Induction of labor: in which cases it is carried out, when and what risks it entails

The controversy surrounding the advisability of early delivery or not, instead of waiting for it to occur spontaneously, is recurrent .

On the one hand, there are those who believe that it is induced too assiduously , even at the whim of doctors or mothers, to ensure that labor takes place when it suits them. And they criticize the problems that this practice can cause the child.

But there are also the professionals, who resort to inducing labor if they believe that the life of the mother or the baby is in danger. This option can even prevent labor from ending in a cesarean section.

Inducing labor is , according to the Spanish Society of Gynecology and Obstetrics (SEGO),

“The initiation of labor by medical or mechanical procedures before its spontaneous onset .”

The study “Attention to childbirth in Spain”, released by the University of La Rioja, describes and analyzes the variability of perinatal care in our country, and concludes that:

“The result of a childbirth depends much more on factors such as the geographical area or whether the hospital is public or private, than on the woman’s own delivery process.”

This helps us to understand the difficulty of generalizing how delivery is attended and to know whether or not there is a tendency to induction in hospitals.

For that reason, we will try to be as objective as possible and meet the recommendations of the official health organizations by which we are governed in Spain: the World Health Organization and the Ministry of Health.

WHO, against instrumentalizing pregnancy

The World Health Organization (WHO) published a guide a few months ago that includes new recommendations for a positive birth experience. Their goal: “to reduce unnecessary medical interventions” and to give mothers greater decision-making power over the birthing process.

According to the WHO report, most of the 140 million annual deliveries in the world occur without complications. However, in recent decades there have been:

“a substantial increase in the application of a variety of medical practices to initiate, accelerate, end, regulate or monitor the physiological process of labor.”

For this reason, the new guide presents 56 recommendations on childbirth care, mainly aimed at minimizing medical intervention in low-risk deliveries and in which there are no complications. Among them: not speeding up labor unnecessarily through the routine application of oxytocin or other mechanisms.

The Strategy for Attention to Normal Delivery in Spain

Most of the WHO recommendations are included in the Clinical Practice Guide on Attention to Normal Delivery, published by the Ministry of Health in 2010.

Regarding the possibility of inducing labor, it establishes that fetal well-being is controlled by monitoring, but without performing an amniotomy (rupture of the amniotic bag) or placing a routine peripheral venous line.

However, there are no official health data to check whether these standards are met or not in hospitals.

In the absence of more recent data, we rely on those collected in the Report of the Strategy for Attention to Normal Delivery of the National Health System, revised in 2015 (page 19).

According to the report: 53.3% of natural births are used oxytocin (compared to the standard provided by the good practice strategy (between 5-10%) and 19.9 of the births were induced, compared to 10% maximum recommended by the WHO and 46.6 percent of them resorted to artificial rupture of the bag.

What does the Ministry of Health say about it?

The recommendations on the possibility of induction of the Ministry of Health, Social Policy and Equality are reflected in the National Strategy for Sexual and Reproductive Health, of 2011 (pages 99 and 100).

1. Adequately estimate gestational age by means of ultrasound in the first trimester , without basing it only on the date of the last menstrual period, which tends to overestimate it, leading to a greater number of interventions for prolonged pregnancy.

2. Inform pregnant women that in 5-10% of cases the pregnancy lasts beyond 42 weeks. Explain that after 40 weeks the risks to the fetus and the rate of cesarean sections begin to increase very slowly. The evidence does not categorically indicate the need to induce labor from a specific date, because it does not reduce some of the risks and may increase others.

3. Offer the pregnant woman from week 41 + 0 of gestation the possibility of waiting for the spontaneous onset of labor or of inducing labor throughout week 41 , with the best available method and adequate information.

4. When the woman refuses induction after week 41, offer frequent monitoring through two weekly check-ups with fetal well-being assessment techniques.

5. Induction of labor is an invasive and painful procedure. In order to make an informed decision and give consent, women require sufficient and reliable information, as well as time to make their decision. They should know the induction method, location, details, support options, and pain relief.

6. Identify by cardiotocogram those fetuses that are in a compromised situation, so that appropriate measures can be put in place to avoid irreversible damage. Begin the fetal well-being study after week 40 in low-risk pregnancies.

7. End the pregnancy before any sign of fetal compromise.

From week 41 of gestation

Precisely in the first point of the recommendations of the Ministry of Health “gestational age” is one of the points that generate the most controversy about the induction of labor.

The association Delivery is ours warns that Spanish hospitals by protocol induce delivery around week 41 + 3, when the duration of a pregnancy ranges from 37 weeks to 42 (as indicated by the WHO).

But are there really so many long pregnancies? The real problem in a large number of cases is the ignorance of the exact date of the last rule (FUR), so this is usually obtained from the ultrasound of the first trimester of pregnancy, “a method full of errors since it is established in depending on the size of the baby “, according to the Delivery is Ours.

