Induced Labor and Informed Consent in Canada
By Gail J. Dahl; originally appearing in
Midwifery Today's The Birthkit (Winter,
2000).
"It is apparent that the overwhelmingly
redundant message of the ... literature ... is
that there is absolutely no study, no evidence
whatsoever, that routine induction at any gestational
age improves perinatal outcome" (Nichols
1985a).
I began to be interested in induced labor shortly
after I experienced a birth induction, also known
as induced labor, forced birth, scheduled childbirth,
daylight obstetrics, Vitamin P, and also described
as "a little something to get you going."
My daughter was born in a large Canadian city
hospital in 1995. Nearing the end of the last
trimester, exactly one week after a 40 week due
date, I was told by my obstetrician that my baby
was overdue, my baby was starving, weighed only
five pounds, and that my placenta was aging. He
also mentioned it was hospital policy to induce
labor at 41 weeks gestation. Reasons given on
hospital records for induction were recorded as
low weight and fetal distress. Although I had
read many books during my pregnancy I did not
find any references on induced labor or its relatively
high risks and possible side effects. After thinking
it over during the weekend I had difficulty coming
to terms with the suggested route of care. Weight
gain throughout pregnancy was normal; the mother
was healthy and the baby was healthy during the
previous ten prenatal visits. I resigned myself
to the obstetrician's advice, however, and arrived
at the hospital on Monday morning, highly concerned
with the health of my baby.
As the prostaglandin gel (also known as Dinoprostone,
Prostin E2, PE2, or Prepidil) was inserted, I
began to have serious misgivings about the procedure.
I asked if I could leave the hospital to move
about during labor. The obstetrician looked at
me and said, as this procedure was still relatively
new they could not be sure of its effects, so
I would not be allowed to leave. My labor started
with a bang, and I was soon overwhelmed with violent,
unceasing contractions—a hypertonic reaction
to the drug. Only because of the tremendous emotional
support and technical support from the nurse-midwives
and others on my team was I able to give birth
normally and avoid an emergency cesarean operation.
The Compendium of Pharmaceuticals and Specialties
(2000, 35th ed.) details the adverse effects and
risks of induced labor including fetal distress,
failure to progress, failed induction leading
to episiotomy and forceps delivery or emergency
cesarean operation, hypercontractility, and fetal
heart rate abnormalities. Contraindications include:
patients with a history of cesarean section, major
uterine surgery; patients with cephalopelvic disproportion;
patients with a history of difficult labor and
or traumatic delivery; grand multiparae and six
or more previous term pregnancies. Patients with
suspected or clinically evident pre-existing fetal
distress, patients with overdistention of the
uterus, multiple pregnancy, polyhydramnios; patients
with pre-existing uterine hypertonus; circumstances
that make it impossible for a responsible physician
to be present. Also contraindicated are patients
with ruptured membranes, engagement of the head
has not taken place; patients with unexplained
vaginal bleeding during this pregnancy, patients
with fetal malpresentation; patients with gynecological,
obstetrical or medical conditions that preclude
vaginal delivery.
During the labor I often felt as though my womb
was being torn from within me, and I began to
hemorrhage. It took months and months for the
bleeding to stop entirely and the pain in my womb
to subside. When my daughter emerged from my womb
and was placed on my breast a refrain was whispered
throughout the room, There is nothing wrong with
this baby. As I gazed into her eyes I began to
feel the white-hot rage of betrayal. She had obvious
signs of prematurity including a covering of soft
down-lanugo and vernix. This was not an overdue
baby, but a premature baby. Her medical records
record her at barely 40 weeks. She could have
easily been two or three weeks premature.
We were both out on the sidewalk two hours after
her birth on an early-release program. Within
24 hours she began to cry, establishing a pattern
of three or four hours consecutively in the evenings
for months after the birth. She soon developed
eczema covering her entire body. That was only
the beginning. Soon we found out at the hospital
that she had multiple allergies, which included
dairy, soy, eggs, Tylenol and various environmental
triggers. This became noticeable after breastfeeding
was stopped. Then her asthma started. After that
we dealt with her brain seizures. The emergency
ward doctors at the children's hospital suggested
a daily treatment of drugs to prevent seizures.
Unfortunately the drugs had the potential to cause
more side effects than the seizures. We decided
to look for other ways to assist her in reclaiming
her health.
