BISHOP SCORE

Some doctors are “induction happy” they like to schedule their lives, it is a though job to be always on call. Often if they see you are getting impatient they’ll suggest and induction. Most doctors really believe that inducing is not harming the child; nevertheless inducing is indeed opening the door to possible complications, baby might not like pitocin and his heart rate may fall resulting in an emergency c-birth. You might not be able to take the strength of the contractions and you will ask for an epidural, which often opens the door for more medical interventions. One of the reasons for a high cesarean rate in this country is due to fail inductions. So ask questions and don’t seem impatient. 

BE INFORMED! Knowledge is power.

To be successful, your Bishop's Score should be greater than 9. Be sure to ask your caregiver for your Bishop Score.

Also many doctors induced on the bases of not enough amniotic fluids.  In the last few weeks your amniotic fluids might be checked often, so will your baby’s heart beat. When you are getting the ultrasound to establish your levels, ask for numbers, if your fluids are at 5cm or more  and baby’s heart beat is fine, all is well.  Less then five (barely less like 4.9 you might just need a glass of water) 4 or less you must be induced.  Get a second opinion on your fluid levels at the hospital.  Often a new inexperienced technician will miss-calculate, sometimes the machines at a dr. office are not as accurate as those at the hospital.  If you are sent to the hospital for low fluids (Unless it is an emergency - ask "is this an emergency or do I have one some time?") consider the following:

 Before you go to the hospital get a good meal (once you get there they will not feed you till the baby comes.) This will only take 30 minutes but it will make a huge difference in your energy level during the induction.

Prepare yourself emotionally; being induced is not the end of the world.  Many of my clients have successfully had a drug-free birth even when induced. Call your doula or your support team they will help.  Take a moment and stay still (if you know how to meditate this is a great time to do so.) Center and tell yourself everything will be ok.  Rushing to the hospital will get you off center.  Low amniotic levels are not usually a terrible emergency.  But remember there is always enough time to come back to center and talk to your baby. 

Once you are at the hospital ask them to re-measure the levels.  Ask for the numbers, if your levels are five or more centimeters ask if you can leave.  It is your right to leave, remember you are a client not a patient. 

Leave and call your doctor tell him/her you'd like a little more time to see if the baby comes naturally.  At this time I would advise acupuncture or a chiropractic visit to try natural induction. Hypnosis really helps to find out if there are any fears left that stand in the way of this birth, and to relax and accept the outcome. 

Often it is a real struggle to leave the hospital once you have entered following doctor's orders.  Choose your battle wisely, any day is a good day for a stress-free birth.  If you decide to stay and begin the induction ask to manage the rate at which the pitocin is administer, and together with your birthing team you can embrace the contractions one at the time and one minute at the time.  Usually nurses will come every fifteen to twenty minutes and automatically raise the pitocin levels without even asking you.  Gently express your desire to manage the contractions and ask the nurse to tell you and ask you before she raises the level.  You are not to follow a time schedule that was established by the hospital procedure, or the medical books, as long as your baby is doing well, and you are progressing there is no need to follow any schedule.  Make friends with the nurse right away, ask her about her birth, her children, the weather, anything.  Remember she is a human being and we all have a big heart even if it is hidden somewhere.  Give love and you will receive love in return.

 Gently manage your pictocin induced contraction one at the time, visualizing your cervix opening up.  If you bishop score is low the doctor might suggest cervadil.  Following is an article about the risks and the drugs used for induction.  Again be prepared, ask a lot of questions to your care provider.  The following information is not meant to scare you but to inform you.  Whatever your birth will be will be ok for you will

www.motherfriendly.org © 2003 by The Coalition for Improving Maternity Services (CIMS). Permission granted to reproduce with complete attribution.

Problems and Hazards of Induction of Labor

A CIMS Fact Sheet

The Coalition for Improving Maternity Services (CIMS) is concerned about the dramatic increase and ongoing overuse of induction of labor. The U.S. induction rate has more than doubled since 1989, rising from one woman in ten to one woman in five in 2001.²² This may, however, grossly undercount the true incidence of labor induction. Nearly half of women in a 2002 survey reported that some effort had been made to start labor artificially.⁵ The World Health Organization recommends no more than a 10 percent induction rate.³¹ Despite modern techniques, induction of labor still introduces considerable risk compared with natural onset of labor, and many, if not most, inductions are done for reasons that are not supported by sound medical research.

HAZARDS OF LABOR INDUCTION

            Prostaglandins include Cytotec (misoprostol), Prepidil (prostaglandin E2), and       Cervidil (prostaglandin E2).

