Being Seduced to Induce: What Women Should Know About Their OBs

Being Seduced to Induce: What Women Should Know About Their OBs

By Marsden Wagner M.D.

Women will only agree to caesarean section if they are convinced it is safe for them and their baby. One of the first efforts of obstetricians promoting caesarean section has been to take the scientific evidence on risks of caesarean section and torture the data until it confesses to what they want it to say.

One example: Obstetric hype in popular and professional magazines says research shows 60% of women who have vaginal birth have urinary and faecal incontinence. But a careful reading of the research papers they refer to reveals something very different. The hype lumps all women with vaginal birth together instead of doing what the researchers did - dividing them into risk groups. When analysis of risk was done, they found that women at high risk for urinary and faecal incontinence have had large numbers of births; have had babies weighing over ten pounds at birth; and most importantly, have been the victims of unnecessary, aggressive obstetric interventions during their labour and birth.

What are these aggressive, invasive obstetric interventions that have been proven scientifically to cause permanent damage to the pelvic floor and urinary tract and also lead to more otherwise unnecessary caesarean section? One example is the use of powerful and dangerous drugs to start or accelerate labour, a practice that has doubled during the past 10 years. These drugs make labour abnormal with violent contractions that can damage the uterus and pelvic floor. The only reason women agree to such induction is because they are not told the truth about the drugs, for example that Pitocin (oxytocin), a drug used for decades to induce labour, doubles the chance the woman will have urinary incontinence in the future. By withholding such facts doctors seduce to induce.

Induction with drugs is not the only aggressive, invasive intervention that is frequently used in vaginal birth and is associated with damage to the urinary system, pelvic floor and rectal areas. Episiotomy has been scientifically shown to result in more pelvic floor damage than a natural tear. When an effort was made in the 1980s to reduce caesarean section in the United States, the rate of using forceps or vacuum extractor to pull the baby out went up some doctors just can't stop doing invasive interventions. And there is good data that using forceps or vacuum to pull the baby out has more risk of pelvic floor damage than any other form of birth.

Obstetricians have turned birth into a surgical procedure and done damage to women's bodies and now suggest the solution is to promote yet even more radical and aggressive surgery; caesarean section. The solution is less unnecessary invasive surgical procedures during birth, not more.

[Re: the Midwifery Today E-News article, Issue 3:23]: The two obstetricians tried to say that vaginal birth can damage a woman, but they never pointed out the ways in which caesarean section can do harm not only to the woman but to the baby as well. The following excerpt from my article 'Choosing Caesarean Section' in The Lancet of November 11, 2000, reviews some of the dangers associated with caesarean section, the alternative to vaginal birth that some doctors are trying to promote:

?In addition to the increased risk the woman will die with an elective caesarean section, there are other risks for the woman including the usual morbidity associated with any major abdominal surgical procedure/anaesthesia accidents, damage to blood vessels, accidental extension of the uterine incision, damage to the urinary bladder and other abdominal organs.1 Some of these risks are common: 20% of women develop fever after caesarean section, most due to iatrogenic infections requiring diagnostic fever evaluation for both woman and baby.1



There are also risks women carry to subsequent pregnancies due to scarring of the uterus including decreased fertility, increased miscarriage, increased ectopic pregnancy, increased placenta abruptio, increased placenta previa.1,2, 3 Recently in the United States the widespread use of the unapproved drug misoprostol (Cytotec) for labour induction has created a new risk of caesarean section in subsequent pregnancies. Women attempting VBAC (Vaginal Birth After Ceasarean) who are given misoprostol have a rate of uterine rupture of 5.6% compared with a rupture rate of 0.2% for women attempting VBAC not given misoprostol, a 28-fold increase in risk of uterine rupture.4 For women choosing caesarean section, all of these risks exist in all of their subsequent pregnancies even if the original caesarean section was not an emergency. The increased risks of ectopic pregnancy, abruptio placenta, placenta previa and ruptured uterus are all life threatening to both woman and baby.

For whatever reasons women choose caesarean section, very few are clearly informed about foetal risks. In an emergency caesarean section where the baby has developed a problem during the labour, the risks to the baby of doing the caesarean section will likely be outweighed by the risks to the baby of not doing it. In an elective caesarean section where the baby is not in trouble, the risks to the baby from doing a caesarean section still exist, meaning the woman who chooses caesarean section puts her baby in unnecessary danger. That some women are choosing caesarean section strongly suggests women are not told these scientific facts.

