12 responses to “Letter to the Editor”

  1. Mrs Farley

    Jo, this is scarily like so many stories my friends have to tell, and very nearly the story i would be telling if i had not gone out and done a little reading behind the back of my private OB.
    for my first child 10 years ago, i did choose to be induced with Gel, (but the decision was not made as naively as some, and i still feel it was an informed choice) but i thouroughly discussed wiht my ob that this was all the intervention i would allow. unfortunately the thing i didnt factor into it was the application of the gel at 9pm and then being put to bed negated to effect it could have. i woke the next morning to the matron (looking like she had walked straight off a carry on movie-i swear) bustling into the room, castigating my for not having gone into labour, and TELLING me i was going down to thelabour ward to have my waters broken, when i refused, she called me a coward, and said the only difference was that it would take 10-15 hours offmy labour. let just say we ehem ‘discussed’it for while, then dragged the poor OB off the golf course, discussed it some more and then i succeeded in khaving the Gel reapplied, went for a walk and drifted into labour and gave birth actively and naturallly 7 hours later, luckily with the constant care of a hospital midwife who thought it was hilarious that i had stood up to the old battle-axe!
    what i have noticed is that in the small community i now live in is that the story described above is standard, so very few of the women haveing their first babies have ever known another type of birth. when i explain to them the consequences of that first intervention, and how it will 9 times out of 10 lead to a cascade of other procedures, i have witnessed every reaction from disapointment thru to grief and fury. the one thing Jo does not mention is the fact that when these women go on to having their second baby they are advised from the start to have a scheduled Ceasar instead of attempting to birth vaginally, because of the risk of exploding in a big gorey mess with the first contraction.
    So sad

  2. pinky

    Could you please give me the evidence that induction increases risk of c-section? I do not disagree with what you are asserting. I would just like to see the studies. I have seen studies that assert induction does not increase c-sections.

  3. midwife of the plains

    Hey Pinky~
    Here are a few places to look:
    download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937808007047.main-abr.pdf
    http://www.aafp.org/afp/20000215/tips/39.html

    I highly recommend reading the article in the American Journal Of Obstetrics and Gynecology.

    Really, if a baby is not ready to be born, induction, no matter what kind, will probably just stress a baby out, increasing the chance of a c/sec.

    There are other articles out there as well. Check out the Cochrane database.

  4. Lib

    Is this an article in response to Pesce and Weaver’s on the ABC website? (http://www.abc.net.au/unleashed/stories/s2538104.htm)
    Looks like there’s a feisty discussion on the comments board, including references to this webpage.

  5. lauren

    Hey Pinky,
    It’s been explained to me that when artificial oxytocin is used, the contractions are not at all like normal contractions. In a normal contraction, there is a build up, a peak, and then it subsides. This squeezes the baby, then releases. With synthetic oxytocin, the contractions can build up to be ‘all peaks’ without build up, which often results in the baby being squeezed unnaturally long, sometimes limiting oxygen supply, causing a drop in heart rate and a pronouncement of ‘baby in distress’ and then a c-sect. (I read this in the book ‘Pushed’ by Katherine Block.)

  6. Anonymous

    For your readers’ information, the Cochrane review of 19 trials of induction of labour compared to waiting spontaneous labour for pregnancies progressing beyond 41 weeks found fewer babies died in the induction group (1 in 2986) than the wait and see group (9 in 2953), and no higher risk of caesarean delivery in the induction group.

  7. midwife of the plains

    Anonymous and all~
    In that same trial it is also explicitly stated that,
    “Women induced at 37 to 40 completed weeks were more likely to have a caesarean section with expectant management than those in the labour induction group (RR 0.58; 95% CI 0.34 to 0.99).”

    Please note that this review does not state what the neonatal outcomes were for the 37-41 week induction vs. non-induction group, which must have comprised around 5000 babies. It just states that there were more c/sec in the 37-41 week induction group.
    That would be helpful information to know. How did those induced c/sectioned mamas and babies fare?

    Here is a link to the actual review
    http://www.cochrane.org/reviews/en/ab004945.html

  8. Anonymous

    Dear Midwife of the Plains,
    May I suggest you a) have another look at the review and b) read the review rather than just the abstract.