Later I realized we both experienced many side
effects from an adverse reaction to the induction
drug. I experienced bleeding during labor and
prolonged bleeding for months after the birth,
blood pressure problems, prolonged and severe
postnatal depression, reduced immune function,
and persistent pelvic pain. My daughter experienced
reduced immune function, which contributed to
eczema, asthma, allergies to foods and environmental
substances, and brain seizures. Pharmacia &
Upjohn report the following adverse effects with
this particular prostaglandin: vomiting, nausea,
diarrhea, fetal heart rate changes, uterine hypertonus,
headache, hypertension, postpartum hemorrhage,
fever, dizziness, chills, hiccough, flushing tachycardia
dyspnea, bronchospasm and rash. A case of seizure
is reported with this product, as are seizures
from the other prostaglandin drugs used to induce
labor. This drug is also used as an abortant.
I believe we have yet to see all the results
to the health of babies forced out of the womb
prematurely in order to schedule childbirth. No
studies currently available show the long-term
effects of this drug on mothers and babies. One
of the reasons for the high failure rate is the
drug's inability to completely mimic the hormones
that cause both muscles of the uterus to work
together to squeeze baby out. Instead only one
set of muscles are activated, causing the baby
to be pounded out rather than squeezed out, often
with the head of the baby smashing against an
incomplete pelvic floor. This action can cause
irreparable damage to the baby's brain; this action
also places stress on the baby's heart and oxygenation
to the brain. These ineffective and incomplete
contractions create a longer labor, tiring the
mother out and often causing her to ask for pain-relieving
drugs to counteract the intense and unending artificial
contractions.
Inductions often fail because of an error in
the due date. Ultrasound-determined due dates
are not accurate (Kramer et al. 1988). Even first
trimester measurements have an error bar of +or
-5 days increasing to + or - 8 days in the second
trimester and + or - 22 days in the third trimester
(Otto and Platt 1991). Nichols (1985b) points
out that 70 percent of women classified as postdates
in his study were incorrectly dated. All clinical
dating methods, including the last menstrual period
(LMP), have margins of error of more than two
weeks He also reports that studies of management
have not found that tests accurately identify
postmature babies or that routine induction improves
perinatal outcome. Epidemiological studies have
found that much of the excess perinatal mortality
in the postdates population is due to other factors
like congenital anomalies, infection or IUGR.
Postmature syndrome is now shown to be derived
from one doctor's subjective evaluation of 37
babies estimated to range from 285 to 325 days
gestation (Clifford 1954). He observed no control
infants, and gestational ages widely overlapped
each other within grades. His signs are objective
and have not been shown to have clinical importance.
Shearer and Estes (1985) show postmature syndrome
that neither associates exclusively with postdates
pregnancy nor do its signs have any clinical importance
whatsoever.
Another factor to consider when setting a due
date is that research shows a first-time mother
to require a longer gestational period, from 38
to 42 weeks and longer (Mittendorf et al. 1990).
Sheila Kitzinger reports that over 70 percent
of first-time mothers normally give birth 10 days
after an estimated due date. Inducing an unripe
cervix leads to long, hard labors requiring additional
pain relief (Arulkumaran et al.1985a). Devoe and
Sholl (1983) found that 30 percent of fetuses
testing normal developed fetal distress when labor
was electively induced, and the cesarean rate
was 15 percent versus 2 percent for spontaneous
labor. Ahlden et al. (1988) found that when labor
is induced, other interventions are also likely
to be part of the scenario including amniotomy,
internal electronic fetal monitoring, many vaginal
exams with a labor ended in cesarean section and
an infected baby.
Induction works best on those who need it least,
and it does least for those who need it most.
Whether the process has gone awry or the mother
simply is not as far along as her doctor thinks,
if her body is not ready for labor, induction
will likely fail. Study after study shows us that
routine induction creates more problems than it
solves.
