#182 | Labor Induction: Risks, Reasons and Results with Dr. Rachel Reed, PhD

October 12, 2022

Dr. Rachel Reed, PhD, author, midwife, researcher and expert in physiologic birth joins us for the second time on the Down to Birth Show to discuss the differences between physiologic birth and induced labor. She shares with us the different ways in which Pitocin/Syntocin impacts the course of labor, including significant risk to mother and baby, versus our own natural oxytocin. You'll learn the unique risks of Pitocin for first-time moms, and the entirely different set of risks Pitocin presents to women who've already given birth before. She explains the general risks of induced labor, and discusses circumstances when induction is absolutely necessary. In this episode, we critique the ARRIVE trial and its flawed results, which have led to many women choosing elective induction at 39 weeks believing it to be a safer option for mother and baby.  If you haven't heard it already,  be sure to listen to our very popular first episode with Rachel Reed.
 #150: Myth of the Aging Placenta with Author/Midwife Rachel Reed


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Most women are not having a physiological birth of the baby. So if you're not having a physiological birth of the baby, then you're not going to have a physiological birth of the placenta, it's actually pretty risky to expect your body to suddenly step in and birth the placenta. However, when we induce labor, there's no significant difference in the perinatal death rate for induction of labor at 39 weeks, there isn't an induction of labor before 41 weeks increases the chance of an emergency cesarean section by 20 to 30%, and increases the chance of instrumental delivery by 10%. Once you step onto that induction train you heading a particular way. And that includes medical intervention all the way along, you can't just get off the train partway through. So that really needs to be made clear to women before they step onto that train.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, Rachel, it's so great to have you back on the down to earth podcast this evening. Your episode number 150 that we recorded. She's a while ago now I can't remember how long it's been but a few months winter winter it was yeah, it was your summer. And now it's our summer, your winter because you're in a sweater and I'm in a tank top and I remember you were wearing a little dress and I was cold. So now we are here we are, again reverse seasons. But the myth episode 150 The myth of the aging placenta was such a popular episode for our podcasts. And we're so thrilled to be talking to you again. Today we're going to talk about induction which is another really important and interesting topic for people. So thank you for coming back. Can you just start again by giving a little background on who you are?

Yes, I am a midwife. I did my midwifery training in the UK. So I was a direct entry midwife. i So I've worked as a midwife in hospitals in home birth, in a variety of settings with a variety of women. I have been an academic for many years, so designed and delivered midwifery curriculum teaching midwives. I have carried out research and I have a PhD, specifically looking at childbirth experience of childbirth and midwifery practice during childbirth. Yeah, and so now I'm not sure what to call myself now because I left academia. So I'm kind of like an independent educator, I guess.

I call y'all I call you many things. But one is the world expert in the placenta? Yes. Cynthia always says that every time I don't think there's been one person who's who's actually looked at all the research in the world, and you did. So I think it's a fair title to give you but I know there are many more. And in fact, today, we're diving into another area where you, you have done all the research. So we're very eager to get into induction because it is, in arguably the easiest route to a woman losing her birth plan, losing control over it, saying later, I don't even know what happened. Perceiving induction as innocuous and casual and not a big deal, as if they're just pre planning the baby's arrival date. But induction is a very big deal. And in the vast majority of cases, the reasons for induction are not evidence based. And we would love for you to get into those reasons as well. So how would you like to kick off this discussion on induction? Where do you think we should begin?

I think acknowledging the induction is very different to physiological birth. And I think that's not understood, nevermind by women, but also by care providers. And as such, it needs to be approached differently, managed differently, because you don't need to manage physiological birth. But with an induction, you really do need to monitor what's happening because it's, you know, increased risk for the baby. In particular, you know, the greatest risk for a baby in labor is Syntocinon or Pitocin. So it's a completely different experience. And I think often women when they're making decisions about whether to be induced or not, or not Thinking about what they're opting out of, you know, in terms of what physiological birth is and what they're choosing to not to do in order to be induced, what they're sacrificing. Let's just let everyone know that Syntocinon Pitocin are the exact same thing. They're just different brand names for synthetic oxytocin. And I think in, I think on the continent of Australia, you say, since in Towson, right, but everywhere else, it's Pitocin. Right? Europe, I think it's the EU, I think it's the EU where that were the outlier. That might be true story of our lives in the UK in the UK Syntocinon as well.

And let's just let's just put it out there too, that it's not the same as oxytocin. Right, so now we've got Syntocinon, Pitocin, and oxytocin?

Well, it is the same, it can all chemically molecular, molecular way it is, but it's a it's that's like saying a molecular composition of Vitamin C is the same as deriving vitamin C from a lemon and it isn't the same, it's received differently in the body. Right? How it works in the body is different. Yes, yes, very different.

