Healthy Birth Practice #1: Let Labor Begin on Its Own

Each month, the Science & Sensibility community will review one of Lamaze’s Six Healthy Birth Practices in sequential order.  Today, new S&S contributor Joni Nichols will discuss Healthy Birth Practice #1:  Let Labor Begin on Its Own.

Reviewing the very first recommendation of the Lamaze Six Healthy Birth Practices immediately brings to mind a popular refrain we use in Mexico,

“Del dicho al hecho hay mucho trecho!”

Literally this expression means that there is a pretty big space between “said” and “done” and is akin to the English expression “easier said than done.”

According to Dr. Wagner ( Born in the USA. 2006, p.39), “Federal studies that analyze birth certificates tell us that the percentage of U.S. births that happen Monday to Friday, nine to five, is rapidly increasing; even emergency c-sections are more common Monday to Friday, nine to five…”  This isn’t caused by global warming or the effects of the moon…we are looking at a procedure called Induction.

Rindfuss, Ladinsky, Coppock, Marshall, and  Macpherson’s Convenience and the Occurrence of Births: Induction of Labor in the United States and Canada used data for the United States and Canada on number of births by day of the week, for their paper in the International Journal of Health Service that pointed to indirect evidence for the widespread incidence of the practice of elective induction. For both the United States and Canada, it found that substantially fewer births occurred on Saturdays, Sundays, and holidays than on weekdays. Controlling for such factors as prenatal care, race, education, legitimacy, birth weight and time, trends strongly suggested that the induction of labor was responsible for the patterns found.

The National US Survey of Women’s Childbearing Experiences, Listening to Mothers I, reports that “almost half of all mothers reported that their caregiver tried to induce labor.” Even more telling:

“One-third of those mothers cited a non-medical factor as at least partially the reason for the attempted induction.”

As Gail Hart points out in her review of current research booklet, Research Updates for Midwives (2005), “If women are being induced for legitimate reasons of health and safety, then mortality and morbidity statistics should be improving.  Yet the statistics are quite flat. An induction and augmentation rate of over 35% has not seemed to improve the health of mothers or babies.”

So if a medical reason isn’t the rationale for this interference in the normal process of labor and birth what is?

NOW you know why this article is being written amidst the hectic activities of the holidays, because major holidays are prime time for inductions!!! Perhaps the caregiver is eager to have assurance that s/he will be able to enjoy the holiday without a call to come to the hospital or birth center.  Perhaps the birth facility is enthusiastic about scheduling fewer personnel for Thanksgiving, Christmas and Easter.  Perhaps the mother is eager to have the baby’s birthday before the holiday, thinking she can enjoy the day with a baby in arms or be assured of spending the holiday with her older children or extended family.  Perhaps she has a family member or friend only available to assist her in the days before the holiday but not during the holiday. Oftentimes she fears that her preferred healthcare provider won’t be available and will agree to a scheduled early delivery to guarantee that the desired provider will be available for the birth (a common concern of women utilizing group maternity health care practices—regardless of holiday proximity).

Considering that induction of labor brings with it some important risk factors, perhaps induction isn’t quite so seductive after all. Five of the documented risks include:

1)    abnormal fetal heart rate[1]

2)    baby being admitted to the neonatal intensive care unit (NICU)[2]

3)    use of forceps or vacuum extraction[3]

4)    prematurity, jaundice and breastfeeding difficulties[4]

5)    cesarean[1] [5],[6],[7]

Given these risks, the gauzy image of hearth and family and newborn at holiday time can look quite different.  Perhaps mother will be scuttling between home and hospital to care for her physiologically premature baby, or struggling with breastfeeding, or recovering from major surgery!

Many women whose experiences I read about in online forums for cesarean support, relay that they signed up for their inductions fully believing they were only hastening a fully developed baby’s arrival and report surprise, sadness,  regret and often guilt when their births ended in the OR.  Not surprisingly, their experiences are corroborated by research findings.