HAZARDS AND PROBLEMS OF INDUCTION AGENTS

Cytotec (Misoprostol)

·        Cytotec, although widely used as an induction agent, is neither formulated nor intended for use inlabor. Cytotec.s manufacturer, Searle, has repudiated its off-label use as an induction/cervicalripening agent because of Cytotec.s attendant risks.²⁷

·        The FDA states that Cytotec.s major adverse effects include uterine hyper stimulation, which can become severe and result in profound fetal distress; uterine rupture; amniotic fluid embolism, which has a high maternal and infant mortality rate; severe genital bleeding; shock; fetal death; and maternal death.⁶ Other adverse effects include retained placenta, cesarean section, and passage of meconium(the baby’s first stool) into the amniotic fluid, which can cause a type of newborn pneumonia if inhaled.⁶

·        Cytotec is commonly believed to pose a life-threatening risk only in women with a uterine scar or with high doses. However, cases of maternal and infant death and hemorrhage requiring hysterectomy have been reported in women with no uterine scar, some of whom were given a minimal dose.^13,28,30

·        Cytotec dosage cannot be controlled because the drug is a small pill that must be cut in pieces.

·        Once given, the drug cannot be rescinded or the dosage reduced in case of adverse effects.

·        Cytotec does not decrease cesarean rates compared with prostaglandin E2, which is FDA-approved for use in labor.¹⁶

·        Cytotec.s only advantages compared with prostaglandin E2 are much reduced cost and fasterlabors.¹⁶ Both benefit only hospitals and doctors as short labors are usually intense, tumultuous, and difficult.

Prostaglandin E2 (Prepidil, Cervidil)

·        Prostaglandin E2 can cause uterine hyper stimulation and fetal distress.¹⁸ Fetal distress can require cesarean section.

·        Prostaglandin E2 does not reduce excess cesareans associated with labor induction.¹⁸

·        Unless the drug is formulated in a tampon (Cervidil), the drug cannot be rescinded or the dosage reduced in case of adverse effects.

Oxytocin (Pitocin)

·        Complications of oxytocin (Pitocin) include uterine hyperstimulation,²⁵ which can lead to fetal distress; twice the chance of the baby being born in poor condition;¹⁵ postpartum hemorrhage;²⁵and greater probability of newborn jaundice.²⁵ Rare, severe, maternal complications include uterine rupture and water intoxication leading to coma and death. Oxytocin may also cause brain damage or death in the baby.²⁵ 

MEDICAL RESEARCH FAILS TO SUPPORT COMMON INDUCTION RATIONALES

·        Elective induction of labor, that is, induction for no medical reasons such as convenience, exposes babies and mothers to the hazards of induction with no counterbalancing benefit.

·        Inducing labor for suspected big baby produces no benefits but increases the likelihood of cesarean section.^12,29

·        No credible evidence supports inducing labor in women with gestational. as opposed to pre-existing. diabetes.

·        routinely inducing labor for prelabor rupture of membranes does not reduce the incidence of newborn infection with the exception of women testing positive for Group B strep who do not receive IV antibiotics during labor.¹⁴

·        Inducing labor in women with Group B strep has not been shown to improve outcomes when antibiotics are given regardless of membrane status and is not part of the Centers for Disease Control recommended guidelines.⁴

·        Studies claiming to support routine induction of labor at 41 weeks of pregnancy have serious flaws.²³ No research supports routine induction at any earlier point in pregnancy; no sound research supports routine induction at any point in pregnancy.

·        Proponents of inducing labor at full-term argue that the stillbirth rate and the rates of other newborn complications increase markedly after that date, but, in fact, these rates show no such increase.^1,23 Induction at 41 weeks in a hypothetical population of 100,000 first-time mothers would theoretically prevent 120 fetal deaths that would statistically occur in the ensuing week, but:¹⁷

·        We don’t know how many of those deaths would actually be prevented by routine induction in that they were unpredictable events in healthy mothers carrying healthy, normally formed babies.

·        That number would be offset by some babies dying as a result of the hazards of induction.

·        Any decrease in fetal deaths would be outweighed by the infertility, miscarriage, and fetal and newborn losses consequent to the excess cesareans. (See The Risks of Cesarean Delivery for Mother and Baby, a CIMS fact sheet.)

·        Forty-one weeks is the median length of pregnancy in healthy first-time mothers.²⁴ This means that one-half of such pregnancies will last longer than 41 weeks.

·        If there is no reason to curtail the natural length of pregnancy, then there is no reason for measures such as stripping or sweeping membranes, which themselves introduce the possibility of risk.

The Coalition for Improving Maternity Services (CIMS), a United Nations recognized NGO, is a collaborative effort of numerous individuals, leading researchers, and more than 50 organizations representing over 90,000 members. Promoting a wellness model of maternity care that will improve birth outcomes and substantially reduce costs, CIMS developed the Mother-Friendly Childbirth Initiative in 1996. A consensus document that has been recognized as an important model for improving the healthcare and well being of children beginning at birth, the Mother-FriendlyChildbirth Initiative has been translated into several languages and is gaining support around the world.

www.motherfriendly.org © 2003 by The Coalition for Improving Maternity Services (CIMS). Permission granted to reproduce with complete attribution. Problems and Hazards of Induction of Labor

Coalition for Improving Maternity Services

P.O. Box 2346

Ponte Vedra Beach, FL 32004

info@motherfriendly.org

Phone toll-free: 888-282-CIMS (2467)

Fax: 904-285-2120

Please contact us for a complementary copy of this fact sheet, or other Coalition for Improving Maternity Services publications.

