is adequate dating'' of the pregnancy to be sure the woman is at least 39 weeks pregnant. By 39 weeks, the fetal lungs contain enough of a crucial substance called surfactant that they are reasonably mature, which means there's less than 1 percent chance of respiratory problems. (For babies born at 36 weeks, the risk of respiratory distress syndrome is 5 percent, and it goes up steeply with shorter pregnancies.)

Some obstetricians start an elective induction by rupturing the membranes of the amniotic sac (what laypeople call ''breaking the waters'') with a small, blunt amniotic hook. Often, this starts spontaneous contractions. If it doesn't, then Pitocin can be given, but once the waters are broken, the delivery should happen (by C-section, if necessary) within 24 hours because the risk of both maternal and fetal infection rises.

It is possible to artificially trigger an unripe cervix to ripen with drugs, chiefly, prostaglandin gels. But a woman whose cervix was unripe to begin with has a higher risk of C-section than one who is induced with an already ripe cervix.

''If the cervix is ripe, the risk for C-section is probably low,'' concedes Riley of MGH. ''However, many people want elective induction with an unripe cervix or want drugs to ripen it. My personal opinion is that any form of intervention that is unnecessary is probably not in anybody's best interest.''

But that doesn't stop Riley's patients from begging for induced labor anyway, even trying to bribe her with chocolates.

''A tremendous number of people want an induction because they want to control everything. Most are control freaks,'' she says, ''I can completely relate because I am one of them. But I don't do very many elective inductions. I refuse because of the risks.''

This story ran on page C1 of the Boston Globe on 9/25/2001.
© Copyright 2001 Globe Newspaper Company.

If you are considering induction, it is good to know how favorable you might be for a vaginal birth. There is a method of testing your favorablity. It is called the Bishop Score test. Go to the link on this page to add up your own score, or there is an interactive test for you to take on the www.childbirth.org site. Here is the link http://www.childbirth.org/interactive/induction.html. There is a great article on inductions and medications used for inductions on the www.mothering.com site. Click on the left side "recent articles" and read the "Case Against Induction."

Know why you are being induced- is it for convenience or is there a medical reason for doing so? Remember to use your brain in determining if this induction is right for you. Read Teresa's article on this site. The article is listed under Articles by Teresa.