A retrospective study, conducted by 12 institutions participating in the Consortium on Safe Labor, examined electronic medical records associated with 228,668 births between 2002 and 2008 at 19 US hospitals. The overall purpose of the study was to assess contemporary labor and delivery practices.  This study offers some observations about why nearly one-third of all US births involve a cesarean delivery and suggests that induction plays a prominent role. Zhang and colleagues found evidence that physicians may be intervening too much and too soon. For example, the researchers found that 44% of women in the study population had their labor induced and that the cesarean delivery rate was twice as high for such women compared with those who had spontaneous labor (21.1% vs. 11.8%).  Additionally, when labor did not progress normally after induction, physicians were quick to perform a cesarean delivery, half the time initiating the procedure before a woman had dilated to 6 cm. “Our study does provide some clues that induction might play some role,” Zhang said. Coauthor S. Katherine Laughon, MD, a postdoctoral fellow at the National Institute of Child Health and Development suggested “more study is needed to determine when induction is clinically necessary and when it might be safe to wait and see if spontaneous labor occurs.”

Roger Freeman, MD, professor of obstetrics and gynecology at the University of California, Irvine, said the results of the Zhang study are consistent with previous studies which have suggested that the way labor is managed is contributing to the upward trend in number of cesarean deliveries performed. Freeman said that induction is clearly a contributor, and suggested that physicians avoid elective induction, which can elevate the rate of cesarean delivery and prolong labor without offering the potential benefits of clinically indicated induction.

“The single most positive thing you can do to prevent primary cesareans is to avoid elective induction of labor.”

On his blog for Frisco Women’s Health Care Jonathan R. Weinstein, MD, FACOG states “Induction has to be the biggest reason for the rise in [cesarean] rate in the United States, likely only second to your doctor’s fear of being sued despite trying to do the best thing for you and your family.  Elective induction can be convenient for both the mom and the doctor but buyer beware.  If your cervix is not ripe (dilated and thinned out) prior to an attempted induction of labor you have up to a 90% failure rate for your induction which usually translates to you getting a [cesarean section].”

Gail Hart succinctly chronicles the way even a “simple” uncomplicated induction can begin an avalanche of interventions.  “Beginning with the cervical stretching and sweep to “ripen” the cervix, then to IV Pitocin, electronic fetal monitoring and amniotomy, then perhaps an intrauterine pressure catheter, amnio-infusion for unusual fetal heart tones, an epidural for the pain of Pitocin-induced contractions, mal-rotation or poor descent for fetal distress. It goes on and on. The mother ends up with a lifelong injury to her uterus. Her baby may be stressed and separated from the family. A normal birth turns into a nightmare and that’s only if all goes well!”

Her conclusion is quite chilling: “If we start a labor with chemicals, we may very well have to finish it with the surgeon’s scalpel.”  This is hardly the scenario a mother imagines when she requests or concedes to the suggestion of nudging her baby out from the uterus to beat the holiday rush!

The chapter on Induction in the 3rd edition of A Guide to Effective Care in Pregnancy and Childbirth by Keirse, Neilson, Crowther,  Duley, Hodnett and Hofmeyr reminds us that,

“there is very little methodologically sound research on the indications for elective delivery.  Irrespective of whether the induction is for social/ elective purposes or is medically indicated, current and recent research focuses instead on HOW to achieve the induction rather than what constitutes the need for induction vs. cost-benefit analysis.”

If, given all these concerns over induction for both mother and baby, a woman still wishes to continue a dialogue about elective induction with her caregiver, then a comprehensive explanation of different induction methods ought to ensue.  These methods were nicely reviewed in a May 2003 American Family Physician journal article: Methods for Cervical Ripening and Induction of Labor” by Josie L Tenore, M.D., S.M.  Likewise, a similar fact sheet written from a midwife’s perspective provides similar content— found at Nicole Deelah’s Sage Beginnings.

Both resources mentioned above review the non-pharmacologic approaches to cervical ripening and labor induction such as herbal compounds, castor oil, hot baths, enemas, sexual intercourse, breast stimulation, acupuncture, acupressure, transcutaneous nerve stimulation, as well as mechanical and surgical modalities such as stripping of the membranes and amniotomy. Pharmacologic agents utilized for cervical ripening and labor induction include prostaglandins, misoprostol, mifepristone, relaxin and oxytocin (Pitocin).  Ms. Deelah’s information provides the “realities” of what each entails for the mother and its attendant risk for both her and her baby.

