What’s a good reason to induce and what’s really NOT?  Today I’ll be sharing thoughts from Jennifer Bock’s excellent exposé, Pushed: The Painful Truth about Childbirth and Modern Maternity Care, as well as opinions offered by Ricki Lake and Abby Epstein via an article “Choosing to Wait” in Fit Pregnancy magazine, Sept 2009.  Ricki Lake and Abby Epstein produced the film The Business of Being Born and have since published a new book Your Best Birth.

Gary Hankins, MD, chair of the obstetric practice committee of the American College of Obstetricians and Gynecologists (ACOG) says he never induces for convenience.  “And induction absent a solid indication absolutely increases all risk to mom and baby” (Block, pg. 8).  So maybe you agree.  You don’t want to induce.  Considering that the induction rate is growing by leaps and bounds, waiting for spontaneous birth may not be as easy as you’d assume.  Educating yourself about what constitutes a “solid indication” for induction may help you choose a good caregiver or at least bolster your resolve if your doctor pressures you at some point to an unnecessary induction.

Pressures?  Do doctors really pressure women into induction?  Author Jennifer Block shares the stories of several women who were induced, all for different reasons.  Interestingly, all three women report being encouraged to induce earlier on in their pregnancies. Here’s what one woman experienced:

“It started at 39 weeks,” says Hilton.  “She said, ‘When do you want to be induced?’ I said, ‘I don’t.’ She said, ‘Well, I’ll give you one more week and that’s it.’”  At her 40-week appointment, Hilton says her OB asked, “So are you ready to have a baby?” and offered to schedule her the following day (Block, pg. 16).

Unfortunately, this kind of attitude is all to common with doctors, for whom an induction scheduled during regular business hours or before a upcomming vacation is so much more convenient.  Doctors are people too, with families to see and personal business to do.  It is easy to see how they would be tempted to put the needs of their families before the best interests of their patients when our culture becomes accepting of questionable medicine.

Poor Reasons to Induce:  Included in this category are indications commonly given for induction that are discredited by medical studies discussed in both Pushed and The Business of Being Born.  There is not sufficient medical justification for inducing based on any of these reasons.

1. The ultrasound technician moves your due date- an ultrasound can accurately determine a due date early on in pregnancy.  Late in pregnancy, an ultrasound technician can only estimate your due date, and can be off by plus or minus 3-4 weeks (Fit Pregnancy, pg. 54).
2. An ultrasound shows your baby is “measuring” big- although you’d think this would be an exact science, ultrasounds only estimate baby’s weight and can be off by pounds in either direction!  This justification is not supported by the American College of Obstetricians and Gynecologists (ACOG).  And, what’s more “statistically, fetal size appears to level off after 40 weeks gestation” (Block, pg. 9).
3. An ultrasound show your amniotic fluid is low – again the ultrasound is only an estimate of your amniotic fluid level.  “Amniotic fluid shifts constantly, with more being produced all the time (Block, pg. 11).  Your doctor should be recommending you drink plenty of fluids and rest, not scheduling an induction (Fit Pregnancy, pg. 54).
4. Your doctor is leaving town – as much as it helps to have the right caregiver, it doesn’t make sense to increase your chances of c-section by 2-3 times to ensure your doctor will be available (Fit Pregnancy, pg. 54).
5. You’re 40 weeks pregnant – you are not “overdue” until 42 weeks.  A baby is considered normal, “full-term” if it is born between 38 and 42 weeks (Block, pg. 11).  “In other words, if we were to distribute a large sample of pregnancies along a graph, we’d see a bell curve.  Forty weeks would be the height of the curve, and an equal number of women would give birth before and after… Thus a due date would be expressed more accurately as a ‘due month’” (Block, pg. 11).

Controversial Reasons to Induce:  Included in this category are indications commonly given for induction that are rejected by some doctors and most midwives, but not entirely without reasonable medical support.

1. You’re 41 or 41.5 weeks pregnant – One large study shows that slightly more stillbirths occur after 41 weeks.  Researches disagree as to the reason why this is so (Block, pg. 11).  If time in the womb is not to blame, than inducing every pregnancy at 41 weeks is foolish for the vast majority of women (pg. 12).  A wise doctor will consider other factors such (fetal nonstress test) and childbirth history, as well as suggesting natural means of encouraging labor, rather than making a beeline for the drugs.
2. Your bag of waters is broken- Most women go into spontaneous labor within 24 hours of the bag of waters breaking (pg. 13).  But, sometimes labor might not begin for a few days.  During that time, there is concern for infection since the seal has been broken, so to speak.  How does infection make its way up there?  Through vaginal exams.  A study of 5000 women (the largest to date) “found no increase in neonatal infection in (women) that were watched for up to 4 days after rupture.  The vagina is a nearly airtight passageway, so loss of the plug and rupture alone don’t significantly increase the risk of infection…” (pg. 12).  As a matter of course, hospitals insist a baby must be delivered within 24 hours of the waters breaking, which means induction within 6 hours in most cases (Fit Pregnancy, pg. 55).  Midwives disagree with this approach, instead opting to use natural means of induction at this point, while avoiding vaginal examines.
3. Baby is smaller than normal – while the authors of Your Best Birth state this is a solid reason for inducing, it seems an odd generalization to me (pg. 55).  If you’re still 39 or 40 weeks, maybe you baby needs more time to grow?  Also, remember that ultrasounds only estimate weight and can be off by over a pound in either direction.  Jennifer Block does not address this issue, and neither have I read about it elsewhere.

Solid Reasons to Induce:  Included in this category are indications commonly given for induction that are supported by good reasearch.

1. You’re 42 weeks pregnant:  the placenta may start to deteriorate after this point, failing to support baby properly with oxygen and nutrients (Fit Pregnancy, pg. 55).
2. Baby is moving less:  your observations and further testing show baby is moving much less than normal (pg. 55).  Keep in mind that babies do move less as they reach term because they have less room!  But, if baby stops moving at all, you should seek care immediately.
3. Baby’s heart rate is irregular:  clear irregularities indicate distress and should be treated seriously (pg. 55).
4. You have signs of Preeclampsia:  spiking blood pressure and protein in the urine indicate preeclampsia (pg. 55).