Problems and Hazards of Induction of Labor

Check out this great article on the problems and hazards of induction of labor.

5 Reasons to Avoid Induction

The Risk of Inducing Labor

By Robin Elise Weiss, LCCE, About.com

The induction of labor can be done for many reasons, including many valid medical reasons. However, the rise in the rate of social inductions, or elective inductions is on the rise. As the induction rate rises there are more babies and mothers placed at risk for certain complications. Here are five risks of induction that you may not know about:

1. Increased risk of abnormal fetal heart rate, shoulder dystocia and other problems with the baby in labor.
Labor induction is done by intervening in the body's natural process, typically with powerful drugs to bring on contractions or devices that are used to break the water before labor starts. Both of these types of induction can cause the baby to react in a manner that is called fetal distress as seen by fetal monitoring.

The nature of induction like contractions may also be more forceful than natural labor. This can cause your baby to assume or stay in an unfavorable position for labor making labor longer and more painful for the mother. It can also increase the need for other interventions as well.

2. Increased risk of your baby being admitted to the neonatal intensive care unit (NICU).
Babies who are born via induction have not yet sent signals to the mother to start labor. This means that they simply aren't yet ready to be born. This risk is worth it if the baby or mother's lives are in danger, but simply to take this risk for elective reasons may not be well advised.

When a baby is in the intensive care unit there is less ability for you to be with your baby or to hold your baby. Breastfeeding usually gets off to a rocky start as well. This can usually be avoided by giving birth when your body and baby say it is time.

3. Increased risk of forceps or vacuum extraction used for birth.
When labor is induced babies tend to stay in unfavorable positions, the use of epidural anesthesia is increased and therefore the need to assist the baby's birth via the use of forceps and vacuum extraction is also increased.

4. Increased risk of cesarean section.
Sometimes labor inductions don't take, but it's too late to send you home, the baby must be born. The most common cause of this is that the bags of waters has been broken, either naturally or via an amniotomy. Since the risk of infection is greater, your baby will need to be born via c-section.

A cesarean in an induced labor is also more likely for reasons of malpresentation (posterior, etc.) as well as fetal distress.

5. Increased risks to the baby of prematurity and jaundice.
Induction can be done before your baby is ready to be born, because your due date is off or because your baby simply needed more time in the womb to grow and mature their lungs. Your baby may also be more likely to suffer from jaundice at or near birth because of the induction. This can lead to other medical treatments as well as stays in the hospital for your baby.

Being born even a week or two early can result in your baby being a near term or late preterm infant. This means that your baby is likely to have more trouble breathing, eating and maintaining temperature.

Reducing Infant Mortality

This is an awesome video on reducing infant mortality here in the states. Take the time and watch it - it is under 17 minutes long.

Reducing Infant Mortality from Debby Takikawa on Vimeo.

Caution urged on inducing labor

By TODD ACKERMAN

July 21, 2009, 12:18AM

Doctors are being advised not to induce labor for non-medical reasons prior to 39 weeks into a pregnancy under revised guidelines released today by the nation's association of obstetricians and gynecologists.

The guidelines, the first since 1999, arrive amid concern about the increase in the number of such procedures in the last two decades. The rate of induced labor has increased from 90 per 1,000 births in 1990 to 225 per 1,000 births in 2006.

“It's really become an epidemic,” said Dr. Mildred Ramirez, an author of the American College of Obstetricians and Gynecologists guidelines and professor of ob-gyn at the University of Texas Medical School at Houston. “The doctor and patient need to weigh the risks and benefits — there will be exceptions — but I hope the consequence of the guidelines is a reduction in the rate.”

But another Houston ob-gyn called the guidelines “pretty lax” and said she doubted they would have a significant effect.

Ramirez characterized the rate as “alarmingly high” in many hospitals and said there are ones in Houston where labor is induced 50 percent of the time.

While induction is relatively safe, it's been associated with increased risk of Caesarean sections. Studies have found it also leads to longer hospital stays and higher costs.

There are many occasions when there are clear-cut medical reasons for inducing, such as when health problems complicate a pregnancy and when pregnancies are more than two weeks past the due date. The health problems include diabetes or high blood pressure in the pregnant woman, premature rupture of membranes that encase the unborn baby and fetal issues such as an irregular heartbeat.

The new guidelines focus mostly on setting forth when and how to induce labor in such situations. Ramirez said there is significant new data since 1999 comparing the different regimens and their side effects.

Guidelines not set in stone

The guidelines are non-binding, but could be interpreted to make a doctor more liable if he or she doesn't follow them and something goes wrong.

Over the past 20 years, the decision to induce has increasingly involved not health concerns but convenience — for the mother, family or doctor. Patients often request induction because they're tired of the pregnancy, want to make sure their doctor is there instead of a different doctor who might have to deliver if labor occurs at night or prefer to time the delivery to most efficiently manage their allotted time off from work.

The guidelines take no position on such so-called “soft” reasons for inducing labor.