Both authors concur that in the absence of a ripe or “favorable” cervix, a successful vaginal birth is less likely. Therefore, cervical ripening or preparedness for induction needs to be assessed before any induction regimen is selected. Assessment is accomplished by calculating a Bishop score. In 1964, Bishop systematically evaluated a group of multiparous women for elective induction and developed a standardized cervical scoring system. The Bishop score helps delineate patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth.

No discussion of elective induction is complete without considering the impact on the baby. “Although we certainly understand that at 37 weeks many women are exhausted from pregnancy and feel they are ready to give birth, their baby is physically not ready,” says Cindy Fahey, MSN, RN, PHN, Executive Director, PAC/LAC. (Perinatal Advisory Council: Leadership, Advocacy and Consultation) “Inducing labor before 39 weeks, with no medical indication, is dangerous for the newborn, and has been clearly shown to lead to increased complications at birth and beyond. We strongly urge pregnant women who plan to be induced to wait until at least 39 [completed] weeks of pregnancy.”

The last few weeks of pregnancy are critical to both lung and brain development. Complications of elective deliveries between 37 and 39 weeks include:

  • Increased NICU admissions
  • Increased respiratory distress and TNN (transient tachypnea of the newborn)
  • Increased need for ventilator support
  • Increased rate of sepsis
  • Increased feeding problems

“We can’t state strongly enough that early induction without clear medical cause is not only unnecessary; it can be damaging to the baby’s health,” says Fahey. “We encourage women who are planning to be induced to discuss early induction and its associated risks with their physicians to ensure that they make the best choice for their baby.”

Cara Terreri recently shared some astute observations on Giving Birth With Confidence about how to avoid a trip down the road to avoidable prematurity and describes the “red flags” a woman may encounter that tip her off to her caregiver’s interest in proposing a medically unsubstantiated induction.

Yes, awaiting spontaneous labor can be inconvenient–but it also has many health advantages!   A Cochrane Pocketbook: Pregnancy and Childbirth which focuses on the effectiveness of interventions on the health and well-being of pregnant women and their babies derived from the Cochrane systematic reviews reminds us that “labor induction is considered when the benefits of earlier labor outweigh the risks of labor induction.”  Those of us who read the evidence behind the Lamaze Six Healthy Birth Practices perceive the benefits of waiting and the risks in inducing.  Those who have only perceived the purported benefits of induction while bemoaning the “risks” of staying pregnant a few days or weeks longer may discover that one of the best holiday gifts they can offer their baby, themselves and their family is permitting the baby to choose his or her own birthday.

Post by:  Joni Nichols BS MS CCE CD(DONA) (CBI)

[1] http://www.ajog.org/article/0002-9378(95)91415-3/abstract


[3] http://aje.oxfordjournals.org/content/153/2/103.full

[4] http://www.marchofdimes.com/pregnancy/vaginalbirth_inducing.html

[5] http://www.ncbi.nlm.nih.gov/pubmed/20027037

[6] http://www.aafp.org/afp/20000215/tips/39.html

[7] http://www.ncbi.nlm.nih.gov/pubmed/10511367

Healthy Care Practices, Practice Guidelines, Research , , , , , ,

  1. avatar
    Andrea Lythgoe
    December 27th, 2010 at 22:59 | #1

    Joni! So nice to see you as a contributor here. Looking forward to more.

  2. December 27th, 2010 at 23:56 | #2

    “If women are being induced for legitimate reasons of health and safety, then mortality and morbidity statistics should be improving.  Yet the statistics are quite flat.”

    That’s simply not true. The primary reason for induction is to prevent stillbirth, and stillbirth is not capture by neonatal mortality statistics. If induction provides benefits, it would show up in the stillbirth rate and the perinatal mortality rate (of which stillbirth is a component), Indeed, That is exactly what has happened. Late stillbirths have dropped by approximately 25%.