So that's why it's, that's why it is convincing for women, that it's just a little oxytocin, or that's why people will call it oxytocin. Because, yes, chemically structured is the same. But you can't just take that to mean that it's going to function the same in your body, and it doesn't impact the body. It impacts the body differently than the synthetic versions. So let's name how, how does it impact it differently.

So for a start with in terms of oxytocin, in order for it to work in the body, you need oxytocin receptors in the uterus to respond and contract. And that the maturation of oxytocin receptors doesn't happen until the end of pregnancy. So particularly for women who are having their first babies, they may not have enough oxytocin receptors that are mature and ready to uptake. The oxytocin if they haven't gone to their full term, and finish those changes that they need to make before they go into labor spontaneously. women who've had babies before different they have good oxytocin receptors. And for them, they can uptake too well, in terms of, if they're regulating their own output of oxytocin in labour, then the body kind of regulates what's happening because it's a complex organism. So it's, it's altering the the oxytocin release, which is happening in pulses in waves. And it's kind of getting bound by your feedback from the woman's body in the baby. So you're not going to over contract. Whereas with oxytocin, it's artificial, it's going into a vein. It's not it's been regulated by a machine, you know, we turn it up until it's a steady rate that's going in or pulsatile. Release. And we can oversaturate the oxytocin receptors in a woman's uterus so we can particularly she's had a baby before. That's why you have to be very careful with oxytocin administration for a woman who has had babies before, because they can over contract which squeezes the placenta reduces the blood flow to the placenta stresses the baby out, a woman who hasn't had a baby will will not respond to the Pitocin because the oxytocin receptors are not ready to respond to Pitocin.

So on one hand, you're looking at a failed induction, potentially where they start really ramping up the other interventions. But in the case of second time moms or third time moms, you're looking at the risks of hyperstimulation of the uterus and so on.

Yes, and fetal distress or ruptured uterus, you know, Pitocin causes uterine rupture. It can I, I personally touch would have, have only seen uterine ruptures happen in labor with Pitocin. I haven't seen them happen with a VBAC. Physiologically laboring, that might just be, you know, my luck of the draw, but after out of hundreds of births, that's what I've seen. I would second that. That is definitely one of the risks of uterine rupture is having an induced feedback, as opposed to just spontaneous physiologic feedback. The other thing is, in natural labor, we release our own oxytocin through the brain, which is calming. And that doesn't when you're getting synthetic Pitocin or Syntocinon. It doesn't cross into the brain. So you have the absence of that. It makes labor harder to deal with. Because you don't have the relaxing effect of oxytocin. We all all of us who have anyone who has had natural labor or breastfed a baby knows how oxytocin can make you feel and it's a feel good hormone. So when you're having an induced labor and you don't get that effect that changes the way you cope with Labor and the way you bond postpartum.

Yeah, and breastfeed, yeah, breastfeed.

Let's talk about why induction is risky. Because I think many women just go into it thinking that this is just going to help my body kick into gear and labor is going to start and it's going to be fine. And I'm just going to meet my baby a few days earlier. But it's not so benign. No.

So really, induction changes the experience of birth right from the beginning. So even in the getting the cervix ready. And each step of the way, it increases risks of certain things, because it's not physiology. So if we think about how the cervix gets ready for labor, all kinds of things happen structural changes to the cervix, so that it can open in response to contractions. With induction, all we do is put in prostaglandin. That's it, we don't do all the other things that need to change all the other chemicals, which I can't pronounce most of them. So that's why I have a written list. So we're kind of trying to get the body to do something it's not ready to do. So with that there are risks of response to the prostaglandin. Some women will respond adversely to the prostaglandin, which is pretty, it can just be fetal distress, or it can be something more significant, which is rare. It's rare that a woman has a very significant response to it. But women need to know that before they have prostaglandins put in. And I was caring for a woman having an induction and I was giving her my usual spiel, which was, you know, do you know the risks and having this conversation around the risks this is when I was working in a hospital. And most women don't know, they haven't been told the risks, and they've turned up with their suitcases ready to have their baby. So I was going to put a prostitute in. And I had to tell the woman the risks of putting a prostitute. So we talked about, you know, the risks of fetal distress. So we would monitor the baby after we'd done that, the risks of me breaking her waters and risks of infection and etc with that the pain because prostaglandin isn't you written to that's how it works. And it can be really uncomfortable and painful. It can start contractions that are kind of very irregular and uncomfortable, but not really doing much. But also I said, you know, and there's this very rare risk that I've never seen, because it's quite rare in that you have a big response to it. And very hypertensive, which is hyper contraction, which is where the uterus just does a huge contraction, which is really dangerous. And we would have to very quickly get your baby out. So I said that put it in the postman. And she had that response. Her uterus just had this massive contraction didn't release. So this baby's two centers getting squeezed. She was rushed to theater, and she actually birthed in theater because the contraction was so strong. It wasn't her first baby.

She was rushed to where this must be an Australian term. What is this word? Theater?

Oh, surgery? Yes.