But for the first time, they stress that mature fetal lung test results before 39 weeks of gestation by themselves aren't enough to justify inducing. Such results — fetal lungs are mature at 37 weeks 90 percent of the time — sometimes have been used as a criterion to induce early.

They also call for a physician capable of performing a Caesarean to be available if induction doesn't produce a successful vaginal delivery.

The increased rate has led some hospitals around the nation in recent years to implement their own stricter guidelines on elective use of the procedure. But Dr. Damla Dryden, an ob-gyn with the Women's Specialists of Houston at Texas Children's Hospital, said the demand is so great it will take a stronger statement than the new guidelines to get more hospitals on board.

“People keep pushing to induce earlier and earlier,” said Dryden. “The new guidelines stress the issue a little more clearly than previously, but journal articles and studies have pointed out the trend for a while now and doctors still feel a lot of pressure from patients for it.”

Dryden called the trend the same one that's caused Caesarean sections to increase recently, “the idea that some patients want to get the baby out before something goes wrong.”

Ramirez said the authors didn't delve more into the overuse of labor induction because they saw the guidelines' purpose as educating physicians about the current state of knowledge given the procedure's frequency, but acknowledged it's “a valid point” that they could have used the occasion to come out more forcefully against the trend.

Ramirez said the authors didn't delve more into the overuse of labor induction because they saw the guidelines' purpose as educating physicians about the current state of knowledge given the procedure's frequency, but acknowledged it's “a valid point” that they could have used the occasion to come out more forcefully against the trend.

There is no one accepted number for the rate of inductions done for nonmedical reasons, but studies have put it from 15 percent to 55 percent of the total number.

todd.ackerman@chron.com

Is the Cord Around the Baby's Neck Really Dangerous?

May 19, 2008 by Misha Safranski

As a confirmed birth junkie, I have heard over and over again birth stories where the baby was born by cesarean for either fetal distress or failure to descend, and the difficulties are blamed on "the cord was around the baby's neck". Is this condition - scientifically termed "nuchal
cord" - actually dangerous? A new study backs up previous research showing that nuchal cord is not the threat it's perceived to be.

A study published this year in the Journal of Perinatal Medicine showed there were no statistically significant differences in outcomes of post-term pregnancies involving a nuchal cord verses no nuchal cord. Drs. Ghosh and Gudmundsson performed color ultrasound on 202 women with post-term pregnancies. Nuchal cords were detected in 69 of the women. There were no significant differences in Apgar scores, umbilical cord anomalies, cesarean section, perinatal death or admission of the baby to the NICU (neonatal intensive care unit).

These findings confirm what has been found in most of the past research on nuchal cord outcomes. A 2006 study from the Archives of Obstetrics and Gynecology was on a much larger scale, looking at the outcomes of 166,318 deliveries during a 15 year study period, 24,392 of which had a documented nuchal cord at birth. The authors, Sheiner et. Al, conclude: "Nuchal cord is not associated with adverse perinatal outcome. Thus, labor induction in such cases is probably unnecessary."
The interesting thing about the Sheiner study is that despite the equivalent outcomes among nuchal cord babies and those without the cord wrapped around the neck, there were higher rates of labor induction and non-reassuring fetal heart tones during labor among the nuchal cord cases.

These two factors are most likely related. We know without a doubt that induction of labor can cause fetal distress. The fact that there were higher induction rates in the nuchal cord group could very well explain the higher rate of transient fetal distress. Induction is nearly always accompanied by AROM (artificial rupture of membranes), which can cause undue pressure on the cord, which can in turn result in blips in the hearttones. Regardless of the cause, the outcomes were still good.

Finally, we look at yet another study which demonstrated that nuchal cord does not result in worse outcomes. In a 2005 study looking at the effects of nuchal cord on birthweight and immediate neonatal outcomes, Mastrobattista, et. Al examined the outcomes of 4426 babies, 775 of whom had a nuchal cord. They found that there were no significant differences between the two groups in birthweight, non-reassuring fetal hearttones, Apgar scores below 7, or operative vaginal deliveries. The cesarean rate was actually highest among the women whose babies did not have a nuchal cord.

The most important thing to keep in mind is that unborn babies do not breathe through their mouth and neck - they receive oxygen through the umbilical cord. This is why it normally doesn't matter if the cord is around the neck (unless the cord is being compressed too much, which is fairly rare). The baby cannot "choke to death" before she/he is born. What we can conclude from the overwhelming majority of data is that nuchal cord - or "cord around the neck" - is not pathological; that is to say, it's not an abnormality. It is a normal condition of the umbilical cord and typically causes no problems with the delivery, even though doctors frequently try to convince parents otherwise.

References:
J Perinat Med. 2008;36(2):142-4. Nuchal cord in post-term pregnancy - relationship to suspected intrapartum fetal distress indicating operative intervention. Ghosh GS, Gudmundsson S. Department of Obstetrics and Gynecology, Malmö University Hospital, Malmö, Sweden.