    In my judgment, medical procedures should be reserved for medical indications and social inductions should not be done. However, it is wrong to suggest that there are no benefits to induction (even social induction) and only risks. The two are not commensurate in any case. Yes, early induction increases transient tachypnea of the newborn and NICU admissions, but it decreases the rate of death in utero, which is far more important.

  3. avatar
    December 28th, 2010 at 08:41 | #3

    An appropriate follow-on article to this would be an exploration of indications so often offered these days as rock-solid proof that the baby “must come out”. Millions of women are walking around convinced of the medical necessity for their inductions for 41 weeks, a “big baby”, and the sneaky little (single, isolated) low fluid measurement. Duped, all of them.

  4. avatar
    gail hart
    December 28th, 2010 at 12:52 | #4

    There are clear medical reasons for induction of labor, and an appropriate induction can save the life of the baby, the mother or even both!
    There are times when the baby is not safe any longer inside the womb; or when the mother’s health is endangered by continuing the pregnancy. These are the reasons for necessary medical inductions.
    If there is enough time to spare the labor may be induced, but if the situation is urgent, the pregnancy should be ended by cesarean.
    I don’t think anyone could argue with this.
    But the un-necessary induction which causes the un-necessary cesarean harms mothers and their babies, raises the risk of birth for both of them, and increases medical expenses astronomically.
    Let’s do inductions for good reasons!
    Otherwise, let labor begin spontaneously to reduce the cesarean rate, and improve birth outcomes for both mother and baby.

  5. avatar
    gail hart
    December 28th, 2010 at 13:25 | #5

    In the last 30 years, the stillbirth rate – which includes Late Intra-Uterine Deaths – dropped almost 25%. But the steep drop has flattened. That drop was caused by the convergence of several changes in Obstetrics since 1980.
    The introduction of Fetal Surveilance Testing (non-stress tests, biophysical profiles, amniotic fluid level indexing, Fetal Movement Counting, Serial Ultrasound etc) allowed the identification of babies who were failing in the womb. Appropriate intervention saved those lives.

    The wide use of genetic testing and of abortion for abnormalities and lethal anomaly, removed those stillbirths from the statistics pool. Some lethal anomalies are now far less common than they were pre-1980. Probably the best-known example is neural tube defects. Anencephally and related defects are now rare due to prenatal screening (and perhaps folic acid supplements). But they used to be a factor in the IUFD and stillbirth statistics.

    Appropriate induction for maternal or fetal indications is life-saving.
    In-appropriate induction raises the ceserean rate and risks harm to mother and baby.
    I’m sure everyone can agree with that!
    even if people have differing emotions about the issue, the facts are clear.

  6. avatar
    December 28th, 2010 at 15:23 | #6

    Chiming in here though I’m not a professional in any capacity–

    I had my third child a month ago and she was induced. With my first two, I had gone late and I did not want an induction unless it was deemed absolutely medically necessary. This time around I was being delivered in a high-risk situation and the induction was necessary.

    However, the way that my doctor went about it was SO sensible. I wish that ALL doctors and caregivers who deliver babies had similar policies in place. While an induction was deemed most appropriate, my doctor was committed to NOT doing anything that would lock us in to ‘having to deliver.’ Breaking my bag of waters was strictly off the table unless my body had progressed to a point that we *knew* the labor was progressing. Pitocin was not started and would not be started until after my cervix favorably responded to two doses of Cervidil. And I was reassured over and over and over again that if the initial efforts (attempts to ripen the cervix) didn’t cause enough progress that I would be sent home and we’d try again later. Yes that’s exhausting and frustrating to all involved, but I knew that my doctor was doing her best not to start off the ‘cascade of interventions’ that I had been warned about by doulas in my first two pregnancies.

    It WAS medically necessary to induce me. And my induction was successful (though lengthy and painful!). But my doctor’s plan was designed with the mantra of ‘let’s not back ourselves into a corner in any aspect of this induction’ being repeated.

