Nulliparous psychosocial induction

I have been reading about induction recently, specifically, nulliparous induction for psychosocial reasons with an unfavorable cervix. In English, that is a first time mom, getting a labor induction for non medical reasons, and her cervix is not dilated or softened.

Induction of labor is relatively common. I recently sat with a doula client during her induction with Cervidil (Dinoprostone). (Not a comfortable placement procedure when you have a posterior, undilated cervix. It seemed more painful than any contraction I have ever seen.) Before it was applied, she was chatting with the nurse, who was 38 weeks pregnant. The nurse was happily anticipating her own induction, saying “I want to get her out before she’s too big.”

I briefly mentioned that estimations of fetal weight were not evidence supported and notoriously imprecise. I didn’t feel it was appropriate to mention that, at least according to the textbook we used for our women’s health system, induction was not recommended for suspected macrosomia. In fact, I had to point that out, politely, after class, to our pharmacology professor. She would read from the lecture notes, then pepper the lecture with the story of her own delivery, which was a failed induction for suspected macrosomia. She had a cesarean for fetal distress. The way she told the story, that was a good treatment decision, and suspected macrosomia was an indication for induction. I showed her the section in our textbook, said I thought it seemed contradictory, and suggested she talk about it with the head of the department.

I knew induction + macrosomia has an association with shoulder dystocia. Well, I was trying to find out more information about induction and Bishop score. Although this particular doula client met the ACOG recommendation of reaching 39 weeks gestational age, I was fairly sure a favorable Bishop’s score was more important. I had told this to my doula client when she mentioned the 39 week induction. I understood why she wanted it. She was on strictly limited maternity leave. Her mother was flying in. Anyone who has been pregnant full term or has talked with women who are in their late third trimester knows they are usually extremely uncomfortable and sick of being pregnant. She was no different.

Also, her obstetrician had already predicted, several weeks before, that she would go into labor a full ten days before her due date. Yes, it was the nature of her job that she was on her feet a lot, but who says that to a nulliparous woman with a long, closed, posterior cervix? I certainly don’t mean to imply she was setting the stage for a 39 week induction that she could work around her clinical schedule, but talk of induction started to happen as soon as that ten-days-before-due-date due date passed. I mentioned the Bishop’s score, and she seemed to think her obstetrician thought her cervix was ready. But, when we got to the hospital for the induction, her cervix was closed and posterior. I didn’t hear an exact effacement, but even with a generous guess, there is no way she was above a Bishop score of 8. I don’t think her doctor told her that it meant she had twice the risk of a cesarean. I didn’t think it was appropriate to tell her, since they didn’t do the cervical exam until the Cervidil was ordered and unwrapped, and she was admitted for the induction that she and her physician had decided was right for her at her last prenatal visit, and the physician was managing the induction over the phone.

Well, when researching the decision making that goes into these common inductions, I have read some interesting things. The first was on the Cervidil site I linked to above, that lists “Patients in whom there is evidence or strong suspicion of marked cephalopelvic disproportion” as a contraindication for Cervadil. In other words, suspected macrosomia.

Secondly, on the ACOG website, a recent article about quality improvement by Dr. D. Ware Branch, Jr., says:

“[B]eginning nearly 10 years ago, the program sought to implement a systematic, multi-institutional approach to discourage elective inductions in nulliparous women with a Bishop score of less than 10.

During the first several years of the project, the number of elective inductions in nulliparous women with an unfavorable cervix decreased from approximately 105 per month (15%) to 60 per month (6.7%) in the 11 hospitals that participated. The total number of elective inductions in nulliparous women also declined by two-thirds.

Currently, the proportion of nulliparous women with an unfavorable cervix undergoing elective induction within the Intermountain Healthcare system is less than 5%. Some facilities have even disallowed any nulliparous inductions whatsoever.”

Also, when rereading ACOG’s Practice Bulletin on Induction, (which is problematic for a few reasons) I noticed it states “Although trained nursing personnel can monitor labor induction, a physician capable of performing a cesarean delivery should be readily available.” Hmm, that sounds remarkably similar to the recommendation in their Practice Bulletin on Vaginal Birth After Cesarean, which states “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”

I am not trying to say that elective inductions should never be done, not even that they should never be done for psychosocial reasons. However, I doubt many nulliparous patients are given a risk explanation for an elective induction that is in anyway similar to the common treatment of VBAC. I am also fairly sure that elective inductions in nulliparous women for psychosocial reasons will not be banned from many facilities, like VBAC currently is. As far as I could tell by this interaction between my client and her nurse, elective induction for nulliparous women seems pretty standard, at least in my area. The quality improvement article from the ACOG website was reassuring, however.


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17 responses to “Nulliparous psychosocial induction

  1. MTFH! Wow, I love it! Comparing a non-medical induction with a low bishop’s score, requiring cervadil to the ACOG statement on VBACs! Brilliant!

