Here is a great letter by Jo Hunter from Homebirth Australia which personalises the issues well.
A 25 year old woman, Jenny (not her real name) chooses to give birth to her first child in a private hospital under the care of a private obstetrician. Jenny makes this choice because she believes it is the only way she can receive continuity of care throughout pregnancy, birth and the postnatal period. Her antenatal visits last for approximately 7 minutes during which time she has her physical check up. Never throughout the course of her pregnancy is her birth plan discussed. She goes to 7 days past her due date and her private obstetrician books her in for her induction in 2 days time, he tells her of the risks of going overdue, he speaks of placental failure and possible death of her baby.
Jenny comes in for her induction 2 days later and gel is placed on her cervix to help it to ‘ripen’ because it is no where near ready for labour. She is left overnight and is taken to labour ward in the morning so a cannula can be thrust into her veins and syntocinon pumped through it to artificially start labour. Unfortunately her private obstetrician is unavailable today so she has been put under the care of one of his colleagues Dr Smith.
Jenny is cared for by midwives throughout this process and Dr Smith pops his head in to introduce himself to jenny. It’s not long before Jenny starts to feel contractions, they are intense from the outset and although Jenny would have liked to try to birth without drugs, it’s becoming clear that she probably will not cope. After 3 hours of contractions Jenny decides she needs some pain relief. There is no midwife sitting with her, offering her support or encouragement, she buzzes and the midwife suggest she has “a little shot of pethidine”; it is administered into Jenny’s thigh. Pethidine is an opioid and from the same family as heroin. Jenny has not been informed as to the risks associated with pethidine. She is not told that it crosses her placenta and will affect her baby, she is not told that babies sometimes need a shot of narcan at birth to reverse the effect of the drug on its tiny immature system, she is not told it can effect babies breathing and often effects the baby’s ability to breastfeed (and women who want to birth naturally are told they are not thinking of their baby but only themselves).
Jenny’s labour continues and the level of syntocinon is increased on a half hourly basis, she is strapped to a CTG machine and is unable to leave the bed. Jenny is hungry but she is told she is not allowed to eat in case there is a need for a caesarean section, by now it is 3 pm and Jenny has not eaten since the night before. Her blood sugar levels are no doubt dropping and she is loosing energy and feeling tired and despondent at the news that she is “Still only 3 cms dilated”.
The midwife occasionally comes to check her and her baby by walking to the print out on the machine and reading it with a knowing look, she rips a section of the print off the machine and leaves the room with a tut tut. The next thing Jenny knows Dr Smith is back and is explaining to her that her babies heart rate is ‘dropping’ and it is not coming back up to its baseline as it should be. This shows that the baby is becoming distressed and this worries Dr Smith because he doesn’t know how much reserve this little baby has and whether or not the baby will be able to continue to cope. He tells Jenny that labour is progressing very slowly and it is likely that they will still be here in 12 hours, BUT in 12 hours this little baby may not be doing well at all. Jenny is scared, of course the most important thing to her is the well being of her baby and she listens intently to everything Dr Smith is telling her. He suggests that it is time to go to theatre and have a caesarean in order to save her baby and to end the pain for Jenny. Jenny’s adrenaline is racing and all she can think about is her baby’s wellbeing. Of course she will do anything it takes to save her baby and she consents to a caesarean section.
Jenny’s baby boy is surgically removed from her body with Apgars of 9 at 1 minute and 9 at 5 minutes; he is immediately taken by a midwife who vigorously rubs him, even though he is pink and breathing beautifully. Jenny first sees her son all wrapped up in blankets for a quick kiss and then he is taken away with her partner while the Drs stitch up Jenny’s broken body. She is alone, without her loved ones and without her baby. Jenny is taken to recovery where she stays for 1 hour before finally being taken up to the ward to meet her baby. On arrival her baby has been weighed, measured and given needles and he is all dressed and wrapped. He is fast asleep and completely disinterested in breastfeeding. The following days are painful, Jenny is an self administration of morphine for pain relief. She finds it difficult to breastfeed because the weight of the baby on her scar is too much to bear. The baby is sleepy and disinterested in the breast, so the midwives suggest he has formula because ‘we don’t want his blood sugar levels to drop”. Throughout this time Jenny is cared for by midwives.
She returns home, in pain with swollen leaking damaged breasts and a fussy baby who is not attaching well. Her next appointment with her private obstetrician is in 6 weeks time for a “scar check”.
Unfortunately Jenny’s experience is not unique; this happens everyday in every hospital across the country.
It is likely Jenny is told that her caesarean was absolutely necessary otherwise her baby may have died. She almost certainly wasn’t told that if she had of avoided the induction in the first place and allowed her body to start labour in its own time that she most likely would not have needed a caesarean section .
Dr Pesce and Dr Weaver, why are you so concerned about a small minority of women, as you say 0.25% of the population? These women and the small handful of midwives who support them are not going to affect your business.
While Private Obstetricians can legally remain in employment so should private midwives be able to.
It’s about choice, if a woman can choose an elective caesarean section for no medical reason, with all its risks, so should the next woman be able to choose to birth in the comfort of her own home with an experienced professional midwife by her side.
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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
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.
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.
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.
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.)
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.
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
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.
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.”
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.
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
Gloria, the Cochrane review accepts the methodology of the study. I suspect that gives it more credibility than an individual opinion.