References

1.Alexander JM, McIntire DD, and Leveno KJ. Forty weeks and beyond: pregnancy outcomes by week of gestation.Obstet Gynecol 2000;96:291-4.

2.Brisson-Carroll G et al. The effect of routine early amniotomy on spontaneous labor: a meta-analysis. Obstet Gynecol1996;87(5 Pt 2):891-6.

3.Cammu H et al. Outcome after elective labor induction in nulliparous women: a matched cohort study. Am J ObstetGynecol 2002;186(2):240-4.

4.Centers for Disease Control and Prevention. Prevention of perinatal Group B streptococcal disease. MMWR2002;51(No. RR-11).

5.Declercq ER, Sakala C, Corry MP. Listening to Mothers: Report of the First National U.S. Survey of Women.s ChildbearingExperiences. New York: Maternity Center Association, Oct 2002.

6.FDA. Cytotec (misoprostol). Access at: http://www.fda.gov/medwatch/SAFETY/2002/safety02.htm#cytote,2002.

7.Fullerton JT and Severino R. In-hospital care for low-risk childbirth: comparison with results from the NationalBirth Center Study. J Nurse Midwifery 1992;37(5):331-340.

8.Garite TJ et al. The influence of elective amniotomy on fetal heart rate patterns and the course of labor in termpatients: a randomized study. Am J Obstet Gynecol 1993;168(6 Pt 1):1827-1832.

9.Goer H. Elective induction of labor. <http://www.hencigoer.com/downloads/elective_induction.rtf>

10.Goer H. The Thinking Woman.s Guide to a Better Birth. New York: Perigee Books, 1999, p 228-9.

11.Goffinet F et al. Early amniotomy increases the frequency of fetal heart rate abnormalities. Br J Obstet Gynaecol1997;104(5):548-53.

12.Gonen O et al. Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol1997;89(6):913-7.

13.Goodman D. Forced labor. Mother Jones Jan/Feb 2001:17-19.

14.Hannah ME et al. Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term:the role of induction of labor. Am J Obstet Gynecol 1997;177(4):780-5.

15.Herbst A, Wolner-Hanssen P, and Ingemarsson I. Risk factors for acidemia at birth. Obstet Gynecol 1997;90(1):125-30.

16.Hofmeyr GJ and Gulmezoglu AM. Vaginal misoprostol for cervical ripening and labour induction in late pregnancy(Cochrane Review). In: The Cochrane Library, Issue 3, 2000.Oxford: Update Software.

17.Kaufman KE, Bailit JL, and Grobman W. Elective induction: an analysis of economic and health consequences. AmJ Obstet Gynecol 2002;186(4):858-63.

18.Kelly AJ, Kavanagh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term(Cochrane Review). In: The Cochrane Library, Issue 2, 2002.Oxford: Update Software.

19.Levy H et al. Umbilical cord prolapse. Obstet Gynecol 1984;64(4):499-502.

20.Lydon-Rochelle M et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl JMed 2001;345(1): 3-8.

21.MacDorman M et al. Trends and characteristics of induced labour in the United States, 1989-98. Paediatr PerinatEpidemiol 2002;16:263-73.

22.Martin JA et al. Births: final data for 2001. Nat Vital Stat Rep 2002;51(2).

23.Menticoglou SM and Hall PF. Routine induction of labour at 41 weeks gestation: nonsensus consensus. BJOG2002;109:485-91.

24.Mittendorf R et al. The length of uncomplicated human gestation. Obstet Gynecol 1990;75(6):929-32.

25.Mosby. Oxytocin. Mosby.s GenRx Access at: http://www.orgyn.com/resources/genrx/d001945.asp

26.Peck P. Preinduction cervical ripening significantly increases risk of cesarean. Medscape Medical News, 2003. <http://www.medscape.com/viewarticle/453298>

27.Searle. letter to health care providers. Aug 23, 2000

28.Stein L. Un-informed consent. Metroactive <http://www.metroactive.com/metro/cover/cytotec1-0212.html>,2002.

29.Tey A, Eriksen NL, and Blanco JD. A prospective randomized trial of induction versus expectant management innondiabetic pregnancies with fetal macrosomia. Am J Obstet Gynecol 1995;172(1 Pt 2):293.

30.Wing DA and Paul RH. Am J Obstet Gynecol 1996;175(1):158-64.

31.World Health Organization. Appropriate technology for birth. Lancet 1985;2(8452):436-437.