February 2, 2005
Volume 7, Issue 3
Midwifery Today E-News
“Induction of Labor”
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The Art of Midwifery

If you watch laboring women who don't have a cheering section, they may push a little at the peak of contractions sometimes, but not every time. They are bringing a high head down. When it is time, they have an overwhelming urge to push. Get ready, because she is going to have a baby, ready or not. Not letting mom be in an upright position for fear of causing swelling, as many nurses do, may cause swelling. Try to get mom to be upright, and bargain with nurses about dilation checks. Put mom on the toilet and stall for time.

Caudia Toms, Midwifery Today Forums


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Research to Remember

The prevalence of low birthweight in the United States showed little improvement during the data-collection period 1993 to 2002, revealing a rate of 7.7%. The prevalence is highest for black infants and lowest for Hispanic infants, when compared among racial and ethnic groups (white, black, Hispanic, Asian). Factors contributing to low birthweight other than race/ethnicity are mother's age, prepregnancy weight, weight gain during pregnancy and smoking during pregnancy.

Centers for Disease Control
www.cdc.gov, last accessed 01/22/05


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Induction of Labor

Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or postdates in conjunction with poor fetal growth or developmental abnormalities does show an increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk until past 43 weeks. The primary "evidence" of a sharp rise in stillbirth after 40 weeks—often misquoted as "double at 42 weeks and triple at 43 weeks"—seems to come from one study based on data collected in 1958 (1). ... Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1000) (2).

There is a creeping overreaction in dealing with postdates pregnancies. It is true that stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than 10% of babies born at 43 weeks suffer from postmaturity syndrome (more than 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks must be compared to the risks of interventions. Induction is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.

Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800 postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering "on time" (between 37 and 41 weeks). Perinatal mortality was similar in both groups (0.56/1000 in the postterm and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery, and low Apgar were actually lower in the postdate group than in the on-time group (3). This is only one of several studies showing postdate pregnancies can be monitored safely until delivery or until indications arise for induction. Even the famous Canadian Multicenter Post-term Pregnancy Trial Group (Hannah) of 1700 postdates women showed no difference in perinatal outcome among women who were monitored past their due date, as compared with those who were induced at term (4).

In some studies, postterm births have shown a higher cesarean rate for suspected fetal distress. However, when a group of researchers conducted a case-matched review of nearly 300 postdates pregnancies, they concluded that the increased rate of obstetric and neonatal interventions "does not appear to be a result of underlying pathology associated with post-term pregnancy." They suggest that "a lower threshold for clinical intervention in pregnancies perceived to be 'at risk' may be a significant contributing factor." In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy (5)!

When monitoring demonstrates that fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40 weeks.

Excerpted from "A Timely Birth," by Gail Hart, Midwifery Today Issue 72

  1. McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational age through the past three decades. Postmaturity, Am J Obstet Gynecol 85: 573–82.
  2. Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies. Obstet Gynecol 69(3 Pt.1): 296–99.
  3. Weinstein, D., et al. 1996 Sep–Oct. Expectant management of post-term patients: observations and outcome. J Matern Fetal Med 5(5): 293–97.
  4. Hannah, M.E., et al. 1992 Jun 11. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587–92. PMID: 1584259
  5. Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term pregnancy following spontaneous labor. J Perinat Med 26(6): 475–79. PMID: 10224605.

Labour Induction Epidemic and Autism Epidemic: Is There a Link?

There are many reasons why further studies about labour induction as a possible risk factor for autism are urgently needed. The first one is that the authors of the oldest studies included in our database came across risks associated with induction, whereas the most recent studies could not take into account this variable. "Labour induction" should be explicitly taken into consideration, because it can be associated either with birth by the vaginal route (with or without intervention such as forceps), or with caesarean birth. Another reason is that the epidemic of autism and the epidemic of induction seem to have developed side by side. Most importantly, a third reason is that the results of recent studies suggest that children with autistic disorder show alterations in their oxytocin system.

The first clues came from a study of midday blood samples from 29 autistic and 30 age-matched normal children, all prepubertal (1). It appeared that the autistic group had significantly lower blood oxytocin levels than the normal group. Oxytocin increased with age in the normal but not the autistic children. These results inspired an in-depth inquiry of the oxytocin system of autistic children. In recent years it has become clear that oxytocin can appear in the brain in several forms. There is the nonapeptide oxytocin (OT) and the "C-terminal extended peptides," which are described together as OT-X. The OT-X represent intermediates of oxytocin synthesis that accumulate due to an incomplete processing machinery. Twenty-eight male children, diagnosed with autistic disorder were compared with 31 age-matched non-psychiatric control children: there was a decrease in blood OT, an increase in OT-X and an increase in the ratio of OT-X/OT in the autistic sample, compared with control subjects (2). In other words autistic children show alterations in the oxytocin system: there are deficits in the processing machinery of oxytocin.

