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Induction to Avoid Cesarean for Large Babies

By Danell Swim

Recently I’ve heard from several women that they will be inducing labor before their due date, or shortly afterwards, to decrease the likelihood of a cesarean section surgery. The theory is that by forcing the baby out sooner, it will be smaller and more able to pass through the pelvis. Macrosomic (any baby more than 8.8 lbs) babies are thought to need extra help to get out of the womb. But evidence illustrates a far different outcome than the one they’ve envisioned.

How is induction of labor achieved?

There are several ways to induce labor, and typically several methods are used conjointly to facilitate a speedier labor and delivery.

Stripping the Membranes can be done in the doctors office, and can sometimes bring on labor. It is done like a vaginal exam, except that the examiner uses fingers to separate the cervix from the bag of waters. It can be very uncomfortable, and can cause bleeding and irregular contractions. There is some fear that the amniotic sac can be broken during the exam, which puts mother and baby at further risk of infection.

Sometimes an amniotomy (artificially breaking the bag of waters) is done along with a dose of Pitocin, the synthetic version of the naturally occurring hormone Oxytocin. This has been used with some success. However, amniotomy raises the risks of a prolapsed umbilical cord, as well as infection. And Pitocin can increase the strength and pain of contractions, as well as lead to other complications like uterine rupture (particularly if the woman has had a previous cesarean section).

Cytotec can be used, but is strictly prohibited from use as a means for induction by the manufacturer. It is a pill taken orally, or placed on the cervix to begin contractions. And it is effective, but the possible complications are too numerous to make it safe. Those complications include uterine rupture, hysterectomy, amniotic fluid embolism, retained placenta, shock and maternal and fetal death.

Cervidil has fewer complications, and has shown to be fairly successful at inducing labor. It is a tampon-like insert that rests next to the cervix to soften and ‘ripen’ it. There are still risks involved, including more painful contractions, uterine hyperstimulation and fetal distress. It is often used with Pitocin.

What does the evidence show?

One study from the University of Cincinnati College found that elective induction of labor for macrosomia (estimated fetal weight more than 4000g at birth) was shown to increase the incidence of cesarean delivery (from 31% to 57%), and increase the incidence of shoulder dystocia (5.3% to 2.5%)—a potentially life threatening complication.

In a study from Women’s Healthcare Associates and the Providence Health System, first time mothers were induced at term, and placed into three categories: induction with a bishop’s score greater than 5, induction with a bishop’s score less than 5, and spontaneous labor. The cesarean rates for those groups were 18.5%, 31.5% and 11.5%, respectively.

A Bishop’s Score is sometimes used to calculate the odds of a successful induction of labor.

Cervix	Points Awarded
	0	1	2	3
Position	Posterior	Midposition	Anterior
Consistency	Firm	Medium	Soft
Effacement	0-30	40-50	60-70	>80
Dilation	Closed	1-2	3-4	>5
Baby’s Station	-3	-2	-1	+1, +2

Points are awarded according to the previous exams findings. A score of 9 or greater is considered ideal for induction, with anything less than that considered unfavorable to induction. So if you are dilated to 2 you would have 1 point; baby’s station is -3 you get no points, soft cervix is 2 points, etc.

More notably, the Soroka University Medical Center conducted a study among 4,755 women who delivered macrosomic newborns in their institution. 20% of these women had labor induced, while 80% went into spontaneous labor. Of the women with induced labor, 17.8% resulted in cesareans, versus 11.9% in the second group. Even after controlling for other complications, there continued to be a significant association between induction of labor and cesarean surgery.

So why is it that women are signing up for these inductions?

I’ve personally talked to dozens of women whose doctors give them the option of labor induction simply because they have an opening in their schedule. Gestation, bishop’s score and possible complications are not discussed, as anything beyond 37 weeks is considered “term,” and bishop’s score is considered irrelevant. Yet despite the overwhelming evidence that labor induction more often leads to cesarean, it is not mentioned by the doctor as a possible complication. Neither are uterine rupture, fetal distress or uterine hyperstimulation.

When no complication risks are discussed, and the induction is said to be to protect the integrity of the birth, it is hard to say no to a convenient, scheduled birth.

Despite the increased media attention on elective primary cesareans, few women go into their third trimester expecting, or desiring a cesarean without good reason. It is major surgery with all the bells and whistles one would expect. This is what makes it so enticing when doctors discuss induction for fetal macrosomia; after all, the induction is supposed to protect against the risk of cesarean section, not lead to it.

