You’re 39 weeks pregnant, not quite full-term. You’re still working, of course – after all, you’re a modern mom – and you’ve got everything under control. Except the obvious.
If you knew exactly when the baby was coming, you could tell your boss when to start the maternity leave clock ticking. You could tell your mother when to take time off from her job to come take care of your older child. You could tell your husband to go on that business trip. Your obstetrician wouldn’t exactly mind knowing the precise ETA of your new baby, either – after all, she’s got kids of her own and would much rather deliver babies between 9 and 5 on weekdays than pull all-nighters on weekends.
Besides, you’ve gained 35 pounds. It’s been a long, uncomfortable summer. And you are definitely TOP, or “tired of pregnancy.”
So, why not do the modern, high tech thing and get your doctor to induce labor so that you, not Mother Nature, can decide when the baby will come?
Actually, there are lots of compelling reasons why not, and we’ll get to them in a minute. But more and more busy mothers-to-be, used to being in control of most things in their lives, are flat-out demanding that childbirth be as easy to schedule into their Palm Pilots as a corporate meeting. And many obstetricians are only too happy to oblige.
Between 1989 and 1999, the number of labor inductions – in which doctors hurry childbirth along with drugs to dilate the cervix and stimulate uterine contractions – has soared to 775,245, according to the National Center for Health Statistics. That’s a whopping 19.6 percent of live births, up from 8.2 percent in 1989.
In many cases, the induction of labor is done for legitimate medical reasons such as toxemia (high blood pressure and other symptoms), gestational diabetes or a birth that’s a week or two overdue (which means the placenta, the organ that supplies the fetus with oxygen and nutrients, may start to break down).
But increasingly, induction of labor is done for “elective” reasons, that is, pure convenience. And while some obstetricians hail this move -as elective inductions rise, weekend deliveries decrease – many obstetricians and nurse-midwives worry that the trend may lead to more Caesarean sections if induction fails, more respiratory problems in babies born with not-quite-mature lungs, and more chance of uterine ruptures triggered by drugs such as prostaglandins and Pitocin.
The national health statistics center does not keep track of how many labor inductions are done for medical reasons, how many for convenience and how many for a combination of the two, such as a woman with a track record of short labors who lives far from the hospital.
But Dr. Lewis Rosenberg, an obstetrician-gynecologist at New Island Hospital in Bethpage, N.Y., believes elective inductions now constitute 40 percent of all inductions.
The trend toward scheduling childbirth, he adds, is also propelled by managed care and the need for doctors who work as solo practitioners or in small groups to maximize their own efficiency. “If you’re going to be seeing a large number of patients in one day, the worst thing is to have a patient in labor – you have to reschedule a lot of people.”
Indeed, a recent online survey by Americanbaby.com, a parenting website, found that 36 percent of 827 respondents said they would “consider” scheduling induced labor and another third said that while they wouldn’t do it themselves, they didn’t object to other women doing so.
And that probably underestimates the actual number of requests for elective inductions.
“Almost everyone who walks through the door to my office wants a scheduled childbirth,” says Dr. Laura E. Riley, 41, a maternal-fetal medicine specialist at Massachusetts General Hospital who counsels against it, from both professional and personal experience.
Five years ago, shortly before Christmas, Riley begged her obstetrician to induce labor. She was 39 weeks pregnant. “I didn’t want to deliver at Christmas,” she says. “I wanted the baby beforehand so I could be home with my two-year old.”
So the week before Christmas, Riley’s doctor admitted her to the hospital, “started the Pitocin and cranked it up to the highest number,” recalls Riley. “I went from having cramps to the most unbelievable labor out of nowhere because there was no ramp-up time. It was awful.”
On top of that, the painkilling drugs – given by injection epidurally (into the space around the spinal cord) didn’t work. “It was a fast labor, only two hours,” says Riley. “But it was so intense I thought I would go out of my mind. Fortunately, I was fine and the baby was fine. But in retrospect it was silly.”
Just how silly, however, is a matter of contentious debate.
The American College of Nurse-Midwives takes a dim view of elective inductions. The American College of Obstetricians and Gynecologists does, too, although that group says labor may be induced for “psychosocial” reasons. But the group warns that obstetricians should be very sure if they induce labor in a woman who is not quite full-term that the fetal lungs are mature or that other tests show the fetus is developed enough to be born. Generally, this means the woman should be at least 39 weeks pregnant and that her cervix be “ripened,” that is, already be soft, flat and at least partially open.