The operating room? What a euphemism. I know. Well, it comes from the olden days when they actually used to perform surgery with people watching in a theater so they could learn. What's the theater?

Okay. Okay, so got if you can continue. Thank you. Yeah. So we rushed into the operating theater. And she actually birthed her baby as they were setting up for general anaesthetic because the baby's heart rate had just plummeted and a baby came out and was, you know, was okay, after recess. The baby was, well, she didn't have the general anaesthetic, she was just absolutely shaking with that adrenaline, you know, it was really traumatic for her. And, you know, there was that one rare experience that and I've never seen it again. But now when I do my spiel, I can say to women, I've only seen it once. Because I've seen it, but prior to that, it was I've never seen it, but it's important women know, she had been told that that potentially could happen, you know, unlikely, but she was that one in however many 1000s You know, so I guess that that step of the induction process is risky in that way. And then of course, Pitocin is I used to work with an obstetrician in the UK, who called it a deadly drug. So he because he wanted us to really think before we asked him to prescribe it. Because it is is to kit can be potentially dangerous. Which is why we monitor babies.

And it can lead to postpartum hemorrhage for the mother. So it can be salutely. Yeah, deadly to both or uterine rupture, like you said. So God, yeah, that's, that's really powerful to hear an obstetrician say that and treat it that way. And that really is how it should be treated. And it just simply is not it's pretty much the opposite of that. It's just the treated very casually, like, oh, we'll just give you a little a little, a little whiff of Pitocin won't hurt anything.

Yeah, whereas he was very much you give me a good rationale for prescribing this medication to this woman. Because, you know, we're now putting her and her baby into a risk category that is going to require probably more intervention. So Pitocin increases the risk because primarily a fetal distress, author of uterine rupture. But I guess the good thing is that you can actually just turn it down or turn it off. And then that risk goes, the most cases involving Syntocinon are settled out of court, because it's understood that it's a risk. And most of the cases that I have been involved in as an expert witness involving Syntocinon, have all been about, you know, not turning it down when there's clear signs of fetal distress, and carrying on with an induction. So there are ways of mitigating that risk in terms of turning the Pitocin down, what you then do is you don't have enough contractions to finish the labor. So you've got this balancing act of trying to turn up the Pitocin to get the cervix to open the uterus to contract balanced with fetal distress. And, and this is this is where most women end up with surgery during an induction is not an emergency rescue rushed to theater for fetal distress, because we're turning the Pitocin down, if that happens, it's the fact that we can't turn the Pitocin up high enough to get the baby out without stressing the baby out. So we had to theater. So that's the usual reason for failed in induction.

That wasn't the body takeover at some point. After enough time with Pitocin. I thought I always thought the body kicked in on its own and started participating. It doesn't know necessarily.

Yeah. Because in especially because of what you said in the beginning, if you know they're not if they're if the woman's body really hasn't laid down the foundation for the receptors for the Pitocin. It's it's not going to work either way, right? Or if she's been oversaturated, with Pitocin, then her own oxytocin can't bind to those receptor sites and her own oxytocin can't do its job and it can't take over. Yeah, we're not meant to mess with this process.

No, and that's the main reason for a hemorrhage after birth is that the oxytocin receptors have been just saturated, and they can't then contract to stop the bleeding and get the placenta out because they're just completely saturated.

So yeah, and then we throw more Pitocin. On top of that, I just hope that we can grab a few receptors that are still available to stop that bleeding. And sometimes it works. I mean, a lot of times it does work, but sometimes it still doesn't.

But usually they end up having to use different medications that act differently and not on oxytocin receptors to try and get the uterus to contract.

Yeah, it's very strange to me. And it always has been that Pitocin both prevents that might be too strong of a word, but prevents postpartum hemorrhage and also can cause it. This is a tangent. So I don't want to take us down a whole other conversation. But if we can just spend a minute on this tangent, what is your comment or opinion on routine Pitocin postpartum I wrote a blog post on this because most women are not having a physiological birth of the baby. So if you're not having a physiological birth of the baby, then you're not going to have a physiological birth of the placenta, it's actually pretty risky to expect your body to suddenly step in and birth the placenta, which increases the chance of hemorrhage. So it's not surprising that, you know, giving Pitocin is routine because most women are being induced or getting Pitocin during labor anyway, what if they weren't, in fact, I'm one of those women who had a natural birth in a birthing center and at home, and in both cases, they said, We think you're hemorrhaging. I feel I have conviction that I wasn't, but we'll never know anything. And I was given Pitocin an intramuscular injection each time but I'm seeing this with my clients, even when they have a natural birth, a large percentage of my clients do birth naturally, but Pitocin has become routine. nonetheless. Many hospitals say they require it. I mean, of course, you have informed consent, but they're very pushy about it. What do you have to say about those who birth naturally when their body should have no problem? In the vast majority of cases, doing that third stage of labor?