  7. avatar
    December 28th, 2010 at 15:57 | #7

    I feel blessed that I have had 7 babies without induction. I know I get anxious, and have had OB’s in the past who wanted to induce. With my 4th the doctor wanted to induce on her given edd…why on earth when I’d had 3 previously naturally? Then with #5 and #6 I was told I could induce so I could get a sitter. With #7 I told the doctor I didn’t want to induce and she said that was fine, but we may need to use pit to help labor along. I switched to a midwife, and that was one of the reasons. Why would a woman who has successfully birthed 6 vaginally without pit need pit to help labor along? I am just glad things worked out and when I was uneducated, I didn’t need it.

  8. December 28th, 2010 at 17:15 | #8

    @gail hart

    The stillbirth rate dropped far more than 25% in the past 30 years. Indeed, it dropped 29% in 1990-2003 alone. It held steady in 2004-2005, but we don’t yet know what has happened since than because the CDC has not updated its statistics.

    According to Fetal and Perinatal Mortality, United States, 2005, by MacDorman et al.:

    “The fetal mortality rate for 28 weeks of gestation or more declined by 29% from 1990–2003, but did not decline significantly from 2003–2005. In contrast, the fetal mortality rate for 20–27 weeks of gestation has changed little since 1990. Thus, nearly all the decline in fetal mortality from 1990 to 2003 was among fetal deaths of 28 weeks of gestation or more.”

    Late fetal deaths are associated with complications of pregnancy, postdates, etc. The decrease in stillbirth occured almost entirely among late fetal deaths. In contrast, early fetal deaths are associated with congenital anomalies and those did not decline. Therefore, your claim that prenatal testing is responsible for the decline in stillbirth is not supported by the scientific evidence.

    There is a lot of data to suggest that the bulk of the decrease in stillbirth comes from induction. Gestational age and birth weight have been declining, and stillbirth follows the same pattern, suggesting that induction is responsible for all three.

  9. avatar
    December 29th, 2010 at 11:10 | #9

    Still birth is one thing, newborn death is another. What are the stats for that?

  10. avatar
    December 29th, 2010 at 15:31 | #10

    What are the converse statistics- how many mothers and babies are we losing to complications of inductions, and cesareans resulting from failed inductions?

    We can’t consider one side without the other to determine a benefit or a detriment, in my mind. It’s not worth it to shift the scale and say we’re successful when on the other side we’re still losing mothers and babes (if that’s indeed true).

  11. December 29th, 2010 at 17:41 | #11

    And not just maternal or fetal/neonatal deaths, but also serious negative outcomes — for instance, a baby that lives, but has lifelong breathing problems related to being born too early. I’m not saying that there is a causation between the increase in inductions and the increase in things like autism, asthma, ADHD, childhood diabetes, etc., but we would have to rule out these things before we can just say, “a decrease in stillbirth is the only measure we should look at.”

  12. December 29th, 2010 at 20:12 | #12

    Plus a high rate of inductions leads to a high C/s rate, leading to a high *repeat* C/s rate, which can have catastrophic or deadly outcomes for mother and baby in the future.

  13. January 2nd, 2011 at 16:56 | #13

    Dr. Amy, medical reasons are not well-defined for the consumer. I would very much appreciate hearing in detail what constitutes a medical reason, the guidelines for defining each of those medical reasons, the guidelines for the protocol handling each of those medical reasons, any non-invasive alternatives to the protocols and the source for the answer to each of these items.

    I am not singling you out. It is only that induction as described here – cervical ripening methods and continuing on with pitocin, etc. – is medical and you are a doctor. If there are any other doctors on here I would like to hear their response as well.

    I am simply posing the question that any parent giving birth in the USA should be asking. I believe Joni’s original post was with respect to early inductions. You’ve posed induction for postdates. It sounds as though you are then proceeding to make death inutero equate with postdates – maybe you could also define what constitutes “postdate”. Perhaps, for the consumer reading this discussion, it would be helpful if you, Dr. Amy as the medical person here, could respond to my preceding paragraph for a more thorough discussion here.

