Tired of being pregnant? Miss seeing your toes? Are you longing to sleep on your tummy again? These are all common complaints of a mom by the last 4 weeks of her pregnancy. Share these complaints with your doctor and if he or she suggests induction (administering a drug to start labor/contraction, or stripping of the membranes) I suggest you get a second opinion. Expectant mothers and their parents deserve INFORMED consent, they need as much information as possible in order to make the decisions that are best for their families. When making decisions regarding your pregnancy and birth always keep this acronym in mind; B.R.A.I.N.

B. What are the BENEFITS of this procedure?

R. What are the RISKS associated with this procedure?

A. What if any, are our ALTERNATIVES? Or, this may be what you usually suggest to your patients but what alternatives are you aware of that we may employ in this situation?

I. What does your gut say? INSTINCT, listen to it.

N. We NEED more time. Ask what will happen if we wait 1 hour to do said procedure, how about 4, or what if we do not do it. Ask for time to make your decisions, unless you are being wheeled down a hall to the E.R. it is not an emergency and you should be given time to decide.

When women are offered induction, very rarely do they get the full story. Here is a list of the dangers of induction from an article by Henci Goer;

“All of the procedures and drugs used in inducing labor can have adverse effects.

• oxytocin (Pitocin, also called “Pit”):
  • uterine hyperstimulation: Uterine hyperstimulation is a more common and serious problem with inductions than when using oxytocin to strengthen contractions in an already established labor because it takes higher contraction pressures to get and keep a labor going from a standing start.²⁰ Of ten studies comparing hyperstimulation rates at two different oxytocin dosages, hyperstimulation rates ranged from 2% to 60% at the lower oxytocin dose, and six of the studies reported rates of 15% or more.¹⁴ At the higher dose, hyperstimulation rates ranged from 13% to 63%, and half reported that 25% or more of the women experienced hyperstimulation.
  • fetal distress: Uterine hyperstimulation can cause fetal distress. Four studies reporting hyperstimulation rates also reported fetal distress rates.¹⁴ One reported an 8% rate at the lower dose; the rest reported rates ranging from 15% to 54%.
  • low Apgar score: A separate study reported that induction increased the percentage of babies born in poor condition from 16% to 21%, doubling the odds after statistical adjustment for interdependent factors.²¹
  • postpartum blood loss and neonatal jaundice.^{4-5,7,13,16,29,37} 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.
• cesarean section: Oxytocin substantially increases the likelihood of c-section in first-time mothers. (See Table.)
• procedures used with oxytocin: Administering oxytocin requires an IV and electronic fetal monitoring, which have their own potential adverse effects. Because labor is more painful, women may be more likely to want an epidural. One study comparing first-time mothers having elective inductions with first-time mothers beginning labor on their own reported that having an epidural before 4 centimeters dilation nearly quintupled the odds of cesarean, and they still doubled with epidural placement at 5 centimeters or more.³⁶
• rupturing membranes: Because amniotic fluid prevents umbilical cord compression during contractions, rupturing membranes increases the odds of episodes of abnormal fetal heart rate and cesarean section for fetal distress.^12,15,28 This may be more of a problem during inductions because contraction pressures are often higher. Since the interval between rupture and birth may be long with an induction, rupturing membranes increases the risk of infection in women who subsequently have vaginal exams and women colonized with group B strep. In rare cases, it precipitates umbilical cord prolapse. Cord prolapse is most likely when membranes are ruptured early in labor when the head is still high, as would happen with inductions.
• prostaglandin E2 (trade names: Prepidil, Cervidil): Prostaglandin E2, also called dinoprostone, is inserted vaginally as a gel (Prepidil) or as a removable tampon (Cervidil) to soften the cervix. It can cause uterine hyperstimulation and fetal distress. In some cases, fetal distress can lead to cesarean section.10
• prostaglandin E1 (trade name: Cytosec): Prostaglandin E1, more commonly known as misoprostol is a tablet whose only FDA approved use is as an oral medication for stomach ulcers. Its manufacturer, Searle, does not formulate it for use in labor and has repudiated its use for this purpose because of safety concerns.³³ The FDA says of Cytotec:¹¹
  