The World Health Organization recommends routine Pitocin because it does reduce the chance of hemorrhage in the general population. That's a general population who are having interventions. Now women who aren't having interventions, if you give them Pitocin, after birth, if they had a physiological birth, it increases this is what the research tells us. There's not a lot of research, it increases their chance of hemorrhaging.

Unbelievable. Wait, do you just said that the postpartum injection of or injection of Pitocin with the birth of of the placenta is increasing the risk of postpartum hemorrhage in the woman who has had a natural physiologic birth?

Yes. The research was done in birth centers work with care providers who knew how to manage a physiological birth of the placenta. So when you compared those women who are birthing in a birth center with midwives who understand how to promote physiology who have a physiological birth of the baby, if you give them Pitocin, it increases their chance of hemorrhaging in that context and setting. So most of the research about hemorrhaging is done on general populations who are having medical birth in settings with care providers who don't know how to support physiology, because they never see it because everybody gets Pitocin.

One last question on this. What about the population of women who have a medicated birth? An epidural, let's say, but no Pitocin? Which category did they fall into? Does the Pitocin reduce or increase the likelihood of that woman hemorrhaging reduces because they have happening? They're not happy with physiological birth?

Got it? So they go into the category of the women who had Pitocin.

Yeah, because they've had interventions during they're not having a physiological birth,

even with an epidural. If that's all they have, that's still non physiologic.

Yeah, ineptitude, alters physiology quite dramatically. And you're significantly alters physiology, not just in the pelvis, but with contractions with the oxytocin loop with all of that it's medicalized birth. If we're talking about routine, just in case administration, then in a general population who are birthing with epidurals with inductions in hospital settings, it reduces their chance of hemorrhaging in a population of women who are birthing outside of that in a birth center or at home with a physiological birth and no medical interventions, it increases their chance of hemorrhaging. Once a woman's hemorrhaging it, it manages hemorrhage pretty well, for most women.

We just got this question today. And I in our q&a, somebody asked the question, what, what is the reason that without a doubt, 100%, you need to be induced, and the first thing that came to mind for us was preeclampsia. And then there's this whole other long list of things that are like on a spectrum.

Yeah, so in my book, I had two different sections to cover. This one was complications. So that's when there's actually something currently wrong. There's a pathology or a complication that's currently happening, that's impacting on the health of the mother and baby right now. Versus variations, which is just the mother and baby are healthy. There's a variation, I, the woman's gone past a particular date, or the baby's being perceived as a particular size, which possibly isn't. Anyway, those are variations. So I think it's very, it's important for women to get clear with their care provider, if they're offering an induction to say, am I having a complication at the moment? Or me and my baby currently undergoing problems? Or is this a variation that you're worried might turn into a complication? Because there are two different categories, I guess.

Right. So even something like high blood pressure, which many women are told that they need to be induced because their blood pressure is high, but if it's high blood pressure, in the absence of preeclampsia, or any other significant warning signs, that's not really an indication, it's a warning.

It's something to keep an eye on. But preeclampsia isn't absolute complication. This is a pathology that's happening, there's only going to stop happening when the baby's born. Right.

So tell me a way to resolve it. Hmm, what about due dates? This is such a big one. There's so much evidence that now says induce earlier than they were saying 15 years ago, they used to say draw the line at 42 weeks, the World Health Organization, I believe, but now it seems everyone is saying 4141 and a half 31 is the first time I'm going to labor on average.

So on average, first time pregnancies will last 40 weeks and five days. Yeah, and 75% of first time women when they're first pregnancies will birth spontaneously by 41 weeks and two days. So if they're left alone 75% Will birth at that point, what about the ones who go later.

So post date pregnancy is or post term once we get into 42 weeks is a variation? And it really you can you can you can look at it generally. And generally, induction will reduce the risk of stillbirth in that population by a very, very small less than 1% but I think it's not helpful to look generally we need to look at specifically the individual woman. So for that individual woman, you know, issue well is the bay Be Well, what's her history does she always birth her babies at 40 to 43 weeks, I've cared for women, for example, as a private practice midwife care for one woman who always birth her babies at 43 weeks and her, her mother did that one of her Auntie's had a baby at 44 weeks. So I'm not expecting to see a baby anytime, you know, before 42 weeks. I guess one of the problems with the stats in the research is there's no nuance or kind of individualizing the context for women?

Do you think women inherit something genetic that predisposes them to birthing around the same time that their mothers did? Or should we look at it as though each of us is 50%? Our mother 50%, our Father, and therefore we don't know how necessarily the women on our father's side births? So are we likely to follow the pattern of our maternal lineage more than our paternal lineage with things like this?

I don't know down to that level of genetics between the two parents, but we do know that the research shows that you are more likely to go post guest date. If your mother did, so there isn't there's a genetic link between women and gestation length.

