Surprise! Induction lowers the risk of C-section


Natural childbirth and homebirth advocates love to bemoan the “cascade of interventions.” Their theory is that every intervention leads to more interventions until finally a C-section is necessary. The implication is that if the first intervention had been withheld, the mother would have gone on to have an uncomplicated vaginal delivery of a healthy baby. But like so much of natural childbirth and homebirth advocacy, the dreaded cascade of interventions is made up crap, designed to demonize tests and procedures that the natural childbirth industry cannot provide or profit from.

In fact, in many cases, the opposite is true. Many interventions make it LESS likely that a mother will have a C-section, not more. For example, there is a growing body of evidence that induction of labor leads to a LOWER C-section rate than awaiting spontaneous labor. A large, comprehensive study just published in the Canadian Medical Association Journal provides the most compelling evidence yet that induction lowers the risk of C-section.

The study is Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis by Mishanina et al.

The authors explain:

Although induction of labour has been criticized for an associated increased risk of cesarean delivery, recent studies have shown that there are fewer cesarean deliveries with induction than without it. However, the findings have not had much impact on practice, in part because the systematic reviews investigated subsets of induction and included few randomized controlled trials (RCTs), and because observational data in a cohort study had risk of confounding. Consumer organizations, guidelines and textbooks have given contradictory information about cesarean risk, which can lead to confusion over decision-making, particularly given a desire to support normal birth in the face of increasing cesarean rates worldwide…

How did the authors investigate the issue?

We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery.

The literature review led to 157 papers encompassing 31,085 women.

What did they find?

Overall, … the risk of cesarean delivery was lower with labour induction than with expectant management (pooled RR 0.88, 95% CI 0.84–0.93)…

In the subgroup analysis by method of induction, 4 methods were associated with a significant reduction in risk of cesarean delivery: prostaglandin E2 (RR 0.90, 95% CI 0.84–0.96; I2 = 0%), misoprostol (RR 0.62, 95% CI 0.48–0.81; I2 = 0%), alternative method (RR 0.66, 95% CI 0.50–0.86; I2 = 60.7%) and mixed method (RR 0.81, 95% CI 0.70–0.95; I2 = 0%).

Subgroup analysis by indication for induction showed a universal reduction in risk of cesarean delivery. Induction without a medical indication provided was associated with risk reduction of 19% (RR 0.81, 95% CI 0.70–0.93; I2 = 13.5%). When we looked at risk of cesarean delivery by gestational age, we found statistically significant reductions in risk with labour induction in term and post-term pregnancies, but not in preterm pregnancies.

In the analysis by definition of induction, risk of cesarean delivery was significantly lower when the definition included cervical ripening alone or combined with stimulation of uterine contractions than when it included uterine stimulation alone. The analysis by cervical status showed a 13% reduction in risk of cesarean delivery if the cervix was unfavourable at induction (RR 0.87, 95% CI 0.81–0.94; I2 = 1.4%) and no difference in risk if the cervix was favourable (RR 0.83, 95% CI 0.60–1.14; I2 = 0%).

The risk of cesarean delivery was reduced in both high- and low-risk pregnancies.

In other words, induction lowered C-section rates for nearly every possible indication including NO indication, using every one of the most common agents, for both term and postterm pregnancies, in both high and low risk pregnancies, and even if cervical status was unfavorable.

The authors include a forest plot that graphically illustrates the results:

Induction cesarean risk

In addition, outcomes were better with induction:

Analysis of adverse outcomes showed a lower risk of fetal death and admission to neonatal intensive care unit associated with labour induction than with expectant management. No impact on maternal death was shown.

The authors conclude:

Our meta-analysis has provided a robust answer to the disputed question of risk of cesarean delivery associated with induction of labour. Women whose labour was induced were less likely than those managed expectantly to have a cesarean delivery. In addition, the risk of fetal death and admission to neonatal intensive care unit were decreased in the induction group. Our findings have implications for guidelines and the practice of obstetrics, and are reassuring for mothers, midwifes and obstetricians.

So it seems that if you want to reduce your risk of C-section, one of the most effective things that you can do is to have an induction of labor.

Ironic, no?

256 Responses to “Surprise! Induction lowers the risk of C-section”

  1. Erinn
    December 1, 2015 at 9:46 am #

    Wow what a complete lie! Absolutely not true induction makes your chance of c section higher as there is no turning back after your water is broken. I have had a failed induction and it was the worst experience I ever had.