The first danger to the baby during caesarean section is the 1.9% chance the surgeon's knife will accidentally lacerate the foetus (6.0% when there is a non-vertex foetal position). (5) Obstetricians may be less aware of this risk - in one study only one of the 17 documented foetal lacerations was recorded by the obstetrician doing the surgery.5 A much more serious risk to babies born by caesarean section is respiratory distress. Many reports in the scientific literature document the caesarean section procedure per se is a potent risk factor for respiratory distress syndrome (RDS) in preterm infants and for other forms of respiratory distress in mature infants.1 RDS is a major cause of neonatal mortality. The risk of newborn RDS is greatly reduced if the woman is allowed to go into labour prior to the caesarean section. Another serious risk to the baby born by caesarean section is iatrogenic prematurity (the baby is premature because the caesarean section was performed too early). Even with repeated ultrasound scans, the standard deviation for estimating gestational age is large, creating errors in judging when to do an elective caesarean section. Doing the elective caesarean section after the woman goes into spontaneous labour would markedly reduce this risk as well. A vast literature documents the increased mortality and morbidity, including neurological disability, associated with premature birth.

So beware. Surgeons try to sell surgery. Never forget that obstetricians are, after all, surgeons. Women must be extremely cautious in the face of this hard sell and get the facts from those who do not have a vested interest in surgery.


Thanks to Leila McCracken and birthlove.com

For more about Dr. Wagner.

1. Wagner M, 1994. Pursuing the Birth Machine: The Search for Appropriate Birth Technology, Sydney, Australia: ACE Graphics.
2. Enkin M, Keirse M, Renfrew M, Neilson J, 1995. A Guide to Effective Care in Pregnancy and Childbirth, 2nd ed, Oxford University Press.
3. Goer, H, 1999. The Thinking Woman?s Guide to a Better Birth. Putnam, New York: Penguin.
4. Plaut M, Schwartz M, Lubarsky S, 1999. ?Uterine rupture associated with the use of misoprostol in the gravid patient with a previous caesarean section,? Am J Obstet Gyn 180:1535-42.
5. Smith J, Hernandez C, Wax J, 1997. ?Fetal laceration injury at cesarean delivery,? Obstet & Gynecol 90:344-6.


First published in byronchild/Kindred, issue 1, March 02

*bump*

Love the article.

However, one of the last sentences: "surgeons try to sell surgery" might be true in many cases. Maybe even in most. But there certainly are exceptions. A conscientious surgeon will not sell surgery. My father is a surgeon, yet, he is forever talking people OUT of surgery. He is of the opinion that surgery is great when needed, but it ALWAYS carries risks so the need for the surgery needs to be quite high to outweigh these risks. He and his colleague, an anaesthetist, were urging me to avoid interventions and epidurals (not that I wanted them) unless really necessary.
So there certainly are doctors that have their patients health and best interest at heart, not their bank account.

I guess with an ob it's more about how good they are as an ob generally, or whether they specialise in the surgical elements of obstetrics. There are certainly obs who don't push intervention, but that's like saying there are drs who take a holistic approach to their practice of medicine. It's not the norm.

Thanks for posting, enjoyed reading it

Hi Kelly,

Thanks for posting this. I came across this website about two weeks ago when I was 40 weeks. It was completely perfect timing as I was really quite ignorant about all things induction and intervention.

Reading this article encouraged me to spend a good 20+ hours looking into induction and intervention risks versus benefits.

I am 42 weeks tomorrow and baby still hasn't arrived yet. I'm being checked daily at my local public hospital, getting CTG scans and Amniotic Fluid Index level checks. The Doctors and Midwives tell me my AFI levels and baby's heartbeat are all good.

Despite this, since my 41 week check up I've been pressured into being induced.

At my 41 week CTG/ATI test, after saying that the baby had a good heartbeat and a relatively normal (considering gestation age) ATI level the Midwife said...

"Look, everything appears to be okay so it's not urgent but we'll get you in for induction tomorrow".


I turned to my husband and said, "Well honey, I guess we're having the baby tomorrow" (sarcastically)

I then went on to explain to the Midwife and Doctor that I did not want to induce the baby and that I'd see them at my next appointment.

They appeared rather shocked that I wouldn't agree to induce and I spent a good five minutes justifying my position.

My next appointment was at 41 +3 days and was again pressured into an induction. Again, I told the Midwife I wasn't interested. She then said I would have to come back every day until the baby came (naturally) to get the CTG and ATI tests done. I agreed.

The next day, this Midwife was considerably rude to me and actually said out loud that I would have to wait to get my tests done despite the fact I was the first person there at 8am in the outpatients clinic. My husband overheard her saying this whilst pushing my report form to the bottom of the pile.

Absolutely incredible... all because I told her I wouldn't do what she wanted (induction).