    I would LOVE to see an informed consent form that indicated those risks as CLEARY as the risks for VBAC are outline!

    This post really touched my heart! good writing and good work MTFH!

    New Moon Birth

    • MomTFH

      Thanks! While it seems like such an obvious comparison now, it didn’t occur to me any of the many other times I read the bulletin, and I have read it several times.

  2. Whoah. This really struck a chord with me. I don’t think I would have ever reached this comparison on my own. To think that these things are so similar in terms of risk and requirements…yet one is so fear-inspiring and forbidden, while the other is done almost gleefully, nay, recklessly!

  3. Jen

    What I always find interesting is that inductions are often labeled as “elective” when the patient is usually unaware that she “elected” for it.

  4. One way I could see docs weasling out of this is by saying, “Oh, but these primips aren’t ‘suspected CPD/macrosomic’ *yet* — that’s why we’re inducing them *now* — **before** the baby gets too big.” Sigh…

    And, yes, the VBAC/induction protocols “immediately/readily available” need to be pasted side by side and shouted from the rooftops, to expose the duplicity!

    • MomTFH

      Exactly. What I have seen is a double speak: we are inducing because the baby MIGHT get big. But, we can’t tell if the baby is big, and since we can’t tell, we should assume the WORST and induce.

  5. Ohhh, my induction hate runs all the stronger for this post! Ditto to the double speak on induction/VBAC. I’m assuming that induction increases uterine rupture risk, although possibly not as high as VBAC? Or is it just a straight-up fetal distress thing? (I suddenly realized that I finished school yesterday and can now research this all myself!! But if you have any knowledge on that already I’d love to hear it.)

    I feel you on the “it’s too late now” doula feeling. Walk in as they’re starting to run the pitocin for an SROM? Too late. Show up as they’re unwrapping the cervidil? Too late. Get a phone call after the c-section for “low amniotic fluid” has been scheduled? Too late. There is most distinctly a place for doulas in preventing unnecessary interventions, but clients really have to be on the ball, advocating for themselves, and reaching out to the doula BEFORE they consent. Because once the cervidil is unwrapped, anything I could think to say just feels like fearmongering.

    • MomTFH

      Sorry it took me two months to answer this post! I was looking over the comments and realized I never did. Cytotec induction + VBAC is, of course, the classic rupture combination. Induction alone, especially with Cytotec (misoprostol) is listed frequently in the literature. I found this study on uterine rupture risk factors, and induction is definitely on the list.

      Yeah, there is a limit to being a doula. You are there to support the mom, and not to make those kind of treatment calls. I find being a doula very gratifying but very frustrating. I am sure I will find being an obstetrician very gratifying and very frustrating, but in the opposite way.

  6. This is interesting. My doctor never even mentioned induction to me until I was past my due date- and that was to recommend that we wait another week before considering it. And I was already at about 3 cm dilated and 50% effaced a week before my due date. (This was for my second baby- the first time, my water broke and no contractions started. We waited something like 8 hours, and then agreed to an induction. I regret not doing more to try to get contractions going without induction, but oh well. I was all prepared to “do better” the second time, and instead got an extremely fast progressing labor, with a surprise breech baby who was on the large side, and had about 5 minutes to decide what to do… we ended up with a C-section.)

    I also recently heard of someone in another part of the country getting induced due to PUPPs. I had PUPPs and it never crossed my mind to get induced because of them, nor did anyone ever mention that possibility. I’ve been wondering if the difference was just in the severity of the PUPPs or if in some places it is common to induce because of PUPPs.

    Anyway, this has me thinking… Has anyone looked at regional differences in inductions? I honestly can’t imagine my doctor agreeing to induce in the situation you describe. I’m wondering if I just got lucky in the doctor I picked or if doctors in my area just don’t induce as readily.

  7. The biggest “difference” between the nulliparous induction and VBAC recommendations is that the “risk” to the *physician* if things go wrong is perceived as much greater with a VBAC….after all, coulda/shoulda just done the repeat cesarean is what you’ll hear if there’s a bad outcome in a VBAC TOL, whereas with the nullip, we aren’t quite at the point yet where “should have just done a c/s” is the automatic response. Yet.

    Once again, the point that “if your facility isn’t capable of handling a VBAC, it really isn’t capable of handling any maternity care” is made….

    • MomTFH

      Also, another major difference is that VBAC TOLs increase women’s autonomy while decreasing the control the obstetrician has over the delivery, while a non medically indicated induction does the opposite.

  8. Sylvia

    I’ve been around maternity care for a long time and remember the days when the physician had to be in house if pitocin was used. We had way fewer inductions then. And when we did, we often tried a breastpump first. Once that recommendation went away, inductions increased dramatically!

    • MomTFH

      That was what it was like at the birth center where I trained. We used the breastpump, and had to transfer to a doctor’s care if we thought she needed pitocin (or cervadil, or cytotec). So we had very few inductions.

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