    • Roadstergal
      December 1, 2015 at 10:53 am #

      Induction doesn’t _guarantee_ that you don’t get a C-section. It merely, as the numbers show, decreases the chance (to a greater or lesser extent, depending on method).

  2. potkettleblack
    March 26, 2015 at 1:25 pm #

    “However, use of oxytocin and amniotomy, still

    widely practised induction methods, did not

    confer a benefit on cesarean delivery”.
    What % of USA inductions don’t use Pit?

  3. Ash
    November 14, 2014 at 2:06 pm #

    Dr. T, could you explain why this meta-analysis indicates that induction lowers risk of C-section when this article explains that induction increase risk of C-section?

    • Poogles
      January 9, 2015 at 2:10 pm #

      My guess would be that the study Dr. Amy was referring to in the older post was retrospective instead of based on RCTs, so confounders were better controlled for in this newer study.

  4. Captain Obvious
    June 10, 2014 at 8:17 am #

    So much crunchy ignorance in this thread. Why be induced with twins at 38 weeks? Waiting to 42 weeks is safer than induction. Not understanding elective induction before or after 39 weeks,

  5. Anna T
    May 8, 2014 at 1:25 am #

    I believe the most effective approach to avoiding unnecessary C-sections is to *really want* to avoid unnecessary C-sections. Right now I’m not going into specifics (inductions/spontaneous births/epidurals/natural unmedicated births, etc), but into attitude. The health care system is flawed and doctors are facing a constant threat of lawsuits, which sometimes (as Dr. Amy wrote numerous times) makes the choice of C-section appealing even for a very tiny risk. Still, a LOT depends on us, as mothers.

    No doubt many women who wanted to have a vaginal birth and had a C-section were very disappointed. If in retrospective it turned out that the C-section could have been avoided, it can cause a lot of bitter feelings (the key word here is retrospective. Things are very different in the here and now). However, a mother who feels very strongly about avoiding a C-section is more *likely* to avoid it when it isn’t strictly necessary than a mother who isn’t that fussed. And there ARE a lot of mothers who aren’t that fussed, or who even opt for an elective C-section despite being told by their doctors that they are perfect candidates for vaginal births.

    Allow me to illustrate what I’m saying. I gave birth in Israel, in a hospital where the C-section rate was just above 14%. There are hospitals in Israel where the C-section rate soared above 30%. Outcomes for moms and babies were pretty much equal in all hospitals. All the Israeli hospitals are government-funded and maintain a relatively uniform high professional level. So why was the C-section rate so dramatically lower in my hospital?

    Very simple: 99% of the birthing mothers who come there are Orthodox Jewish women. They want to have large families (8, 10, 12 children), and thus are VERY keen to preserve their fertility options and avoid C-sections. Obviously the life of the existing baby is sacred and no one will foolishly risk it, but they will prefer a vaginal birth, however exhausting and painful, as long as it doesn’t pose a real danger. Orthodox women are also more likely to take calculated risks, like vaginal birth of breech babies (under careful monitoring and with the knowledge that the OR is ready and waiting should things go wrong). They will also fight for VBACs after 1 C-section, because they know that if they have another section, that pretty much closes their options for natural births and limits the number of children they can have. Another consideration is that when a woman has a houseful of children waiting for her, she wants her recovery to be as quick and easy as possible (which usually means a vaginal birth is preferable).

    I see this as a very good thing. The flip side of the story, however, is women who can’t birth vaginally (for various reasons) and just continue to have C-section after C-section because they are unwilling to give up their desire to have a large family, even though risk rises with each subsequent surgery. I personally see this as horribly irresponsible and even selfish. The mother owes it to her existing children to be as healthy as possible and not to risk her life! If I had several children at home, I’d count my blessings and be content with a smaller family rather than go to 9 C-sections (if you think I’m exaggerating and that nobody would actually be that reckless, read sine stories on the web).

    I believe religious authorities should also do their best to discourage women from being so irresponsible about their health and very life. The lives of existing people matter far more than a potential pregnancy.

    • Young CC Prof
      May 8, 2014 at 1:59 am #

      “I believe the most effective approach to avoiding unnecessary C-sections is to *really want* to avoid unnecessary C-sections.”

      I agree. Right now, a lot of American women don’t really want to avoid a c-section, or at least don’t want to take risks to avoid a c-section.

      However, here’s another interesting fact. If a woman delivers her first baby without needing a c-section, the probability of her needing one the second time goes down, way down. Hence, even in an equally risk-averse environment, the c-section rate on a population that desires large families will be lower, simply because the women who bear easily will keep doing so, driving down the overall rate.