My appointment today lasted 2.5 hours.

I was hooked up to the CTG for 1.5 hours and then had to see a Doctor who again... tried to persuade me to induce.

So... my husband and I are incredibly tested atm. We have the 42 week appt tomorrow and no doubt they'll try yet again to book me in for induction.

I'd appreciate any links to testimonies from women who have had babies naturally without induction past the 42 week mark.



It will confirm in my mind that childbirth is natural.


Thanks again.

Hi Francoise,
My first I was induced at 42 weeks. Second time round I went with midwifery care - we fully expected to have a long pregnancy again adn wanted less pressure.
Well, at 42+1 I decided to have a stretch & sweep, which my midwife performed at my house. (so technically I did have some intervention to bring on labour, but not a full inductino)

We discussed things previously and I decided I would go in for monitoring at around 42 weeks (and likewise would not consider an S&S till then).
So I went to the hospital at 42+2 and everything looked fine. The doc said induction. We said not unless there's a medical reason.
He was very taken aback by this and got a bit flustered! Kept insisting that just because things looked ok now, didn't mean they would still be ok later (of course, I realise that!) and that, well, it's hospital policy (NOT a good enough reason for me!).
Well, as it turned out, labour started that afternoon and she was born the following evening.

It sseems quite a few medical practitioners in maternity care think it's their responsibility to make all decisions etc - and they really get bent out of shape if you try to take responsibility for yourself (as is quite right, in my opinion, since it's your body on the line and your baby!).

The same doctor who was so insistent that we should induce - because it's hospital policy and all - was really good after the birth. I had a PPh and he came in and explained all the options, including all the risks and benefits of each, and gave his recommendation and then encouraged me to think about it and let him know what I wanted. Wow - so once the baby's out I'm suddenly capable of making rational decisions, hey?

Anyway - I hope your baby decides to make his or her appearance very soon and you have a beautiful birth!

Francoise sending you much strength!

Francoise sending you much strength!

Me too. Waging war against induction is the last thing you need at 42 weeks. I gave up the fight after 12 days, but managed to beat a full blown induction. I wish I'd fought harder, but didn't have it in me.

So, yeah, strength!

Thanks for your replies ladies.

MadB, it is encouraging to hear that you got to 42+3 weeks and had a healthy baby. Really encouraging.

We just had our hospital check up and my Amniotic Fluid Index level came back at 4cm.

Yesterday it was 6.4cm

The day before it was 5.7cm

The day before that it was 6.9cm.


After the check up my husband and I went for our Doctor appointment and met with the 'Senior Doctor'.

He actually introduced himself as the Boss. haha.

He said that the reason he needed to talk with us was to ensure we were aware of the risks with prolonging the pregnancy further and declining induction.


He told us that basically the Amniotic Fluid Index level indicates that if we don't induce, there is a 1 in 100 chance the placenta could stop working and baby will die. He then said that even if we chose to induce at this stage, the increase in a need for a C-section is greater and induction could cause more complications.


So, my husband and I feel like we're at a crossroads.

We're going back tomorrow for another CTG and Amniotic Fluid test and will see how we go from there.


We really just want to stick it out and hope that baby comes soon and isn't that 1 in 100.

MadB - do you remember what your Amniotic Fluid Levels were around the 42 week mark?



Thanks heaps...

feeling a little pushed into a corner atm.


We have a lot of thinking to do.

xx

They didn't tell me, only that it was ok. Same first time round as well (also got checked around around 41 weeks).
Keeping an eye on things is a good idea, but sometimes all the extra information is just that, information. At the end of the day you have to go with what you feel is right. It is hard, we don't know what's going to happen. It's just really important to make decisions that you're comfortable with - you have to live with them after all.

If they're giving you statistics adn such like, you could ask where they came from and what research/evidence they're basing their recommendations on.

I know several people who have birthed at 42-43+ weeks with no issues (my mother included). It's just very unusual here as most women are made to induce.
There are risks. There always are. I do not mean to be flippant about it at all, but it's something we all have to face.

I don't know if any of this helps you make a decision - probably not - but it is your decision to make. I hope your baby takes the choice out of your hands very soon! Just by the by, have you been having sex and bouncing on fit balls and things like that?

I know this is an old thread, but throwing my comment in as we are currently experiencing something similar! 41+4 today. Trying to avoid induction desperately. At 41+2 went into hospital for monitoring and had AFI levels of 9; they said that they'd be happy with a 5.

My opinion is that at 41+4 you should be starting to think about getting induced. I know others on here will oppose this, but my first ds was born at 42 and weighed 5kg. I am still having complications from that birth nearly 7 years ago. I have just got out of hospital from having a repair surgery. Just my honest opinion. If I was you I would be starting to work out a plan with your health provider.