    For example, you’ve stated gestational age and birthweight have been declining. The rates of induction include induction for postdates. Let’s start there because I can only therefore presume that you mean to say gestational age and weight somehow play a part in defining a medical reason for induction. What is the medical guideline of full-term? Please provide the evidence of what date constitutes full term and what is meant by full-term? Do you mean to suggest that induction to limit the gestational age and birthweight is a medical reason for induction? If so, please state clearly the benefits for doing this.

    Joni’s position that spontaneous labor does not carry a high risk of cesarean will include a range of gestational age and birthweight among its outcomes – for anyone new to Joni, her observational experiences come from being present at hundreds of births in a free standing birth center. I would not want anyone to make the presumption that this discussion is by two extremes, but rather by two positions coming from two individuals who have been present for births. I cannot testify as to how many births Dr. Amy has been present for, but I do know of Joni’s experiences. Gail Hart is well known to me via a third party, so I don’t mean you any disrespect Gail – I agree with your post and the information you provided. Just being clear and up front that I do know Joni, full disclosure.

    Your position, Dr. Amy, is for a controlled environment. I do wish to see the full definition of that controlled environment and then the context of c/s rate for that controlled environment (per the questions posed by other readers here).


  14. January 3rd, 2011 at 13:48 | #14

    @ Dale:

    Thank you for chiming in and requesting more in-depth definitions amidst this conversation. I think many readers will benefit from the responses heretofore.

    In the form of a quick answer to one of your questions, the generally accepted definition of “term” pregnancy, per the World Health Organization, is between 37 completed weeks of pregnancy – 41 completed weeks. These numbers are based on the woman’s first day of her last menstrual period (and assuming she previously maintained a “regular” menstrual cycle with ovulation occurring on or around day 14…obviously not true for many women). Due to the four week interval represented in this time frame, my personal belief is that in-depth assessment of mother readiness and fetal maturity must be pursued before inducing for non- or soft-medical reasons prior to 41 completed weeks. Likewise, I believe it prudent to pour more research efforts into determining the various causes of late pregnancy fetal demise and, hopefully, ways to prevent/eliminate these, v.s. employing a blanket approach to widely inducing at some arbitrarily selected gestational date, “just in case.”

    An additional, interesting commentary on this topic can be found here: http://www.lamaze.org/Research/WhenResearchisFlawed/PosttermPregnancyCochrane/tabid/173/Default.aspx

    Also, a recent study published in The Green Journal looked at the ramifications of inducing “early term” pregnancies. Abstract can be viewed here:http://www.ncbi.nlm.nih.gov/pubmed/20567179

    On another note, and less as an argument / more a clarification, I find it important to point out to the entire S&S community that Amy Tuteur does not represent the only “medical person here.”

    In fact, many of the Science & Sensibility writers and readers boast medical backgrounds of one form or another. The varied backgrounds we bring to the table–doctors, nurses, physician assistants, physical therapists, (nurse)midwives, doulas, childbirth educators, researchers, parents–whether through penning original posts or commenting on the posts written by others, provide the strength of the dialogue contained herein. However, as Dale points out, it would be extremely helpful to encourage the addition of other MD voices–providing a more representative balance to that segment of our readers/writers.

  15. January 3rd, 2011 at 14:53 | #15

    I think this information is so important for expecting moms to know. Choosing to be induced is a big choice and having a good understanding of the pros and cons is the best way to make the right choice.

    I have made a video covering the pros and cons which I share for free to interested moms. http://www.enjoybirth.com/kno-induction.html

  16. January 4th, 2011 at 00:55 | #16

    Thanks for sharing a link to the video! Nice resource to share with expectant parents.

  17. January 13th, 2011 at 23:18 | #17

    An article from the Texas Tribune regarding this very same topic–and a hospital that banned elective inductions, altogether:

  18. January 23rd, 2011 at 12:03 | #18

    Evidence that IF induction IS offered that enough TIME is provided!

    Obstet Gynecol. 2011 Feb;117(2, Part 1):267-272. Failed Labor Induction:
    Toward an Objective Diagnosis.