      • Anna T
        May 8, 2014 at 2:47 pm #

        Also, this debunks the myth that as soon as you step through the hospital doors, your human rights are stripped off and you have no control of what will happen to you.

        The proof is in the pudding: where women are strongly against C-sections, hospitals indeed perform less C-sections.

  6. Arwen
    May 2, 2014 at 12:41 am #

    Gee, you mean having a controlled landing is better than just winging it, with your only recourse if things don’t go smoothly being a crash landing? You mean people who want an induction aren’t just whiny selfish brats who don’t want to be pregnant anymore, but are actually intelligent, health-conscious women who are trying to attain the best possible outcome for their babies and themselves?

    But it gets me that people act like a c-section is a bad outcome at all. I’d be all for letting women choose inductions for no reason other than it’s their bodies and they get to decide these things, but if people truly do accept that inductions -> fewer c-sections, I could see where the flipside could become true: women are forced into inductions in order to avoid the moral failing that c-sections are considered to be.

    C-sections are wonderful. One saved my life and my mother’s. And I wish I would have had one myself. That’s not a bad thing.

    • The Bofa on the Sofa
      May 3, 2014 at 7:42 am #

      I could see where the flipside could become true: women are forced into
      inductions in order to avoid the moral failing that c-sections are
      considered to be.

      Yeah, kind of puts the “avoid interventions” crowd in a bind, doesn’t it?

      But you are correct, it’s all based on the incorrect premise that there is something wrong with a c-section in the first place.

  7. deanna
    May 1, 2014 at 9:56 am #

    There doesn’t seem to be a survey on how this procedure affects the momma. For the sake of convenience, my doctor broke the water when I went to the hospital for my first planned delivery. He was going to be out of town when my due date was. I was young, not experienced at having a baby, scared and way too trusting. Completely trusting my doctor, I thought he knew what he was doing. The baby was not in trouble, it was by suggestion of the doctor to do this procedure and who was I to questioned this well seasoned doctor. My due date wasn’t for two more weeks. The doctor had difficulty breaking the water and struggled to puncture the bag. Hum. I went into labor quickly and would vomit. A few years later, this same doctor would induce labor for my sister causing her baby to be born a month early. Again the baby was not in trouble. Say what you will…hello.

    • Amazed
      May 1, 2014 at 10:27 am #

      I will. Say what I will.

      First, it seems quite strange to me that you’re complaining not that your doctor wanted you to have your baby two weeks early but that he broke your waters. If it was a planned delivery, it should have started this way or that. What’s your complain, that he insisted for an early delivery for an entirely uncomplicated pregnancy that any other doctor could have handled in his absence, or that he broke the water? Why did you agree to the planned delivery if you felt so strong that you should have waited till your due date? Surely he wasn’t the only doctor around and you would have found another OB in the hospital when you showed up in labour after your normal pregnancy.

      Second, when a doctor did something that harmed me, you can be sure none of my family went to him any more, least of all to handle the same problem he botched with me. One person harmed is enough per family, I think. Why did your sister go to the same doctor that caused you harm?

      Third, without even knowing the specific details, I find it completely preposterous that a trained doctor would take out a premature baby just because. Since you give no reason for his decision. I can only assume it was just because he enjoyed harming your sister and her baby.

      Sorry, anything you wrote made sense.

      • deanna
        May 3, 2014 at 12:15 am #

        Amazed, Where I lived there were two OBGYNs. Not a huge number to choose from and they weren’t always available. There are times that you could go to the hospital and there’d be no doctor available. My doctor was going to be out of town around the due date. The year was 1975 and 1977 for the births of the babies. Yes, it is preposterous that a trained doctor would take out a premature baby just because, but he did induce labor to a 8 month pregnant sister. I’m not my sister that had this happen to her, so I wasn’t actively making her decisions as to why she and her doctor decided on this procedure where the baby would be a premie. When you live in a area as we did, you took what you could as a doctor. I stated that I was inexperience at having a baby, was scared, too trusting of the doctor, etc.

        • Stacy21629
          May 3, 2014 at 12:52 am #

          You realize that it’s 2014, right? Not the 1970s. Maternity care and obstetrics have changed quite a bit.

          • deanna
            May 3, 2014 at 5:00 pm #

            Stacy, It is 2014. A lot has changed. duh.

          • Hannah
            May 3, 2014 at 5:35 pm #

            So why are you sharing anecdotes about 1977 as if they’re in any way reflective of obstetric care in 2014?