Such findings are of paramount importance at a time when an accumulation of data from animal studies confirm the potent effects of oxytocin (and the parent hormone vasopressin) on social behaviour, communication and rituals. Furthermore we are currently learning that oxytocin brain receptors undergo major changes during development. Among humans, the period surrounding birth is considered a period of dramatic reorganization of central oxytocin binding. We must add that, when reaching a certain degree of maturation, the oxytocin system of the fetus probably participates in the physiological initiation of labour. Artificial induction of labour in general, particularly the use of drips of synthetic oxytocin, create situations that undoubtedly interfere with the development and the reorganization of the oxytocin system in such a critical period. This fact alone is a reason for further epidemiological studies focusing on labour induction as a possible risk factor. It would be useful to know also how autistic children release oxytocin. Oxytocin is more effective when released rhythmically, in a succession of fast pulsations. Today it is not impossible to measure the rhythmicity or pulsatility of oxytocin release.

Primal Health, by Michel Odent, MD
http://www.birthpsychology.com/primalhealth/, No. 12: "After the MMR Fuss: Autism from a Primal Health Research Perspective," last accessed 1/22/05

  1. Modahl, C., et al. 1998. Plasma Oxytocin Levels in Autistic Children. Biol Psychiatry 43(4): 270–7.
  2. Green, L., et al. 2001. Oxytocin and Autistic Disorder: Alterations in Peptides Forms. Biol Psychiatry 50(8): 609–13.

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Forum Talk

I have been dealing with vaginal yeast infections for as long as I can remember! The only thing that ever kept them away was, back in college, to use a douche of thyme infusion combined with a few drops of tea tree oil 3 times per day for 3 weeks. I went without a problem for over a year. I am now 30 weeks pregnant and dealing with vaginal yeast (it's varied in intensity throughout the pregnancy) and I want to know if this same douche would be safe to use while pregnant? Also I am still nursing my toddler. I am so sick of the itching!

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Question of the Week

Q: I recently had a c-section for twins because twin A was a footling breech. Unfortunately, I had to be put under general anesthesia because my platelet levels were too low to safely have an epidural. Is there any sort of homeopathic or herbal remedy that I might try to build up my platelets? My platelets generally are around 70 and have been that way for years, with 50 being the point where treatment is needed, but 100 is the cutoff to get an epidural. When I have another child, I would like to have a VBAC, but if it doesn't work, I don't want to have to be knocked out again.

— J.B.


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message. Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Reflections

It has been my experience that preterm labor is a cry for help—a cry from the baby or a cry from the mother. Sometimes a woman is doing too much, and the baby shouts, "Hey mom, take a rest!" In these situations, bed rest is probably a good idea.

But I feel the most important thing we are missing in these cries for help is the absolute necessity for the mom and baby to be pampered. Pregnant women should be treated with the utmost respect and valued for the incredible job they are doing growing their babies. Our culture doesn't recognize this, sadly. Pregnant women should receive the highest quality and most delicious foods—especially towards the end of pregnancy. Massage should be a weekly routine, as well as competent, woman-centered prenatal care (which I think includes care with a chiropractor and/or a cranial sacral therapist). Her dreams should be listened to and her fears addressed.

Where can women get this type of care? Doula? Grandma? Sister? Partner? Neighbors? Friends? Co-workers? The answer is, all of these people. Our society has a duty to its future citizens to create an environment that fosters optimal growth.

Besides the fact that tocolytics have many side effects, the worse thing they offer is a false sense of security. I am not judging women who have taken them to stop preterm labor. What I mean is, the idea that a pill will fix a problem like this is insulting to the woman, and most importantly, ignores the real reason for the cry. It covers up the issue instead of getting to the root of it.

Ruth Trode, Minneapolis, MN
Midwifery Today Issue 72


Feedback

Editor's Apology: As the result of an e-mail address malfunction, letters to E-News bounced back to their senders during the month of January. If you have written to E-News after January 1 and have received your correspondence back, please try again! The problem is fixed, and we greatly look forward to hearing from you!


I was stunned to see this in the Art of Midwifery section from Gloria Lemay [Issue 7:2]:

"One of the reasons we have so much interference in North American birth right now is that young women are overly dramatic."

I would like to know what evidence Gloria has regarding this statement. This sounds like unsubstantiated opinion and mother-blaming to me. I am disappointed that you published this and spread it further. What were you and Gloria thinking?

— With respect and surprise,
Sandy Caldwell, CD (DONA)
Redwood City, CA

The author replies:

Of course, there are no randomized controlled trials on drama in young women. All one has to do is turn on the TV or sit in a booth at an after school coffee shop. Perhaps young women have always been dramatic, but there were older women to tone them down and teach them priorities, conduct and smart behaviour. Maybe it's not the young women being dramatic but the older women abdicating their responsibility to show them the way. I actually have no idea what is creating this jabbering din in the world but I do know that it doesn't help to have a smooth birth at all, and the evidence I have that things are not working is the 28% nationwide c-section rate. "Being nice and politically correct is not helping one bit either." One of my favourite expressions is "The truth shall set you free, but first it will make you mad."

Gloria


Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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