Studies in favor of induction

However, inducing labor is not always a negative option , according to the same association ‘Labor is ours’. In addition, they explain the studies related to this practice.

Until 2003, no comprehensive scientific studies had been conducted comparing the risks of induction versus waiting for labor to start naturally, even after 42 years of pregnancy.

What was shown is that:

“An induction at week 41 prevented one death for every 500 deliveries, and that from this date each day the risk of mortality increased, even with daily monitoring control”.

It was also accepted that routine induction around week 42 of gestation was associated with an increased need for caesarean section and a greater loss of fetal well-being.

However, a 2012 Cochrane Investigator Network review, including 22 trials on the topic, concluded that:

And he adds that: “With a policy of induction of post-term labor, some morbidities in neonates such as meconium aspiration syndrome were also reduced.”

And with these conclusions, the research indicates that:

“Women should be appropriately counseled to make an informed choice between planned induction of postterm pregnancy or monitoring without induction (or delayed induction).”

Consistent with these conclusions is a new study from Northwestern University (Illinois, USA), published in the New England Journal of Medicine (NEJM). Notes that:

The research involved more than 6,100 women in 41 different locations in the United States. Induced women at 39 weeks experienced fewer cesarean births, lower rates of maternal and fetal complications, fewer newborns needing help with breathing, and a lower incidence of pre-eclampsia.

And cesarean section, although also necessary sometimes for medical reasons, is still an intervention, with the risks that it entails. For this reason, it is better to seek natural childbirth whenever possible.

The researchers conclude that:

“The results of this new study refute the previous belief that induced labor before 41 weeks increased the risk of cesarean delivery and the likelihood of serious complications.”

Medical reasons for inducing labor

The Spanish Society of Gynecology and Obstetrics (SEGO) recommends ending the pregnancy when “the maternal and fetal risks are less than the risk of continuing with it .”

SEGO protocols indicate labor induction in case of:

• Post-term pregnancy. The pregnancy lasts more than 42 weeks. From this point on, the placenta usually stops working well enough to keep the baby healthy.

• Premature rupture of membranes at term and preterm.

• Cases of hypertension in pregnancy (preeclampsia, eclampsia and HELLP syndrome).

• Maternal diabetes mellitus.

• Fetal growth retardation.

• Twin pregnancy

• Chorioamnionitis.

• Premature detachment of the placenta.

• Intrauterine fetal death.

It also contemplates voluntary induction for non-clinical reasons (without specifying what they are), never before the 39th week of pregnancy.

This practice would be contraindicated if there is:

• Anterior caesarean

• Pregnancy after uterine rupture

• Herpes infection.

• Umbilical cord prolapse

• The fetus is located in a transverse position

• Cervical Cancer

How do you know if induction is necessary?

The Federation of Midwives explains that the Bishop test is used to assess the cervix in labor and predict whether an induction of labor will be required.

The total score is achieved by evaluating these parameters on the vaginal examination:

• Cervical dilation

• Cervical erasure

• Cervical consistency

• Cervical position

• Fetal lace

A score that exceeds 8 points means that the woman is more likely to have a vaginal delivery.

A score of 6 or less suggests that labor is unlikely to begin without induction.

More than 9 or more indicates that it will probably start spontaneously.

A low Bishop score indicates that the induction is unlikely to be successful. Only a score of 8 or more predicts a successful induction for sure.

How is labor induced?

According to the SEGO you can choose:

PHARMACOLOGICAL METHODS:

With synthetic oxytocin. It can be used to induce labor (never alone) but also to stimulate and maintain uterine dynamics during labor.

Prostaglandins. They help soften, erase and dilate the cervix.

MECHANICAL METHODS:

• Amniotomy or artificial rupture of the amniotic sac. It is usually done in conjunction with the administration of oxytocin. This practice alone is not recommended to accelerate labor due to its invasiveness and risk of infections.

Induction risks

Although induction is generally safe, it may involve some risks, which vary according to the method used and the particular characteristics of the woman.

For example, a study by the University of Rochester Medical Center concluded that elective induced labor poses a greater risk for first-time pregnant women. But there is more.

• The duration of labor is longer than in spontaneous natural delivery, especially if it begins with an immature cervix.

• It causes a uterine hyperstimulation, so the contractions hurt more.

• Some studies affirm that there is a greater chance of ending up in cesarean section, although others point out the opposite (they avoid them).

• Greater chances of infection if the membranes are artificially ruptured, both for the mother and the baby.

What all official bodies do agree on is that the woman must be well informed at all times so that she can decide whether or not she wants to wait for the birth to occur naturally when all the medical tests confirm that the baby is fine. .

Or if, on the contrary, you want to follow hospital protocols that advise ending the pregnancy at week 41 of gestation.

And be advised by professionals in case they perceive any danger to the mother or the baby . They are the experts.

Photos | iStock

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