          • deanna
            May 3, 2014 at 6:59 pm #

            Hannah, Eventually I believe that you’ll get it.

          • MLE
            May 3, 2014 at 7:41 pm #

            Get what? Are you drunk? Just state your thesis clearly please.

          • Susan
            May 3, 2014 at 8:04 pm #

            LOL this thread is funny. Just glad I am for once not the oldest poster.

        • Amazed
          May 3, 2014 at 5:12 am #

          God. 1975. Deanna, I wasn’t even BORN then. Many things have changed.

          Do you realize that the doctor didn’t want you to deliver under possible uncontrolled circumstances? Do you know that women and babies still die today if medical care if not immediately available? More than 10 years after your horrifying induction my mom saw the tunnel of light – she had a near death experience bleeding after her second delivery. But hey, in no way can this hold a candle to you vomiting. You poor thing *pats your head*.

          That’s, that’s what your doctor wanted to avoid on your behalf. Or a similarly gory scenario. I am stunned at your self-entitlement. You expected your doctor to give up on his life to wait for your due date, didn’t you? Twenty other mommas like you, and he’d have effectively no life at all. But hey, who cares! What is his life worth against the horror of Momma Deanna vomiting.

          I suppose he had an equally stupid reason to deliver your sister’s baby earlier. You can invite her here to badmouth him, too.

          I feel so blessed that God saw fit to give me a mother who isn’t this stupid or self-entitled.

          • deanna
            May 3, 2014 at 4:58 pm #

            Good God woman…take a chill pill. It’s alright to express a comment or two. Are you always so defensive? You’ve read into my previous comments more than necessary.

          • Amazed
            May 3, 2014 at 5:49 pm #

            It’s absolutely alright to express a comment or two, or two hundred twenty two. It’s also all right to call posters out for posting stupidity when you see it.

            I only take the pills that my doctor prescribes, thank you very much.

          • deanna
            May 3, 2014 at 7:05 pm #

            Amazed, It wouldn’t be very entertaining if others such as yourself stopped calling out posters.

          • The Bofa on the Sofa
            May 3, 2014 at 9:38 pm #

            Good God woman…take a chill pill. It’s alright to express a comment or two.

            If it is alright to express a comment or two, why are you telling Amazed to “take a chill pill.” Isn’t she allowed to express a comment or two, too?

            I am always fascinated by people who complain about others responses with the defense, “I’m allowed to express my opinion.”

          • Amazed
            May 4, 2014 at 9:07 am #

            Awww, Bofa, but the problem isn’t that I expressed a comment or two. The problem is that I am meen. Well, I suppose I ought to be. I am Meen Dr Amy’s shoe, remember?

            What can I say. Silly people, I can stand. Entitled ones, I can stand. But a combination of the two, and idiotic diminutives thrown in the mix? Not gonna happen.

            By the way, even after relaying her dramatic vomiting experience, Momma (or should it be Grandmomma?) Deanna still hadn’t told us what she thinks should have been done differently, doctor resigning his life, or her squatting among the trees to pop her kid out all naturally.

          • deanna
            May 4, 2014 at 11:41 am #

            AMAZED~ Sweetheart, where I lived there weren’t forest and there were very few trees….Not going to pop a baby out like an animal in the forest as you put it. You completely missed the point. There’s more to the story than the doctor resigning his life or squatting. The doctor wasn’t trying to spare a horrible birthing experience for the mothers or babies. He was encouraging mothers to have their babies when it was convenient to his schedule, not for health reasons. He frequently took advantage of pregnant women and wasn’t concerned about if the baby was full term or if the baby or mother were in trouble. End of story. Enough said. It isn’t odd to me when others use being a grandmother as an insult. Because one is ancient doesn’t mean that they stop living. You’re getting older by the second yourself. Dr. Amy isn’t exactly a young chicken and you seem to be alright conversing on her blog and reading the latest. Blab away.

          • Susan
            May 3, 2014 at 8:07 pm #

            Sort of laughing because anyone born in 1975 is going to be treated as advanced maternal age… gee probably 1978.

          • Amazed
            May 3, 2014 at 8:16 pm #

            I wonder what anyone who gave birth in 1975 should be called here… advanced grandmaternal age? For dispersing birth wisdom, I mean.

          • Susan
            May 3, 2014 at 8:20 pm #

            I was quite young but my first was born in 1979, one in 1982 and one in 1998 and I was still young enough to crank one out but spanning four decades wasn’t in the guiness book so I decided it wasn’t good enough for bragging rights. And I am going to be a grandmother so I am EXCITED!