Okay. So coming back to induction for postdates, what do you say? You're saying? What has to be looked at on an individual basis? What if they are going for that induction? Because they hit 41? Or 41 and a half weeks? What do you feel like the most important things for them to consider?

Well, they need to consider what they're opting out of which you know, physiological birth, what that is, what the risks are of induction. And then I mean, that's why I would never say you need to or recommend induction is really about that woman, looking at her circumstances context, what she wants to do, some women will want to get induced a 39 weeks for no medical indication, and that's what they want to do. And that's fine, if they understand the risks and the benefits for them. And that's their decision. So I would, I would encourage, and I included in my book, the entire decision making framework to kind of work through around making a decision to have an induction or not to have an induction, because I'm not anti and induction. There's some very good reasons for induction, and there's some very good, and that includes women choosing induction for no reason if that's what they want to do, and then making an informed decision. And I also included in, then a birth plan for induction, you know, if you're going to have an induction for whatever reason, then here's some things choices within that. So I think we need to be careful not to completely demonize induction of labor, because actually a lot of women have them. And in Australia, more women have induction, or most of them going to spontaneously, but that's where we're at with it. So I would encourage her to look at her own circumstances, and look at the risks because the key risk of post dates pregnancy is the increased perinatal death risk in a general population. So what we're looking at is, if you induce labor after 41 weeks, so before 42 weeks, you reduce the perinatal death rate. So we're talking about induction of labor before 42 weeks reduces the perinatal death rate from naught point 3%, to naught point naught 3%. So that's a statistically significant number. And for some women that might be significant enough for them to choose an induction for other women, they might look at that and go, Well, I've got a 99 plus percent chance that this baby is going to be absolutely fine. And I don't want to take the risks of the induction because there are risks that come with the induction, particularly for women having their first babies in terms of subsequent births, if they then end up having a cesarean. So it's really complex. And the discussions around choosing induction should take a long time, they should be individualized. And it should be a case of a care provider sharing evidence and the woman making her decisions based on that and her interpretate interpreting the evidence, how she wants to, because we all do that we all make decisions based on what we want, not necessarily what somebody else is telling us. And timing of induction is important. I mean, if you're not, if you're being pressured into it at 39 and a half weeks and you're not feeling it, and you want to wait another week, that's going to make a really big difference in the outcome of the birth and the complications because of what we talked about in the beginning with that the receptor availability for receiving that Pitocin versus Dosen. Yeah, yeah. I just if you don't mind, I want to make sure I'm understanding what you said. So you said 0.3 is reduced. So we're talking three deaths per 1000. Yeah. And it's improved down to three deaths. For 10,000 Women are induced to cry or 242 weeks. Yes. So my two questions How much prior? Because obviously there's a too early for things like this, I'm sure that that statistic doesn't hold at every week, this month. And then what about the women after 42 weeks? So can you dive a little deeper on that? If you have that data?

I do, but I have to look at it in my book. Second, you've got to, you've got to refer to the expert.

This is why I write books is what I tell my husband, I don't keep things on my head. No, I keep it on paper, I teach with a big binder and syllabus. I've taught the class hundreds of times and I still have to, you know, I still refer to my notes all the time.

Yeah. Okay. Let me see.

Because that's a big decision. Should I get induced at 39 weeks? Should I do it at 41 and a half? That's a very good very well, the research that I've just cited, whether stats had come from as a Cochrane Review, and that route, that would have been 41 weeks, because that was the standard time for induction inducing. So all those studies would have been inducing at 41 weeks before 42 weeks. Okay, add 41 weeks 41. Zero, is what we're talking about that usual stuff would have been a difference amongst the studies. But those studies, were looking at induction of labor after 41 weeks.

So that reduction, that tenfold reduction, basically, is at 41 weeks. Okay? And then what about after 42? Is there data on that?

There is? And I think the thing is with riskier, there are risks, versus risky that we can get away from that.

That's, that's absolutely correct. That's a very important thing for everyone to understand what cannot eliminate risk no matter what we did, and if and if you consider that smaller, and remember, it's a general population. So when we were talking about the percentages, we were talking about this. So in the perinatal death rate included babies who had congenital abnormalities. So there may be something happening for babies who have congenital abnormalities who are not initiating labor, as we know that babies have congenital abnormalities are more likely to be preterm or post him. So that might explain why there's an increased perinatal death rate for those babies. Or it might be what is done to women during a post dates, labor and birth because they're more likely to have intervention. I don't know. We don't know the why from these stats, these are just being general.

Right? They don't look at the inverse. No. Right that and they never will, we're really not going to know that.

No, and one of the problems with with looking at anything beyond 42 weeks is that it's a very small population of women, right? Because most women get induced. So you don't really have the research looking at what happens to women at 42 plus weeks who are induced or not induced, all you have is that perinatal death rate risks as pregnancy progresses, and it creeps up and creeps up. It's still even at 43 weeks, it's less than 1%. You know, we're still talking about these tiny amounts of increased perinatal, desperate as gestation continues, right? We're splitting hairs over this, I do imagine that the Netherlands would be able to provide those data points because they have traditionally supported women going to 43 weeks without induction. So they with all their home birthing, I would think they have a good population, but maybe it's still not enough.