On a personal note, a niece-in-law of mine recently elected to be induced because her doctor warned her that her baby would be large. And so at 39 weeks gestation, she went into the hospital for an induction. Four days later, she left with a cesarean scar after her labor failed to progress, and a healthy 8 lb baby (not macrosomic).

Why do doctors tell patients to consent to a labor induction to decrease the odds of a cesarean?

It baffles the mind, because studies continually reveal that labor induction more commonly leads to cesarean section, even in those instances when the mother is carrying a large fetus.

More than 1 in 5 pregnancies are induced, according to the Centers for Disease Control, and for various reasons. Third trimester ultrasounds are becoming more common, which lead to increased diagnoses of complications that may necessitate a labor induction; such as oligohydramnios (too little amniotic fluid), hydramnios (too much amniotic fluid), suspected fetal distress and, of course, fetal macrosomia. This partially explains the increased number of inductions, but the reasons go further.

The convenience aspect seems to be a large factor in the rate of inductions. Doctors are finding it easier to simply schedule the births to fit into their busy calendar rather than wait for spontaneous labor to arrive. This is often considered to be another explanation for the increase in the rate of elective cesareans, as well.

Are doctors unaware of the medical studies that have found inductions for fetal macrosomia lead to cesareans? It seems unlikely, given the ease with which the information can be found. Just google “induction, macrosomia and cesarean risk”, and you’ll find a plethora of studies and information that shows that it is just flat not a good idea. Not to mention that they must have seen in their own practices that those patients they send for induction more often leave the hospital with a scar on their abdomen than those whose labors are spontaneous.

Even the American College of Obstetricians and Gynecologists recommend spontaneous labor for suspected fetal macrosomia, and they are one of the more interventionist-happy institutions in this country. Yet their own members persist in recommendating induction for large babies, contrary to the evidence, advice and data that shows it to lead to cesareans.

What should I do if my doctor tells me to induce for a large baby?

Ask them for the evidence that shows that induction for fetal macrosomia reduces the rates of cesareans. They may feed you a line about shoulder dystocia being a concern, and while it is true that half of all cases of shoulder dystocia occur with macrosomic babies, it still happens in less than 1% of births. However, when induction of labor is used with large babies, the risk of shoulder dystocia increases 3-fold.

Induction, like any medical procedure, can not be done without the patient’s consent. Ask your doctor how they feel about not inducing, and try to be reasonable with them. If the doctor insists that induction is necessary to avoid cesarean with a large baby, ask to see further evidence that disproves what you already know (from the references listed in this article).

Typically, a doctor won’t press for an induction if the patient is well informed and confident in their choices. But if doubt persists and the patient defers to the doctor to make all of the decisions, the care provider might just decide to fit you into the convenient schedule of induction “for their own good.”

The Bottom Line is this: if your doctor is telling you that an induction will decrease the odds of requiring a cesarean, they are lying to you. If a doctor is telling you that an induction carries fewer risks than spontaneous labor (whether for large baby or not), they are lying to you. If your doctor tells you that the risk of baby getting stuck (shoulder dystocia) is reduced by induction, they are lying to you.

Ask for evidence, be informed, and don’t be afraid to exercise your right to refuse treatment. It is sometimes the first step in commanding control of your motherhood, to take that power away from care providers, and put it back where it belongs: safely in the arms of the person who cares most about that child.

 

References:

Risk of cesarean delivery after induction at term in nulliparous women with an unfavorable cervix (Am J Obstet Gynecol 2003;188:1565-72.)

Labor induction with a prenatal diagnosis of fetal macrosomia J. Matern.-Fetal Med. 6:99-102, 1997.

To Induce or Not to Induce Labor: A Macrosomic Dilemma Gynecol Obstet Invest 2004;58:121-125 (DOI: 10.1159/000078942)

Elective Induction Versus Spontaneous Labor After Sonographic Diagnosis of Fetal Macrosomia Obstetrics & Gynecology 1993;81:492-496

http://www.cochrane.org/reviews/en/ab000451.html

http://www.fda.gov/medwatch/safety/2000/cytote.htm

http://www.medsafe.govt.nz/Profs/Datasheet/c/Cervidilpessary.htm

http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_01.pdf

http://www.greenjournal.org/cgi/content/full/93/4/523

 

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