          • Amazed
            May 3, 2014 at 8:27 pm #

            You’re having a new addition to the family? For real? Congratulations!

          • Susan
            May 3, 2014 at 8:28 pm #

            Thank you I am so excited!

          • yugaya
            May 3, 2014 at 8:54 pm #


          • Amazed
            May 3, 2014 at 8:57 pm #

            Damn you, now this world entered my vocabulary. I might even use it to address my own grandmother. Good thing she doesn’t speak English. Old girl is tough as nails and can’t stand idiotic diminutives. As long as I don’t slip and translate it, I am quite safe.

          • Trixie
            May 3, 2014 at 10:53 pm #

            Lil Grandmomma.

        • yugaya
          May 3, 2014 at 8:47 pm #

          Goodness grief woman, I was born back then. I do not doubt your anecdote represents the way you gave birth in 1975., and how it may have been for a number of women.

          Since then, world changed, hospitals changed, doctors changed. I myself gave birth a couple of times since being born cca 1975/1977. I’m sure my mom and you could swap anecdotes.

          Can we now concentrate on year 2014 and discussion of the most recent study on inductions please?

          • deanna
            May 3, 2014 at 8:51 pm #

            yugaya, You go ahead and concentrate on whatever your lil heart desires.

          • yugaya
            May 3, 2014 at 8:54 pm #

            I’m actually concentrating on a broken washing machine at 3 AM at the moment that is choke full of water and threatening to induce major disaster. Momma stories from times long gone are a way to kill the clock indeed, but I would prefer something more recent. 🙂

            EDIT: And the condescending tone is a must I guess when all your input on the subject is telling vintage birth stories of evil doctors.

          • deanna
            May 3, 2014 at 9:03 pm #

            yugaya, Sorry about the broken washing machine. Been there…done that. May all go well.

          • yugaya
            May 3, 2014 at 9:27 pm #

            Nah that is just a washing machine doing what it was “made to do”, but having some difficulties due to individual multiple risk factors ( age, number of times it was used previously, extra heavy load of laundry this time), so I am just waiting here until the qualified person comes and looks at it and fixes it if needed. I could have tried to do it on my own, but then there would have been no guaranteed outcomes. I also could have just gone to bed, and left it to finish “what it was made to do” on its own like it normally and naturally does. I mean, it has done it so many times before without slightest hint of trouble, and I have many friends who never have any problems with their washing machines staying full of water.

            I could have just… you know… prayed and waited for the natural end of its cycle. I mean, how many washing machines really completely break down and flood everything over night? That must be like totally rare compared to how many don’t and are just fine and can wait for the repair man in the morning …and… maybe I should wait until Monday? That would certainly be much cheaper and far more comfortable that this situation.


          • Box of Salt
            May 3, 2014 at 9:45 pm #

            “Nah that is just a washing machine doing what it was “made to do”
            yugaya wins the internet today.

          • yugaya
            May 3, 2014 at 10:46 pm #

            I’m so putting this quote on the commemorative T-shirt:

            “If you cannot stand the deliberate use of baby talk in what is supposed to be an objective, science based discussion perhaps you should refrain from replying to those that use diminutives.”

            That is how NCB replies to criticism – you meeen people should all just shut up if you cannot stand the subject of childbirth being deliberately dumbed down and infantilized.

    • Sullivan ThePoop
      May 1, 2014 at 10:38 am #

      I am very confused by this story. I never had an induction like that.

    • Stacy21629
      May 3, 2014 at 12:52 am #

      Can we not use diminutives, please? How this procedure affects the *mother*. I can’t stand the deliberate use of baby talk in what is supposed to be an objective, science based discussion. If you want people to take you seriously, let’s use grown up words, please.

      And what exactly is your gripe about being induced? In what way does it negatively affect the mother? That it made you vomit? The horror.

      Guess what, I have had 2 unmedicated, non-induced labors and puked the whole way through both and 1 into the immediate post-partum too. The fact that you were induced is not responsible for vomiting during labor. Some women simply react that way.

      I assume you had a healthy baby after this procedure?

      • deanna
        May 3, 2014 at 5:14 pm #

        If you cannot stand the deliberate use of baby talk in what is suppose to be an objective, science based discussion perhaps you should refrain from replying to those that use diminutives as you have put it. I wasn’t griping. I was sharing some comments.

        • Hannah
          May 3, 2014 at 5:35 pm #

          You made comments that that didn’t actually make a point.

