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.