Induction Decision

Want to schedule your baby's birth date? First you should consider whether it's worth the potential risks

In early June of this year, a Northern California mother-to-be faced a fiendish dilemma. Mindful that the Bible's Book of Revelation described 666 as the mark of the devil, she arranged to have her labor induced before June 6, lest her son be doomed to spend a lifetime responding "6-6-06" every time anyone asked him his birth date.

And for those who might roll their eyes and say "only in California," consider this: Earlier in the year, a Pittsburgh Steelers fan asked that her labor be induced to make sure she'd be able to watch the Super Bowl.

These anecdotes tell a larger story: the dramatic increase in induced labors in the United States. In 2003 (the most recent year for which we have national statistics), the incidence was 20.6 percent--more than double the 1990 rate. The increase is due, at least in part, to elective--non-medical--requests for induction, a procedure that's controversial even though the opportunity to choose when to give birth has practical implications beyond the oddball examples offered above. Mothers with young children at home, single moms hoping to arrange for support from visiting family members, women who live far from the hospital where they plan to give birth, working mothers with complicated schedules--all may benefit from a scheduled birth. But if performed too early, elective inductions are also linked to unplanned Cesarean sections or even the delivery of "near-term" infants with medical problems.

Why inductions are increasing There are two primary reasons for the rising induction rate, says Robert O. Atlas, M.D., chairman of the department of obstetrics and gynecology at Mercy Medical Center in Baltimore. "One is patient desire--when a woman doesn't want to go past her due date," he states. "This convenience factor applies to physicians as well," he adds. "As medical practices get larger, it is understandable when a woman wants to arrange for her delivery to be overseen by the physician she has come to know during her pregnancy, and not by a doctor who happens to be on call. And doctors themselves are often eager to be present at the birth after caring for a woman throughout her pregnancy."

The second major cause of induction is medical necessity, fueled largely by increasing obesity rates among pregnant women and the growing number of "older" mothers. Both groups are at greater risk for nonelective induction due to causes that include: • premature rupture of the membranes (aka the "water breaking") • preeclampsia (a potentially dangerous high blood pressure condition that requires the immediate delivery of the baby) • an infection inside the uterus • placental abruption (separation of the placenta from the abdominal wall) • diabetes or gestational diabetes, both of which are linked to large babies • an abnormal fetal heart-rate pattern • a postdate pregnancy (being one to two weeks past your due date) • a pregnancy with multiples

How early is too early? Recently, researchers reported that the most common length of a pregnancy in the United States has decreased from 40 to 39 weeks. Induction is one reason. "Some patients just do not want to wait for spontaneous labor to occur," says Carol Salerno, M.D., an OB-GYN at Northwest Hospital & Medical Center in Seattle. "But generally speaking, we would not do an elective induction prior to 39 weeks, the point at which we would anticipate fetal lung maturity. If there is a question that the fetus may be less than 39 weeks," Salerno adds, "we recommend an amniocentesis to check lung maturity prior to initiating an elective induction."

In cases of medical necessity, the decision to induce is often straightforward. But if a woman's cervix is not yet ripe--ready for labor--induction enters that "gray area" of concern to some physicians. A study of more than 41,000 births released this year by Sutter Health in Sacramento, Calif., showed "skyrocketing" C-section rates when elective inductions were performed on first-time mothers experiencing normal pregnancies or on those entering the hospital at the very start of their labor. The study indicated that risk for an unneeded C-section can be reduced if a woman is not admitted to the hospital until her cervix is at least 3 centimeters dilated.

Predicting a successful induction The likelihood that induction will lead to a desired vaginal delivery depends on a set of five readiness indicators you may hear your doctor refer to as a Bishop score. Cervical dilation (opening), effacement (thinning), softness or firmness and position, as well as the position of the baby in the pelvis, are each given a number. With some exceptions, the higher the total, the more "inducible" the patient; the lower the total, the greater the risk of C-section, the need for delivery with the aid of instruments such as forceps or vacuum, or a prolonged rupture of the membranes that might lead to intrauterine infection.

"Nowadays, with the availability of cervical-ripening agents and other techniques, a Bishop score greater than 6 is highly associated with a successful induction leading to a vaginal delivery," Atlas says. "Still, women should be aware that inducing labor without a specific medical indication poses the risk of additional interventions in the event that a baby is simply not ready for labor to commence."

If you're considering induction, ask your doctor about the pros and cons. "Become as educated as you can about the process, and try not to become too attached to having a certain type of experience," says Atlas. (See "What to Expect When You're Inducing," next page.) "Some women appear to believe that induction is easy, and it is not," he adds. "An induced labor may take anywhere from several hours to several days. The more a woman knows about induction if she is considering requesting one, the more satisfied she is likely to be with her decision."

What to expect when you're inducing Once the decision has been made to induce, the likely scenario is that you'll be hooked up to a fetal monitor and have an intravenous line placed to provide IV access for fluids throughout labor. A cervical-ripening agent (prostaglandin) will be inserted into your vagina or up into the cervix. If your cervix is already slightly dilated, your doctor may perform a procedure called sweeping the membranes--a vaginal exam that attempts to separate the amniotic sac from the lower uterus, stimulating the body to produce its own prostaglandins. A catheter might be inserted to mechanically dilate the cervix.

When your cervix has ripened sufficiently, your doctor is likely to administer oxytocin (Pitocin) intravenously to get your contractions under way. Many women who have experienced both an induced and a noninduced delivery say that the contractions associated with induced labor are more painful, requiring an epidural. While studies of whether an epidural slows down the labor process have been conflicting, the most recent ones indicate that it does not.