"Let Labor Begin on Its Own"
By Shannon Valenzuela, PhD, LCCE
The purpose of this series is to explore the historical context behind each of the Lamaze Six Healthy Birth Practices in order to understand where we've been, where we are, and where we need to go from here.
This week, we're focusing on Healthy Birth Practice #1: Let Labor Begin on Its Own, which recommends that labor induction should be avoided unless there is a medical indication. According to ACOG's 2005 guidelines, there are six medical reasons for labor induction:
- your water has broken and labor has not begun
- your pregnancy is postterm (more than 42 weeks)
- you have high blood pressure caused by your pregnancy
- you have health problems, such as diabetes, that could affect your baby
- you have an infection in the uterus; your baby is growing too slowly[1]
In its 2009 revision of the Induction Practice Bulletin, ACOG indicated that there are possible nonmedical indicators which might make induction prudent, though not necessary.[2] According to both ACOG and the Milbank Report, the national average induction rate is 22%, a figure that leads ACOG to advocate for a reduction in unnecessary elective inductions.[3]So this is where we are now: needing to reduce the overuse of the practice of labor induction in order to improve outcomes for both mother and baby. But how did we get to this point, and where do we go from here? Where We've BeenThe knowledge of certain practices (such as rupture of membranes or nipple stimulation) or substances (herbs like blue cohosh) that could induce a woman to go into labor have been known for centuries. In fact, descriptions of ways to mechanically open the cervix can be found in both ancient and medieval medical writings.[4] The idea of getting labor to start before it begins on its own is nothing new, but it was not until after birth moved to the hospital at the beginning of the 20th century that the practice of labor induction became more common.The use of Twilight Sleep (a combination of the drugs scopolamine and morphine) in the early 20th century necessitated that women be hospitalized and tied down because they were either conscious but unaware of their surroundings or completely unconscious. This in turn required that doctors find ways to intervene and manage the processes of labor and birth.[5] For an amazing video presentation of this period in the history of birth, see the video clip Changes in Birth Practices, on the Mothers' Advocate channel on YouTube.[6]In 1906, Henry Hallet Dale discovered that pituitary extract could induce contractions, and in 1909 this extract was first used to induce labor. By 1913, it was rapidly gaining acceptance by the obstetrical community.[7] Because the outcomes were unpredictable and, in many cases, highly dangerous for mothers and babies, pituitary extract fell out of favor after a few years. When the structure of oxytocin was finally mapped in 1953, it made the production of a synthetic version possible, and this has been in common use since 1955.[8]It was during the heyday of the rise of this new birth culture with its new technologies for the medical management of childbirth and the unconscious or barely conscious birthing mother that Grantly Dick-Read released Childbirth without Fear (1944) and Ferdinand Lamaze released Painless Childbirth (1946). These books and organizations like Lamaze® International (formerly ASPO/Lamaze, founded in 1960), emphasized the need to educate women about their bodies and the process of birth. And, as birth technology evolves, the need for education grows.Even with the advent of synthetic oxytocin (Pitocin), the rates of labor induction were still fairly low, until recently. In 1990, for example, the induction rate was only 10% -- by 2006, it was 22%. This jump correlates with the similar rise in the rate of cesarean birth, which is now over 30%.[9] Looking at these statistics, we have to wonder why there has been such a significant jump over the last two decades. What's happening in our birth culture? Where Do We Go from Here?As we look back over the history of birth, we can see a definite ebb and flow in the use of technology. For example, after the discovery of x-rays in 1895, practitioners used them to monitor fetal well-being. The dangers of radiation exposure weren't discovered until the 1950s, at which point practitioners reduced their use. When ultrasound was discovered in 1958, it replaced x-rays as the diagnostic tool of choice.[10] So, the enthusiastic adoption of technological advances often seems to lead to their overuse, only to be scaled back as research shows where those technologies are most beneficial.
The problem, in short, isn't necessarily the technology the problem is the application of the technology to situations where it isn't warranted. With ACOG's recent revision of its induction guidelines, the buzz in the media on the dangers of late preterm birth, and the growing number of studies revealing that inducing for non-medical reasons doesn't contribute to best outcomes, perhaps we're witnessing the beginning of the ebb in elective labor induction.[11]Lamaze's Healthy Birth Practice #1 is part of this movement toward equilibrium, boosting awareness and encouraging mothers to demand the best care for themselves and their babies.
[1] Lamaze Healthy Birth Practice #1. http://www.lamaze.org/Portals/0/carepractices/CarePractice1.pdf
[2] ACOG Press Release. http://www.acog.org/from_home/publications/press_releases/nr07-21-09.cfm
[3] Milbank Report. http://childbirthconnection.org/pdfs/State-Level-Maternity-Care-Statistics.pdf.
[4] Sanchez-Ramos, L. and A. Kaunitz. Induction of Labor. http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=130.
[5] Obstetrics and Midwifery. Encyclopedia of Children and Childhood. www.faqs.org/childhood/Me-Pa/obstetrics-and-midwifery.html. Also see Conception and Birth. Encyclopedia of Children and Childhood. http://www.faqs.org/childhood/Ch-Co/Conception-and-Birth.html.
[6] Mother's Advocate YouTube Channel: http://www.youtube.com/user/MothersAdvocate.
[7] Sanchez-Ramos and Kaunitz.
[8] Ibid.
[9] O'Callaghan, Tiffany. Too Many C-Sections: Docs Rethink Induced Labor. TIME Health Online. August 2, 2010. http://www.time.com/time/health/article/0,8599,2007754,00.html.
[10] Conception and Birth.
[11] For an example of media coverage, see Hospital Bans Elective C-Sections and Labor Inductions. Parenting.com. July 12, 2011. http://www.parenting.com/blogs/show-and-tell/melanie-parentingcom/hospital-bans-elective-c-sections-and-labor-inductions. For more information on the studies on labor induction, see Childbirth Connection (www.childbirthconnection.org). For information on the campaign against late preterm birth, see the March of Dimes (www.marchofdimes.com).Shannon Valenzuela is a certified as a Lamaze Certified Childbirth Educator and has also trained with DONA International as a birth doula. She is the mother of four boys and a baby girl, who provide her with energy and inspiration. Prior to becoming a childbirth educator, Shannon taught English Literature at the college and high school level. She graduated in 2000 Summa Cum Laude with a B.A. from the University of Dallas, and received her M.A. (2004) and Ph.D. (2007) in English Literature from the University of Notre Dame.
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