Arch Gynecol Obstet. 2006 May;274(2):81-3. Epub 2005 Dec 23. Nuchal cord is not associated with adverse perinatal outcome. Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel. sheiner@bgu.ac.il

Why Every Week of Pregnancy Counts

New Research Shows Why Every Week of Pregnancy Counts
By MELINDA BECK

This time of year, some hospitals see a small uptick in baby deliveries thanks to families eager to fit the blessed event in around holiday plans or in time to claim a tax deduction. Conventional wisdom has long held that inducing labor or having a Caesarean section a bit early posed little risk, since after 34 weeks gestation, all the baby has to do was grow.
But new research shows that those last weeks of pregnancy are more important than once thought for brain, lung and liver development. And there may be lasting consequences for babies born at 34 to 36 weeks, now called "late preterm."
New research shows that the last weeks of pregnancy are more important than once thought for brain, lung and liver development.
A study in the American Journal of Obstetrics and Gynecology in October calculated that for each week a baby stayed in the womb between 32 and 39 weeks, there is a 23% decrease in problems such as respiratory distress, jaundice, seizures, temperature instability and brain hemorrhages.
A study of nearly 15,000 children in the Journal of Pediatrics in July found that those born between 32 and 36 weeks had lower reading and math scores in first grade than babies who went to full term. New research also suggests that late preterm infants are at higher risk for mild cognitive and behavioral problems and may have lower I.Q.s than those who go full term.
What's more, experts warn that a fetus's estimated age may be off by as much as two weeks either way, meaning that a baby thought to be 36 weeks along might be only 34.
The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the March of Dimes are now urging obstetricians not to deliver babies before 39 weeks unless there is a medical reason to do so.
"It's very important for people to realize that every week counts," says Lucky E. Jain, a professor of pediatrics at Emory University School of Medicine.
It's unclear how many deliveries are performed early for nonmedical reasons. Preterm births (before 37 weeks) have risen 31% in the U.S. since 1981 -- to one in every eight births. The most serious problems are seen in the tiniest babies. But nearly 75% of preterm babies are born between 34 and 36 weeks, and much of the increase has come in C-sections, which now account for a third of all U.S. births. An additional one-fifth of all births are via induced labor, up 125% since 1989.
Are parents too eager to induce labor or schedule an early C-section for sheer convenience? Are doctors too willing to go along?
Many of those elective deliveries are done for medical reasons such as fetal distress or pre-eclampsia, a sudden spike in the mother's blood pressure. Those that aren't can be hard to distinguish. "Obstetricians know the rules and they are very creative about some of their indications -- like 'impending pre-eclampsia,'" says Alan Fleischman, medical director for the March of Dimes.
Why do doctors agree to deliver a baby early when there's no medical reason? Some cite pressure from parents. "'I'm tired of being pregnant. My fingers are swollen. My mother-in-law is coming' -- we hear that all the time," says Laura E. Riley, medical director of labor and delivery at Massachusetts General Hospital. "But there are 25 other patients waiting, and saying 'no' can take 45 minutes, so sometimes we cave."
There's also a perception that delivering early by c-section is safer for the baby, even though it means major surgery for the mom. "The idea is that somehow, if you're in complete control of the delivery, then only good things will happen. But that's categorically wrong. The baby and the uterus know best," says F. Sessions Cole, director of newborn medicine at St. Louis Children's Hospital.
He explains that a complex series of events occurs in late pregnancy to prepare the baby to survive outside the womb: The fetus acquires fat needed to maintain body temperature; the liver matures enough to eliminate a toxin called bilirubin from the body; and the lungs get ready to exchange oxygen as soon as the umbilical cord is clamped. Disrupting any of those steps can result in brain damage and other problems. In addition, the squeezing of the uterus during labor stimulates the baby and the placenta to make steroid hormones that help this last phase of lung maturation -- and that's missed if the mother never goes into labor.
"We don't have a magic ball to predict which babies might have problems," says Dr. Cole. "But we can say that the more before 39 weeks a baby is delivered, the more likely that one or more complications will occur."
In cases where there are medical reasons to deliver a baby early, lung maturation can be determined with amniocentesis -- using a long needle to withdraw fluid from inside the uterus. But that can cause infection, bleeding or a leak or fetal distress, which could require an emergency c-section.
Trying to determine maturity by the size of the fetus can also be problematic. Babies of mothers with gestational diabetes are often very large for their age, but even less developed for their age than normal-size babies.
Growing beyond 42 weeks can also pose problems, since the placenta deteriorates and can't sustain the growing baby.
Making families aware of the risks of delivering early makes a big difference. In Utah, where 27% of elective deliveries in 1999 took place before the 39th week, a major awareness campaign has reduced that to less than 5%. At two St. Louis hospitals that send premature babies to Dr. Cole's neonatal intensive-care unit, obstetricians now ask couples who want to schedule a delivery before 39 weeks to sign a consent form acknowledging the risks. At that point, many wait for nature to take its course, says Dr. Cole.

http://online.wsj.com/article/SB122999215427128537.html?mod=article-outset-box