Saturday, October 3, 2009

Labor Induction and the Knowing-Doing Gap

Elective induction of labor is one of the most common, and arguably one of the most dangerous practices going on in obstetrics today. But surely midwives aren't part of that. Are we?

Actually, according to the BMJ study of CPM-attended births, we are. Midwife clients were experiencing induction of labor 9.6% of the time (click on table 3). Now, some of those were likely after transfer out of midwifery care, and many likely for legitimate reasons. But nearly 10% induction rate doesn't sound that far behind the 21-44% the hospitals are reporting.

There are two problems with knowing when to recommend inducing labor. One is what I call the knowing-doing gap. Alright, I didn't call it that first--there's a book by that name. But basically, the gap between knowing what we should do, and actually doing it when faced with the situation. It's not as easy as we like to think. In my family we use the quote, "If ye know these things, happy are ye if ye do them!" It's easy to know the right thing, but far harder to do it when faced with an exhausted, 41-week mother who is crying because she really thought she'd have her baby by now.

The other trouble is the vagueness of most reasons we use in determining whether to induce labor. How late is too late? How big is too big? How ripe is ripe enough? Even the usually obvious reasons for inducing are called into question. Because womens' bodies and babies are so individual and situations vary so much, it's very much a guessing game. Lamaze has a new video out, helping women try to navigate this, because it's one of their 6 Healthy Birth Practices.

According to A Guide to Effective Care in Pregnancy and Childbirth (a great reference that is available free online), "The decision to bring pregnancy to an end before spontaneous onset of labor is one of the most drastic ways of intervening in the natural process of pregnancy and childbirth" (p. 375).

Just because an induction doesn't involve Pitocin doesn't make it any less a drastic intervention with serious risks to mother and baby. Despite what ACOG may say, induction is not to be taken lightly, or commonly. As midwives, we must question ourselves any time we're faced with the decision to end a pregnancy early.

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