    Rouse DJ, Weiner SJ, Bloom SL, Varner MW, Spong CY, Ramin SM, Caritis SN,
    Grobman WA, Sorokin Y, Sciscione A, Carpenter MW, Mercer BM, Thorp JM Jr,
    Malone FD, Harper M, Iams JD, Anderson GD; for the Eunice Kennedy Shriver
    National Institute of Child Health and Human Development (NICHD)
    Maternal-Fetal Medicine Units Network (MFMU).

    From the Department of Obstetrics and Gynecology at the University of
    Alabama at Birmingham, Birmingham, Alabama; University of Texas Southwestern
    Medical Center, Dallas, Texas; University of Utah, Salt Lake City, Utah; The
    University of Texas Health Science Center at Houston, Houston, Texas;
    University of Pittsburgh, Pittsburgh, Pennsylvania; Northwestern University,
    Chicago, Illinois; Wayne State University, Detroit, Michigan; Drexel
    University, Philadelphia, Pennsylvania; Brown University, Providence, Rhode
    Island; Case Western Reserve University-MetroHealth Medical Center,
    Cleveland, Ohio; University of North Carolina at Chapel Hill, Chapel Hill,
    NC; Columbia University, New York, NY; Wake Forest University Health
    Sciences, Winston-Salem, North Carolina; The Ohio State University,
    Columbus, Ohio; the University of Texas Medical Branch, Galveston, Texas;
    and The George Washington University Biostatistics Center, Washington, DC,
    and the Eunice Kennedy Shriver National Institute of Child Health and Human
    Development, Bethesda, Maryland.


    OBJECTIVE: To evaluate maternal and perinatal outcomes in women undergoing
    labor induction with an unfavorable cervix according to duration of oxytocin
    administration in the latent phase of labor after ruptured membranes.

    METHODS: This was a secondary analysis of a randomized multicenter trial in
    which all cervical examinations from admission were recorded. Inclusion
    criteria: nulliparas at or beyond 36 weeks of gestation undergoing induction
    with a cervix of 2 cm or less dilated and less than completely effaced. The
    latent phase of labor was defined as ending at a cervical dilation of 4 cm
    and effacement of at least 90%, or at a cervical dilation of 5 cm regardless
    of effacement.

    RESULTS: A total of 1,347 women were analyzed. The overall vaginal delivery
    rate was 63.2%. Most women had exited the latent phase after 6 hours of
    oxytocin and membrane rupture (n=939; 69.7%); only 5% remained in the latent
    phase after 12 hours. The longer the latent phase, the lower the vaginal
    delivery rate. Even so, 39.4% of the 71 women who remained in the latent
    phase after 12 hours of oxytocin and membrane rupture were delivered
    vaginally. Chorioamnionitis, endometritis, or both, and uterine atony were
    the only maternal adverse outcomes related to latent-phase duration:
    adjusted odds ratios (95% confidence intervals) of 1.12 (1.07, 1.17) and
    1.13 (1.06, 1.19), respectively, for each additional hour. Neonatal outcomes
    were not related to latent-phase duration.

    CONCLUSION: Almost 40% of the women who remained in the latent phase after
    12 hours of oxytocin and membrane rupture were delivered vaginally.
    Therefore, it is reasonable to avoid deeming labor induction a failure in
    the latent phase until oxytocin has been administered for at least 12 hours
    after membrane rupture.


    PMID: 21252738

  19. January 27th, 2011 at 21:35 | #19

    If you’re referring to sweeping the membranes (sweeping/pushing the amniotic sac away from the internal cervical os (opening)–many consider this a “soft” form of induction as it often results in a responsive release of hormones that can prompt the onset of uterine contractions.

  20. May 21st, 2011 at 13:06 | #20

    Newest issue of “Birth: Issues in Perinatal Care” has an article about women’s “initiative” in trying to induce their labors.


  1. December 28th, 2010 at 03:09 | #1
  2. December 28th, 2010 at 03:09 | #2
  3. December 29th, 2010 at 17:19 | #3
  4. January 17th, 2011 at 17:32 | #4
  5. January 27th, 2011 at 18:30 | #5
  6. August 9th, 2011 at 03:05 | #6
  7. September 26th, 2011 at 01:02 | #7
  8. June 5th, 2012 at 16:36 | #8