    There was a statistically significant higher Caesarean section rate in the expectant management group (ie spontaneous labour) for 37 to 40 completed weeks, not for the induction group. So there is no group for whom induction of labour resulted in a higher caesarean section rate than for spontaneous labour in this review. I posted my original response because there were claims that inductions result in higher caesarean rate, but the evidence shows otherwise.
    Contrary to your statement, the neonatal outcomes for the 37-40 completed weeks group are reported in that Cochrane review. Perinatal outcomes were not different, although there was a non statistically significant lower perinatal mortality rate in the induction group (0 deaths in 299 births) compared to the expectant management group (2 deaths in 285 births).

    In summary, the most reputable review of induction of labour compared to natural labour finds no evidence of an increased risk of caesarean section for women who are induced compared to those that go into labour naturally, and for babies of women who are induced at 41 weeks or beyond, a significantly lower risk of death.
    This does not mean that women should actively seek induction of labour, as there are other disadvantages ie stronger contraction pain, need for continuous monitoring in induced labour, and consequent restricted mobility. I also believe first time mothers are at higher risk of caesarean section if induced, but this review does not break down the stats into first time mothers, and women with previous vaginal deliveries. In addition, for the 37-41 week induction group, there was a 70% higher incidence of assisted vaginal delivery (ie vacuum or forceps). The risk of assisted vaginal delivery was not elevated for the induction group >40 completed weeks.

  9. Lisa Barrett

    Dear Anonymous, I would suggest you look at the South Australian hospital figures. 2007 are out.
    first time mothers who had an induction 64% had a section.
    Sort of speaks volumes without Cochrane.
    and there’s this
    “#

    To illustrate, in a 1992 study, researchers randomly assigned 3,400 women—two thirds of them first-time mothers—to planned induction at 41 weeks gestation or to await labor.18 The women assigned to induction at 41 weeks were, in effect, elective inductions since at the time, women were not considered postdates until 42 weeks. Twenty-one percent of the planned induction population had cesareans versus 25% of the expectant management group, leading the authors to conclude that planned induction was the better policy. The study has been cited since as an argument for elective induction. But these were all healthy women with full-term, singleton, head-down babies. In other words, this was a population that should have been at minimal risk for cesarean section.

    A follow-up analysis reported cesarean rates according to whether labor began spontaneously or was induced.19 Among first-time mothers, 26% of women beginning labor spontaneously, whether in the planned induction or await labor group, had cesareans. This rose to 30% of women induced as planned and a whopping 42% of induced women in the await labor group, of which only 17% were done for abnormal fetal testing results.18 By comparison, a study of 12,000 low-risk women beginning labor at free-standing birth centers reported a cesarean rate of 4% with 10% of first-time mothers having cesareans.34
    #

    bias toward intervention over the natural process: The lead author of the study above thinks that every woman should have a cesarean as evidenced by her chairing a conference entitled “Choosing Delivery by Caesarean: Has Its Time Come?”17 This goes a long way toward explaining why the main paper misrepresents the true risks of induction and ignores the appallingly high cesarean rates in both spontaneous and induced labors.”

  10. Anonymous

    Dear Lisa,

    I have reviewed the 2007 Pregnancy Outcomes SA Health Report. There is no reference to caesarean rates in induced primips in that report. Have I missed something, or are you referring to another report?

    I am puzzled by your response. It confirms there is no increased risk of caesarean section in the planned induction group versus the expectant management group.

    This thread of the discussion was prompted by an often repeated statement that induction of labour increases the risk of caesarean delivery, and an invitation to examine the evidence. The evidence provided by randomised controlled trials refutes this statement.

  11. Gloria Lemay

    Trouble is, the evidence is flawed. Have you read “Nonsensus Consensus” by Dr. Philip Hall of Manitoba, Canada pub’d in the BJOG?
    He looked at the raw data of the largest study on 41 w.g.a. induction (Hannah, et al). Here’s the reference:
    Routine induction of labour at 41 weeks gestation: nonsensus consensus
    BJOG: An International Journal of Obstetrics and Gynaecology Vol: 109 Issue: 5pp: 485-491 PII: S1470032802010042. Copyright © 2002 RCOG All rights reserved..
    Savas M. Menticoglou, Philip F. HallDepartment of Obstetrics, Gynaecology and Reproductive Sciences, University of Manitoba, Winnipeg , Canada. Accepted 16 2002
    email me if you want me to send the whole thing.
    Gloria in Canada

  12. Anonymous

    Gloria, the Cochrane review accepts the methodology of the study. I suspect that gives it more credibility than an individual opinion.