It took my daughter and myself over three years
to regain our health, and during that time I began
to study induced labor. I was very concerned about
what had gone wrong during the birth, so I asked
for an investigation by the College of Physicians
and Surgeons. Two years later it was discovered
that an error had been made in my daughter's due
date. I talked personally to the Registrar of
the College of Physicians and Surgeons about this
hospital policy to induce labor and about informed
consent on the procedure. Meanwhile I had spoken
to hundreds of women across Alberta and had heard
from many women who experienced their preterm
baby being forced from their womb or who underwent
an emergency cesarean because induction drugs
failed. Recently in one Alberta hospital there
were four scheduled induced labors that ended
in four unplanned emergency cesareans, a waste
of resources and health for all these the mothers
and babies. These babies were taken out on schedule,
the objective was accomplished as though the feeling
of being physically raped of your baby would have
no effect on your emotional health or your ability
to bond with your baby. The adverse physical side
effects of the drugs used for labor induction
can last for years after the birth, as it has
in my own case and that of my daughter. It is
time to stop this dangerous, unnecessary intervention
in childbirth.
I began to write a book for my daughter that
would give her guidance when dealing with her
own childbirth. My book, Pregnancy & Childbirth
Tips, began gaining prominence in the health community
and great attention from media as I began a cross-Canada
tour to promote the book and the concept of having
a faster, easier and safer childbirth. I joined
a local birth association but soon became frustrated
with their lack of concern for women giving birth
in hospitals. During this time the seeds for the
Canadian Childbirth Association began to be formed.
This association would work towards informed consent
on birth inductions in Canada and work to see
that all women, regardless of birth setting or
chosen caregiver, would have the opportunity to
have a faster, easier and safer childbirth.
New research shows that by reducing the numbers
of induced labor we can also reduce the numbers
of episiotomy and unplanned emergency cesarean
section. A new study, First Births - A Continuous
Quality Improvement Project with the British Columbia's
Women's Hospital, shows that by reducing labor
inductions in first-time mothers by 22 percent,
there is a corresponding decrease in unplanned
emergency cesarean section by 21 percent with
no change in newborn outcomes. Also included in
the study was a reduction in early admission,
reduction of electronic fetal monitoring and a
reduction of epidurals offered in the first stages
of labor. Also observed was a difference in the
number and timing of epidurals in induced compared
to non-induced labors. The input of over 80 clinicians
went into creating this manual of improved maternity
results for first-time mothers.
The Canadian Childbirth Association contacted
the Calgary Regional Health Authority, hospital
legal departments, and head of the obstetrical
department for the province, various governmental
officials including the Minister of Health and
the Alberta Medical Association (AMA) to set up
informed consent on induced labor in Alberta.
Eventually we were connected to the Committee
on Reproductive Care for the AMA. After our initial
submissions were sent we were invited to review
and provide the association with our feedback
from a consumer perspective for their proposed
Patient Information Sheet on Induction of Labor.
We returned with the new research showing the
importance of establishing due dates without ultrasound
and the new gestational range for first-time mothers.
We also asked that women be informed of the risks
and possible side effects of the drug used in
this elective procedure. Previous AMA Clinical
Practice Guidelines for Induction of Labor for
1993 did not include any mention of informed consent;
it had been completely left out.
On February 16th, 2000 the Canadian Childbirth
Association received a letter from the AMA as
follows: "I'm happy to report to you that
the clinical practice guideline for the induction
of labor includes a strong recommendation that
informed consent take place before the procedure
is initiated," signed by Dr. Robert A. Burns,
Executive Director, the Alberta Medical Association.
As the new guidelines have not yet been released
to the physicians we do not have observations
on the reaction to this precedent-setting move.
The AMA Clinical Practice Guidelines are expected
to be released shortly. It is our hope that the
AMA will also include a sample of informed consent,
including risks, side effects and natural alternatives
to the physicians when they send out the new guidelines.
The Canadian Childbirth Association is now lobbying
to have informed consent in place across Canada.
Pregnancy & Childbirth Tips is now a national
bestseller and has shown thousands of Canadian
women how to have a faster, easier and safer childbirth
regardless of their chosen birth setting. The
Canadian Childbirth Association will be creating
an audio-visual program to provide basic pregnancy,
childbirth, breastfeeding and newborn care and
newborn crying information at the high school
level throughout Canada.
Gail J. Dahl is the Executive Director of
the Canadian Childbirth Association, childbirth
researcher, educator, media advisor and best-selling
author of Pregnancy & Childbirth Tips (1998),
Innovative Publishing, ISBN 1896937-00-4, $18.95.
Available at bookstores, drug stores and health
food stores. International Toll Free Order Line
1-888-999-2080. Visit our award winning website:
www.pregnancytips.com
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