e-CIMS News: Coalition for Improving Maternity Services Newsletter

The American College of Obstetricians and Gynecologists (ACOG) recently revised its 2003 guidelines for induction of labor. The ACOG Practice Bulletin, Number 107, published in the August 2009 issue of Obstetrics & Gynecology serves as a resource to help medical practitioners make decisions about appropriate methods of cervical ripening and induction of labor and their effectiveness. At least two of the ACOG recommendations, inducing labor for "psychosocial" (non-medical) reasons and cervical ripening with the synthetic prostaglandin misoprostol (trade name Cytotec), differ from labor induction practice guidelines issued by the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the National Institute for Clinical Excellence (NICE), which drafts clinical guidelines in the U.K.

Induced labor puts women and babies at risk. Compared to women who go into labor on their own, women who have an elective induction are at increased risk for intrapartum fever, instrumental birth, cesarean section, and are more likely to use analgesia including epidurals. Babies are at risk for irregular heart rate patterns, shoulder dystocia, neonatal phototherapy to treat jaundice, neonatal resuscitation and admission to a neonatal intensive care unit. These risks are documented in CIMS' "Evidence Basis for the Ten Steps of Mother-Friendly Care" (see Step 6, pages 42-43). According to the white paper "Idealized Design of Perinatal Care" published by the Institute for Healthcare Improvement, "Based on a review of U.S. medical malpractice claims, [the labor-inducing drug] oxytocin is involved in more than 50 percent of the situations leading to birth trauma."

These complications of labor also impact mother-infant attachment and the initiation and continuation of breastfeeding. See "Breastfeeding is Priceless" (PDF).

Although ACOG approves of "psychosocial" induction, NICE clinical guidance (PDF) warns that induction of labor has a significant impact on the health of women and their babies; it should be clinically justified and should not routinely be offered on maternal request except under extraordinary circumstances. SOGC advises that there is no benefit to elective induction (PDF). Because it is associated with potential complications, elective induction should be discouraged and only provided after women have been fully informed of the risks and of the inaccuracy of establishing gestational age. ACOG approves of inducing labor at 39 weeks while SOGC states gestational age should be at least 41 completed weeks, and NICE guidelines state induction for non-medical reason can be considered at or after 40 weeks.

Misoprostol, an inexpensive synthetic prostaglandin, was developed and is marketed to prevent and treat gastric and duodenal ulcers. The use of misoprostol for cervical ripening and induction of labor (off-label use) is approved by ACOG, but not recommended by either SOGC or NICE. Misoprostol, also known as PG1, is not approved by the manufacturer for use in pregnancy (PDF). Misoprostol is associated with excessive uterine contractions, fetal heart abnormality, hemorrhage, hysterectomy, and sometimes fetal death. Both SOGC and NICE recommend its use be restricted to clinical trials. For a more detailed discussion of the use of misoprostol for induction of labor, see Science & Sensibility.com.

Nearly one in four births in the U.S. is induced (PDF) and according to the Agency for Healthcare Research and Quality (AHRQ), although it is not entirely clear what proportion of these inductions are elective (i.e. without a medical indication), the overall rate of induction of labor is rising faster than the rate of pregnancy complications that would lead to a medically-indicated induction. According to Childbirth Connection's report, "Evidence-Based Care: What it Is and What It Can Achieve," the most common gestational age at birth among single babies in the U.S. is now 39 weeks rather than 40 weeks.