  A major adverse effect of the obstetrical use of Cytotec is hyperstimulation of the uterus which may progress to uterine tetany [sustained contraction] with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy [surgical removal of ovaries and Fallopian tubes]), or amniotic fluid embolism [very high maternal and fetal mortality rate]. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia [dangerously slow fetal heart rate], and fetal and maternal death have been reported. . . . The risk of uterine rupture increases . . . with prior uterine surgery, including Cesarean delivery. Grand multiparity [several prior births] also appears to be a risk factor for uterine rupture.

Unlike oxytocin, where the drip can be turned down or off, Cytotec cannot be rescinded if it is causing problems.”

So now that you are aware of the facts, what can you do to keep you and your baby safe? I have included Henci Goer’s answer to that question here:

(adapted from The Thinking Woman’s Guide to a Better Birth © 1999 by Henci Goer)

Refuse induction if you have no prior births. Induction will increase the chances of cesarean by anywhere from 50% to 250%. (See Table.)

Refuse Cytotec (misoprostol, prostaglandin E1). As noted above, Cytotec has a propensity for precipitating women into short, violent labors and a potential for catastrophic complications. Cytotec was not formulated for use in inducing labor and has not been approved by the FDA for this purpose, although recently, lobbying by ACOG led the FDA to lift a ban. Besides being riskier than Prepidil and Cervidil (prostaglandin E2), Cytotec offers no compensating advantages—at least not for women. Cytotec produces virtually identical cesarean rates compared with inductions involving prostaglandin E2.²² The higher risks and equivalent effectiveness notwithstanding, hospitals like Cytotec because it costs mere pennies a dose compared with $75 to $100 dollars per dose of prostaglandin E2. Obstetricians like it because it allows them to practice “daylight obstetrics”—insert the pill in the morning, return later in the day for the delivery or the cesarean, be home in time for dinner.⁴¹

Refuse rupture of membranes before labor is well-established and progressing. Having intact membranes means you can back out if the induction doesn’t work. Refusing early rupture also reduces the risk of fetal distress from cord compression; the risk of infection, which avoids IV antibiotics and septic workups; and the rare but catastrophic risk of umbilical cord prolapse.

Consider refusing induction with an unready cervix and/or little or no dilation. These conditions greatly increase the probability of cesarean section regardless of the use of cervical ripening procedures.^27,43-44

When cervical ripening is necessary, request Cervidil. Unlike Prepidil, it can be removed should uterine hyperstimulation occur.

Avoid mechanical dilators for cervical ripening. These materials gradually dilate the cervix by absorbing water. They are not as effective as prostaglandin E2 at either promoting successful labor induction or achieving vaginal birth, and they may increase the risk of infection.^25,43 Again, lower cost is the single advantage.

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.¹⁴

Have continuous electronic fetal monitoring. It reduces the risk of newborn seizures.²⁶

Insist on a low-dose(physiologic) oxytocin regimen that allows at least 30 minutes between dose increases.¹⁴ 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.

Arrange to have the nurse try turning off the oxytocin once active, progressive labor is established. When labor kicks in, it may continue on its own without the extra stimulus. This will be less painful for you and easier on the baby. A plain IV will be kept running, so oxytocin can easily be restarted if needed.

Low-dose, long-interval protocols increase the odds of being able to turn the oxytocin drip down or off in active labor.³

Avoid or at least hold off on an epidural. Because epidurals slow labor, they can substantially increase the risk of cesarean section, especially when given early in labor. Epidurals also cause fevers with prolonged use. A fever in labor indicates a possible infection in mother or baby and leads to a cascade of interventions.

Limit vaginal exams once membranes are ruptured. There is a clear relationship between length of time since rupture, the number of vaginal exams, and infection.³⁸

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.⁶