And I think one of the issues is that we all we get really focused on women want the numbers, and it has nothing to do with them individually. I know. Yeah. I know. And there's so much anxiety around it. Um, so, oh, I've got the perinatal death rates rising for week by week. Okay. Alright, so again, this is a general population and this is the perinatal death rate. This is why induction is offered, okay. It's because there is a risk, the risk is increased perinatal death rate. So a nought point 1% at 40 to 41 weeks. So that's really the 40 weeks. Mark. Once you get to 42 weeks, you got to nought point 3% chance, and then after 43 weeks naught point 5%. So that's the stats looking at a general population continuing the pregnancy onwards, which is why induction is then offered Okay, well, we'll get in there at that, you know, before it goes up to naught point three and induce that's why it's awkward, but they'll never do that research on what exactly happens with all those women, and those inductions and the side effects and what happened?

No, and what you've got to think I mean, we've got About 1% of women in Australia get to 43 weeks less than 1%. So you can't do a study on tiny numbers of women.

Right? Right. That's so true. But I wish we could look at, you know, 10,000 women who went past 42 weeks compared to 10,000 women who were induced it 42 weeks, because it would show some very valuable data. That's the other side of the risk. We're only looking at eliminating or reducing one risk, but we're not looking at the risk we're taking on. Yes, and that data is ever going to be available to women. And that's what so because you're looking at frustrating of you're looking at the risk of perinatal death, and that's women need double the risk on the other side is also death of the mother or baby. They're also mortality rates because of induction that might have been unnecessary, right?

And you go to factor in if you're having your first baby in juice, there's a very, very good chance you're going to have a cesarean section. And then for your subsequent baby, the risk of stillbirth is higher than the risk of stillbirth because of postdates because you have a scar in your uterus. So nobody's talking to women about subsequent babies or subsequent pregnancies and the risks of the interventions associated with induction for future.

So we're saying the risk of VBAC has a higher perinatal death rate than the risk of postdates in a first pregnancy. Is that right? Yeah, yeah. And yeah, they're not usually presenting that data to you when you talk about induction. No. So so let's go back to the reasons that women might be influenced or coerced into an induction like the, you know, premature rupture of the membranes. The babies getting too big, the fluids too high, the fluids too low. They have gestational diabetes. I mean, these are all things that women are being told that they should be induced for maternal age. Did you mention that? Oh, yeah. You're trying to raise?

Yeah, that's a big one.

Geriatric - ridiculous. Do you know how many women are do with their babies around their 35th birthday? And they're sweating it out thinking? Well, my doctor says, If I'm 35, when I go into labor, it's just become off the rails.

Yeah. Even though I was 34 it at 40 or 38 weeks, you know, and then they turn and they turn 35 at 40 weeks, and they suddenly high risk.

Well, again, we're not looking at research that's comparing induction versus not induction. What we're looking at his general stats around stillbirth, and the general rate of stillbirth does increase for women as they go over 35 and after 39 weeks, so women who are over 40 years old, have a nought point 2% chance of stillbirth 39 to 40 weeks. Okay, and that's compared to a nought point 1% chance for a woman under 35. Again, we're talking about tiny little numbers here. A woman over 40 years old and 42 weeks pregnant, she has a 1% chance of stillbirth. So now now it's the 1%. Okay. However, when we induce labor, we don't necessarily there's no significant difference in the perinatal death rate for induction of labor at 39 weeks, there isn't an induction of labor before 41 weeks increases the chance of an emergency cesarean section by 20 to 30%, and increases the chance of instrumental delivery by 10%. And women and babies are more likely to be readmitted to hospital within 28 days after the birth or after their induction of labor. So we need to also look at those factors, because that's what the research is kind of telling us is yes, there's increased risks this way. But with induction, there's increased risks also.

Exactly. And that's what I was saying earlier, they don't test that population and see the outcomes in inducing those large populations of women, and we will never have that data stolen will care enough to pay for it?

