Labor Induction ro Anxiety Reduction?

 

Elizabeth Soliday
esoliday@vancouver.wsu.edu

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             When I was interviewing mothers for my forthcoming book, Delivery Derailed, I was struck by their responses to induction, the set of obstetric procedures designed to kick-start labor in female bodies that stubbornly refuse to begin on or near a professionally predetermined date. It made me realize that as much as women look forward to becoming pregnant and ensuing motherhood, there is also a period—one that is rarely discussed—when women look forward to becoming unpregnant. And I worry that this urge to get the baby out is pushing women into the wrong decisions.
             About 40% of my interviewees were induced, which may have included intravaginal inserts of prostaglandins orIV administration of synthetic oxytocin. Labor induction also often involves manual manipulations, including the common practice of breaking the protective membranes surrounding the fetus, and, less commonly, inserting a catheter to dilate the cervix.                
             Hearing mothers talk of their induction experiences got me thinking about how truly miserable the last few weeks and days of pregnancy can be.  Your feet and ankles can get terribly swollen, neither eating nor sleeping is particularly comfortable or satisfying, and you’ve grown weary of comments that you must be carrying a whale, rather than a human.
             Tales of attempted self-induction abound among women of generations past, before medical labor induction became the common practice that it is in the U.S. today.  My mother-in-law shared hers with me: desperately wanting to birth her son on Valentine’s day, she said she drank castor oil and, against spousal advice, she jogged up and down stairs -- anything she could think of to help her baby start his journey to the outside.  I’ve heard plenty of similar stories from today’s mothers.  Look on the internet, and you’ll see all the things women try – special teas, herbal preparations, walking, nipple stimulation, spicy foods, and my personal favorite only for its title, “Italian induction,” or engaging in intercourse (ejaculate contains prostaglandins like those used in medical labor induction, but in a lesser concentration).  Acupuncture has recently entered the menu of non-medical induction alternatives.        
             Two important characteristics distinguish self-induction from medical induction: agency, or who is in charge of administering the technique-of-choice, and power, with medical induction considerably more powerful than self-induction techniques.  On the first matter, agency attempts at self-induction rest solely in mothers’ hands, as most traditionally trained physicians would be loathe to recommend any self-induction procedure based on the lack of scientific data showing they actually work.  (To its credit, however, the medical community has at least given a nod to self-induction techniques in a few isolated attempts to scientifically study their effects.) 
             In contrast, medical induction rests almost solely in the hands of obstetric professionals, a statement that contradicts current language used in presenting medical induction practice rates: according to national data, up to 2/3 of 21st century medical inductions – which by my own conservative estimate would amount to about one million such interventions per year – are “elective.”  The relative upswing in medical labor induction over the past decade or so must certainly have some association with 1999 and 2009 guidelines published by the American College of Obstetricians and Gynecologists (ACOG), in which medical labor induction is justified for certain physical conditions as well as non-medical reasons such as “logistics” – when a mother lives far away from a hospital, for example – and “psychosocial reasons,” which are undefined.   
             As a psychologist, I am of course most interested in the as yet undefined “psychosocial reasons” for “elective” medical labor induction.  As an educated guess, I would say that the primary “psychosocial reason” is that the medical labor induction serves to reduce all around anxiety: mothers, especially first-timers, get the relief of knowing when labor will start rather than waiting for something they’ve never felt; obstetric providers get relieved of any further guesswork as to whether a mother’s pregnancy might become increasingly risky as she waits.  Not to be overlooked, mothers’ families get to schedule travel around a known newborn arrival date and working mothers can, at last, have a firm idea of when to schedule work leave if they’re lucky enough to have it. 
             When a seemingly simple, controlled, and professional obstetric procedure like medical labor induction exists, mothers’ relative unquestioning acceptance of it makes perfect sense.  After all, knowing she will go into labor at some point, why not take advantage of a little push in the desired direction?  But it is here that the term “elective” becomes problematic:  because the term “elective” is also applied to medical procedures such as breast enlargement and tummy tucks, one could easily be misled into believing that contemporary mothers are marching into their obstetricians’ offices by the thousands asking to have labor induced.  And from what I hear, that’s just not true – by and large, mothers don’t view medical labor induction as desirable, particularly when compared to, for example, epidurals.  But when their obstetric providers do alert mothers to some concern about continuing pregnancy past the expertly calculated “due date” – which I believe comes partly from clinicians’ anxiety -- mothers listen, and they generally go along with the proposed solution, even if it is to address a vague concern, one of low enough risk that the term “elective” would appropriately apply. 
             It’s easy to say that mothers can simply say “no, thanks, I’ll just wait”; after all, in the U.S., we all have federal legal protections granting us the right to refuse any medical procedure.  Unfortunately, from what mothers tell me, their practitioners rarely, if ever, give them a detailed or realistic picture of the downsides to so-called “elective” labor induction’s power in the birth process – one of the hazards of typically brief office visits.  Few women are aware that labor induction is associated with the introduction of additional obstetric procedures, including twice the rate of cesarean delivery in induced mothers vs. those with natural labor onset.  While many mothers might forge ahead confident that they’ll beat those odds, they most certainly can’t beat the odds of having to report to a hospital to have labor induced, of having their movement severely restricted withsynthetic oxytocin running through attached tubes and the usual electronic fetal monitoring that goes with it, and of watching the clock tick away as they near the deadline for delivery that labor induction has set. 
             Together with a recommendation that mothers receive full information on labor induction in the same conversation that it is offered, I’d like to forward another piece of advice to the obstetric profession (though I do so with some hesitation as I’m not medically trained).  I have often wondered why, when normal human gestation ranges from 37 to 42 weeks, we all get stuck on a precise date of newborn arrival?  Why not, instead, speak of a safe “due range?”  Thinking of a several weeks-long range in which a newborn might arrive – after all, childhood has its own timelines – could go far in reducing the professional, maternal, and contextual anxiety that starts ramping up each minute a pregnancy passes beyond a given day.  
             Again, mothers always have and will continue to anticipate the birth of their newborns.  But before they jump onto the all-too-tempting labor induction bandwagon, they deserve to be told what medical labor induction can and often does lead in the same conversation that the procedure is offered.  Finally, in considering labor induction that’s not clearly medically necessary – as I do recognize that, according to the World Health Organization, about 10% of induced births constitute true medical necessity – it might help mothers to give serious thought to going home, eating some spicy food, taking a long walk, and maybe even trying Italian induction.  Because once the baby’s born, keeping her or him alive and safe from the outside becomes considerably more complicated than doing it from inside, and the real anxiety begins.  

 

About the Author

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    Dr. Elizabeth Soliday is Associate Professor of Psychology at Washington State University
    Vancouver (USA) and a licensed psychologist. Her research on maternal health has been funded
    by federal agencies and foundations; her works appear in professional publications such as
    Pediatrics and the Encyclopedia of Motherhood. Her book, Delivery Derailed, is slated for 2012
    publication.

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    Published: March 13, 2011