The chief argument against elective induction of labor is that nature does such a brilliant job of orchestrating the delicate dance of chemical signals that cause the cervix to ripen and the uterus to begin contractions that it’s tough for mere mortals to do nearly as well.
One theory is that when the fetal brain is mature, notes Joyce Roberts, a nurse-midwife at Ohio State University, it sends signals to the fetal adrenal glands to secrete cortisol, a stress hormone. That in turn may trigger a shift in the placental metabolism of the two key hormones of pregnancy, estrogen and progesterone, so that estrogen begins to dominate. That, in turn, may make the uterus more capable of contracting.
Meanwhile, scientists believe, the fetal lungs secrete signals signaling that they are mature, along with enzymes that trigger the release of prostaglandins, which in turn tell the cervix to ripen and the uterus to contract. Oxytocin, made in the mother’s body, triggers further uterine contracts. (It is the natural hormone of labor on which Pitocin is modeled.)
“To push those mechanisms is foolish,” she says. “There’s an optimal timing” in nature’s method “and most of the time, it works out amazingly well.” When labor is induced “for no good reason, the fetus may not be optimally mature and the mother’s uterus may not be capable of good labor contractions.”
But some obstetricians argue that, when done carefully in the right patients, elective induction of labor can be safe.
“Personally, I think if the patient is well worked up in terms of the baby’s maturity” and if the cervix is ripe, ” I don’t think there’s anything wrong with it,” says Dr. Alan De Cherney, chairman of obstetrics and gynecology at the UCLA School of Medicine. “But you have to do it in the right people.”
A good candidate, he adds, is a woman who has had one previous vaginal delivery, whose cervix is ripe and who is likely to go into labor spontaneously in a few days anyway.
Dr. Lewis Rosenberg, of New Island Hospital, agrees. “You have to make sure there is adequate dating” of the pregnancy to be sure the woman is at least 39 weeks pregnant. By 39 weeks, the fetal lungs contain enough of a crucial substance called surfactant that they are reasonably mature, which means there’s less than 1 percent chance of respiratory problems. (For babies born at 36 weeks, the risk of respiratory distress syndrome is 5 percent, and it goes up steeply with shorter and shorter pregnancies.)
Some obstetricians start an elective induction by rupturing the membranes of the amniotic sac (what lay people call “breaking the waters”) with a small, blunt “amniotic hook.” Often, this starts spontaneous contractions. If it doesn’t, then Pitocin can be given, but once the waters are broken, the delivery should happen (by C-section, if necessary) within 24 hours because the risk of both maternal and fetal infection rises.
It is possible to artificially trigger an unripe cervix to ripen with drugs, chiefly, prostglandin gels. But a woman whose cervix was unripe to begin with has a higher risk of C-section than one who is induced with an already ripe cervix.
“If the cervix is ripe, the risk for C-section is probably low,” concedes Riley of MGH. “However, many people want elective induction with an unripe cervix or want drugs to ripen it. My personal opinion is that any form of intervention that is unnecessary is probably not in anybody’s best interest.”
But that doesn’t stop Riley’s patients from begging for induced labor anyway, even trying to bribe her with chocolates. “A tremendous number of people want an induction because they want to control everything. Most are control freaks…..I can completely relate because I am one of them. But I don’t do very many elective inductions. I refuse because of the risks.”
SIDEBAR
The American College of Obstetricians and Gynecologists recommends that labor be induced only if the doctor is sure that the fetal lungs are mature or that at least one of the following criteria of fetal maturity have been met:
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The fetal heartbeat has been documented for 20 weeks by a stethoscope or 30 weeks by a more sophisticated “Doppler” test of gestational age.
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It has been 36 weeks (or more) since reliable lab tests showed the presence on a blood or urine test to detect a hormone called HCG, or human chorionic gonadotropin, a sign of pregnancy.
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The fetus can be assumed to be at least 39 weeks old as judged by an ultrasound measurement of the length of the fetus from crown to rump, obtained at 6 to 12 weeks of pregnancy.
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An ultrasound taken at 13 to 20 weeks confirms a gestational age of 39 weeks determined by the doctor’s clinical impression and a physical exam.
It is also important, the doctors’ group says, that medical personnel carefully monitor uterine contractions stimulated by Pitocin because they can cause fetal distress and uterine rupture. And a recent paper in the New England Journal of Medicine suggests that inducing labor after a woman has had a previous C-section may lead to a higher incidence of uterine rupture.