No, and if we do have it, we don't report it. Right. Exactly. Which is really interesting, isn't it? We could frame this in looking at whether or not induction of labor reduces the chance of cesarean because there is a few different studies around that looking at mixed populations and first laborers and the arrive trial was a first labor one. So then we could talk about the arrive trial, which is the most famous one, looking at first laborers. So the the biggest reason I think that induction of labor is offered before term. You know before full term is this idea that it reduces this is our infection rate or your Here wouldn't be offered as this area and being told that it doesn't increase this area infection rate, which is not really the full story. So I think when women are looking at whether or not they're going to have an induction, they need to understand the risks of cesarean with induction, because in a mixed population, so that's women who have had babies before. And women where we've mixed them in with women who haven't had babies before, then, in some studies, it lowers the chance of cesarean section. And these are studies in 2012 2014. And these are being meta analysis study. So it does reduce the risk of cesarean section in a mixed population. And then there's also studies showing higher risk. So we've got Swedish, more recent Swedish studies showing a higher risk and mixed mixed population of in a scenario with induction. And we have an Australian study that showed a mix with mixed risk population and increased the chance of severe infection. So when we then look at first labor, so these are studies that look at mixed, but when we start to go, Okay, well, let's look at the first labor because actually, from my personal experience of caring for women having surgery and induction of labor, for women who had a baby before says there is not actually the end result, often, you know, they'll birth their babies before we get to that point. So I think it's, it's not fair to have, you know, to just generalize that into women, if you're having a baby, first baby, like you're saying there is if they had included women who had had a baby already, the numbers would not have looked so compelling. In the end.

Yes. So these studies, combined populations, and because he has, obviously women who'd had babies in before, who will birth without having a cesarean section quite easily, often with induction, they then made the results look better. Yeah. So then you go, Okay, well, let's take that group of women out and just look at the first time mothers, because they're really, from my perspective, they're the ones most at risk with induction. women who've had babies before are usually pretty good at laboring, their body remembers what to do. And they've got good oxytocin receptors, and it all works. We just have to watch out for fetal distress. So we're the first labor. Probably the most, the most famous W it's often used to convince women to be induced is the arrive trial, which I am not an expert on the arrive trial, because I kind of looked at it and got irritated and same. So what they found they looked at a low risk population of women having their first babies, and they looked at induction to the induced the women versus first is not induction, but that's kind of not really what they looked at, at. And what they found was that they reduced Mrs. Aryan section rate. So for the women who were being induced at 39 weeks, they had an 18.6% chance of injury versus area, which is really low, actually, in general. But anyway. And then the women who didn't get allocated to the induction arm of the study had a 22.2% chance of success, Aryan. But that study wasn't done to look at accidentally infection rates, the primary purpose of that study was to look at whether or not there was a difference in the outcome for the babies. That was the point of doing the study. And then that got hidden because it didn't find what they wanted it to find. So the publication is all about reducing cesarean section rate, which is not what they went in looking for. And what they found was no difference in the primary outcome for the baby. So it didn't reduce perinatal mortality to induce women, that 39 weeks. But that got buried in favor of this idea that it reduces to zero in section. But what we need to think about with this trial is that they only had a 27% participation rate. So when they offered women to be in the trial, that's a very low participation rate of women saying yes, I will be allocated to be induced or not be induced, that tells me that women didn't want to be induced at 39 weeks. So we had a very low participation rate. It also tells me that the women who are choosing to be induced would be quite highly motivated for that induction arm wouldn't you wouldn't opt to be in a study that was going to allocate you to induction if you didn't want to be induced. They didn't compare spawn inductive labor with spontaneous labor. They're compared women who chose to be induced at 39 weeks, women who possibly ended up being induced at 42 weeks, or had their labors augmented or had other medical intervention.

They included women who were induced in the other population. Yes.

That's just not a 39 weeks.

That's not, that's not a mutually exclusive setup at all. I mean, I thought we were looking at induced versus not induced. No, it's funny after I canceled, so both populations included induction itself. Studies are so manipulative. I mean, this is the thing and you don't know who's doing them, and you don't know what they're being paid for. Yeah. And so they end up in the duction, reduced the serious sexual rate by 4%. If we're going to look at, you know, the positive, they're positive outcome of the study, as publicized. But other other interventions are more effective at doing that, for example, continuity of care, with the midwife reduces cesarean section by more than 4%, significantly more than 4%. So why are we not looking at other interventions? Right, that reduces their infection. In conclusion, that's the conclusion of the study that people should be talking about.

Absolutely. So we know now, is that interesting women at 39 weeks doesn't improve the outcomes of their baby. That's what we know from that trial.

And also, could there have been some provider bias for those women who are getting induced to to support a longer induction and give the mother more time? Because this was a selected induced population. So they already had all under control, and they may have been more tolerant and given them more time and thereby skewed the Cesarean rate? Yeah, absolutely. It's really just a lot of nonsense. But what that other population includes with a higher C section rate is women who went past 39 weeks, who say, developed preeclampsia, and had to be induced with Pitocin. And ended up with a C section there. And it's implying this is the comparison of induction with Pitocin versus expectant management of labor, which is not being induced, that whole segment of the study should be discarded, like, bad, it's just steady shooting accurate. Well, maybe the part about the part about inducing women versus letting them inducing women at 39 weeks did not reduce. That was the primary finding. That's your primary finding. And but that's not been the focus, the focus has been on this reduction in C section, which is bogus.