Ginger - I don't completely disagree with you, because at 41+3, we discussed induction and booked a date (42+2). Mainly because I felt like I needed an 'end' date for my sanity, although I hoped to go naturally before then.

However, I ended up giving birth at 41+6... Baby was 3.5kgs and it was a very smooth and natural 2.5 hour labour.

I understand that you have had a difficult experience, but that doesn't mean everyone will. There can be negative implications as a result of being induced also.

My opinion is that women have the right to make decisions about their bodies. Medical practitioners are obliged to give clinical advice, including the risks and benefits of all options, and then do what they're asked to do.
There are no absolutes. There are always risks. Those risks are ours to bear. You can never know what things might have been like if you'd done it differently, you can only guess. Confidence in yourself, the information you've been given and your carers will reduce the likelihood of regrets later on.

Statistically speaking, the normal gestation for first time mums is more like 41+ weeks, not 40, anyway.

I feel very conflicted about this topic. My DD1 was born after a long & extremely horrible induction, @ supposedly 42 weeks (by my dates 42 +4). Her head circumference was quite large & i had pretty bad tearing, at the time someone made a comment about her skull being less flexible (?). She had the cord twice around her neck, an arm and a leg. She was born with no fluff, none of the greasy stuff, She weighed less than her head size & length would suggest - so I guess those are all signs that she was over cooked. The placenta was on its last legs & when they broke the membrane no fluid came out (!!!). When she was finally born (which was kind of a rush because she was pretty distressed by then) her first apgar was low, and she was sleepy for a long time. She now has a number of attentional deficits & I wonder sometimes what degree of oxygen deprivation she had at that time.

The actual induction was poorly managed & I was quite traumatized by the experience. But here's the thing (and why I feel conflicted) - I cannot for the life of me understand how I could have birthed her 'naturally' any further past that date. I had been having strong runs of extremely painful contractions for 5 weeks by that point, I'd done all the walking, pineapple eating, nipple tweaking sex possible & there was no signs of my cervix budging. I was big on reiki, meditation, visualization, etc - so it's not like I was sitting on a big psychological block either. And given how she had already started to shrink & dry out, and the tattered state of the placenta, how much longer would have been safe? I don't think I really understood how long the pregnancy was and what impact that had until I had DD2 who was born by CS after 37 weeks, who was chubby and furry and in proportion and full of life and vigour. So while I'm not a fan of early induction, my own experience is that there is a point in the gestation after which things get a whole lot more difficult for both mother & baby.

ETA
However that point is extremely difficult to assess, partly because there is such a wide variation in 'normal' gestation. I know women who were induced earlier & more gently than I was and who had pretty decent birth experiences. On the other hand I also know of at least one home birthing mumma who happily went past that date & birthed a not-overcooked-at-all baby peacefully and without intervention. But there are also women whose babies die at the end of long pregnancies. Certainly, better analysis of more detailed statistics might shed light on where the sweet spot lies between the benefits of waiting versus the risks - but I'm not sure that we even have the right science to measure it with any accuracy. I suspect there are specific bio markers that haven't been identified yet. Until that happens, it remains guess work, and it really comes down to the care provider's general level of compassion & involvement of women in decision making that makes the most difference.

Totally agree that there are no absolutes. In retrospect, however, I would not have waited so long to be induced with ds1. I was induced at 40+1 with ds2 and that was a much better birth for me. Again, just my personal experience. If I was to have a baby again, I would ask for an induction just past the 40 wk mark again.

I guess that's the thing, sometimes the system doesn't work right. We know this because sometimes we lose babies and this, ultimately, is why we have these interventions in the first place. The point for me is that we all need information and support, and importantly respect, to make decisions that concern our bodies. We can't know everything and we can't always get it right, but we have to try and do the right thing as we see it in that moment. It's on us in the end, not the doctor or the midwife - though obviously it's distressing for them, also, to lose babies and even mothers, and naturally they wish to avoid this - so it's our responsibility to make these decisions.
I had what I believe to be an unnecessary induction at around 42 weeks which was very distressing. The reason given by the OB was that otherwise my baby will die. Second time round I birthed at 42+3 and again the (different) OB wanted me to be induced, despite the fact that I was already in early labour (he didn't believe me, what would I know?). The reason he gave was lame beyond belief: hospital policy.
Nobody ever mentioned the risks of the induction to me and my baby. Nobody gave me good reasons to have the induction, either, aside from the fear of a negative outcome. This is not a context conducive to good decision making.