So in the past month, two different women on Instagram sent us videos, one was potentially unlawful, because someone recorded her female doctor, that was saying, like, Look, I'm not going to let you be pregnant forever, we're not going to like as if a woman would be pregnant forever, we're not going to let that happen. So that's not a choice. So we're going to be inducing you she's very pushy doctor, she was really gifted at being pushy, gifted at rhetoric, it was a very daunting, even for me to listen to, I was just feeling frozen, listening to this woman speaking to the client. And then there was a male doctor who has an Instagram page who is like, this is why we reduce. This is why we induce all women at 39 weeks because it lowers that C section rate as if he cares about lowering the C section rate. But it this says they're taking this partial bit of a conclusion. And they're running with it.

And they're ignoring other research. They're ignoring all the other research, right here. There are, there are multiple other trials that have actually specifically looked at the this is their inception rate with induction versus not induction in different contexts. And they have very different findings, they find that induction increases the chance of cesarean section for first time mothers. And I would encourage women to find ask about studies that relate to their population. So for example, in Australia, the study looked at a low risk population who had been induced or not induced and found that if the woman was induced, she had a 26.5% chance of a cesarean. And if she had a spontaneous labor, because you need to really compare it against spontaneous labor. She had a 12.5% chance of cesarean section. So if you're in Australia, you're low risk woman. That's the kind of study you want to be looking at to work out whether or not ping induced is going to increase your chance of having a cesarean not a study based in the US with primarily private obstetricians that didn't even set out to find that. And with a 27% participation rate, it's like it's not doesn't answer that question for you. Yeah, I think it's important for care providers to understand the difference in terms of how they care for women. So a lot of my writing is around physiological birth and supporting childbirth physiology. And time and time again, I'm reminded that you Often what I am teaching around physiology is being applied to induce laborers, and it doesn't apply to induce laborers. So for example, early and I'm using brackets here early urge to push, or you know, women pushing before their cervix is completely open is a normal part of a physiological birth. But if a woman's being induced, it can cause a problem, because it's not a physiological birth. So what you can get is like an obstructed labor pushing in the cervix can swell and it can cause problems. So as a care provider, your care providers it will will, you know, I do that because women have smaller cervixes. It's all really dangerous sight. Yes, they might do if they're being induced, but when I'm talking about, you know, pushing early and not doing vaginal examinations, I'm talking about physiological birth. And it's the same with baby monitoring babies, you know, sometimes I hear stories being told about induction of labor, and the girl is amazing, the labor is reduced, and she didn't even have monitoring. So Oh, my God, like, but it's not physiological birth and the baby is. So I think it's really important as care providers we are very clear about physiological birth requires very different support, which is actually just to keep out of the way. induce labor requires us to do things to make sure to ensure the mother and baby are safe to, that's when we get to do our things. That's when you get to do the rebels or, you know, shuffling around with the pelvis when the woman's got the epidural leave the woman who's having a physiological birth alarm. So I think I just really wanted to make that point is that yeah, induction is not physiology and shouldn't be treated as physiology.

Yeah. It's such a simple, it's such a simple way of looking at it that is so often overlooked. It's just not the same thing there. And they're in different realms. Yeah. And women that I've talked to women who are really upset that they had the injection of Pitocin, after the birth for the placenta, and, you know, saying to me, I didn't consent to that, and I don't know why I got it. And then you kind of tell me about your labor and the Polos induced and fabricate. So obviously, that woman was not informed that once you step onto that induction train, you're heading a particular way. And that includes medical intervention all the way along, you can't just get off the train partway through. So that really needs to be made clear to women before they step onto that train.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

Just for fun, what would you have said if we went into the big baby thing? Well, there's two. There's two factors here, isn't it? There's the big baby. And there's the gestational diabetic baby. And they're actually two different things. So you can't perceive is perceived big babies, you can't diagnose a big baby, full stop.

Right? And even so even if you've got a scan where you think the baby is big, you don't increase. You don't improve outcomes by inducing on suspicion of a big baby, which is why actually the guidelines NICE guidelines World Health Organization guidelines also do not induce based on an assumption or perception that this baby's big. So if you think if you think the baby's big inducing is not it's not even recommended by guidelines. Gestational Diabetes is a different ballgame altogether. And if a woman has got that label and has, you know, maintained her blood sugar's then she's not going to have a big baby. And it's all about her blood sugar management.

Well, if she hasn't, then she is if she hasn't, she's more likely to be birthing a big baby and women can birth big babies. I'm trying to read this Cochrane review here there's insufficient evidence to clearly identify if there are differences in health outcomes for women with gestational diabetes in their babies, women elected booths undertaken compared to waiting for labour to start.

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About Cynthia Overgard

Cynthia is a published writer, advocate, childbirth educator and postpartum support specialist in prenatal/postpartum healthcare and has served thousands of clients since 2007. 

About Trisha Ludwig

Trisha is a Yale-educated Certified Nurse Midwife and International Board Certified Lactation Counselor. She has worked in women's health for more than 15 years.

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