          I am not bothered about diminutives, personally, but I am bothered by people sharing anecdotes about births that happened 35 years ago, that follow classic NCB tropes, accuse doctors of inducing for convenience and confuse correlation with causation.

          • deanna
            May 3, 2014 at 5:43 pm #

            Hannah, my dear child, then you must be a very bothered person. Many people share anecdotes. Including you. Please check your math facts.

          • deanna
            May 3, 2014 at 5:44 pm #


          • Hannah
            May 3, 2014 at 5:45 pm #

            Are you saying ‘haha’ to your own comment?

          • deanna
            May 3, 2014 at 5:46 pm #


          • Hannah
            May 3, 2014 at 5:49 pm #

            Oh, so you’re a troll. Done now.

          • yugaya
            May 4, 2014 at 5:35 am #

            “There doesn’t seem to be a survey on how this procedure affects the momma.”

            Save for the study being discussed in this blog post, and the previously published 157 papers that it reviews. 🙂

          • Anj Fabian
            May 4, 2014 at 8:23 am #

            A survey? A SURVEY?

            A well constructed survey with careful demographic sampling can give very accurate and relevant results.

            However I’ve seen a lot of surveys touted as definitive that had flaws such as selection bias.

            Have Gallup or Pew or another one of the major polling companies do your surveys. I’ll be impressed.

          • Bombshellrisa
            May 4, 2014 at 12:00 pm #

            She means where is the surgery that puts feelings about something into the mix-and there is the Press-Gainey survey that the hospital sends out now so there Is indeed a survey she just hasn’t given birth lately so she wouldn’t know that

          • Box of Salt
            May 3, 2014 at 5:46 pm #

            deanna, according to my math your child is 39 years old and you are at least in your 50s. Is it to much to ask of you to behave like an adult when you post comments?

          • deanna
            May 3, 2014 at 7:16 pm #

            Salt, You’re wonderful.

          • Hannah
            May 3, 2014 at 5:47 pm #

            I share anecdotes if they’re vaguely reflective of what’s happening in maternity *right now*. Of things that are happening to my friends and family *right now* that demonstrate that the negative trends happening that are reflected in studies about maternity care *right now*. Fundamentally different.

            My dear? You are an adult, aren’t you? I misread and thought you wrote 1979 for the last birth. Sue me.

          • deanna
            May 3, 2014 at 5:54 pm #

            I have no desire to sue you.

          • AmyP
            May 3, 2014 at 8:48 pm #

            I had my first almost 12 years ago and my most recent 18 months ago. There have been dramatic developments in standard procedures both in obstetrics and in pediatrics even just over that short length of time.

    • Bombshellrisa
      May 4, 2014 at 11:54 am #

      Most hospitals in the past 15 years have started sending out surveys to patients to evaluate their feelings about the care that they were given. A lot of those surveys come back with negative reviews, which is understandable as there are a lot of unpleasant things that can happen on the way to getting better or (because NCB types always say pregnancy isn’t a disease) during pregnancy and birth.
      Almost every home birth and birth center birth I attended involved a laboring woman who vomited. It’s just something that happens to laboring women, even attended by midwives. When I did my doula training, helping ease nausea was a big subject.

  8. EricaS
    April 30, 2014 at 1:58 pm #

    Thanks for this. I seem to think that my induction caused my C-section. I was induced with Cytotec at 41 weeks. I started labor surprisingly soon after at about 8 pm on a Friday. I did not have my son until 11:19 am on SUNDAY through C-section. My cervix kept progressing and regressing (8 cm back to 6 cm to 7 cm back to 5.5 cm etc). But I think now there was another reason for my lack of progress in labor unrelated to the induction.

    • Young CC Prof
      April 30, 2014 at 2:24 pm #

      Maybe your baby was actually stuck, due to his size or something weird about his position?

      • EricaS
        April 30, 2014 at 2:41 pm #

        They really did not give me a reason. He was 8 lbs 8 oz. My OB said my son was face up when he open my abdomen up. I was so exhausted from my labor I didn’t really go into it. I now guess position may have been the reason not the induction.

  9. Renee Martin
    April 30, 2014 at 12:34 pm #

    I think we need to pool all of these recent, damning of NCB and HB studies, and make a blog called “The Case Against NCB”.

    NCB must be taken down off the pedestal, even more than HB, because its NCB that makes moms think HB is needed, or even a good idea. NCB poisons the well, infecting CNM education, some OBs, and hospital policies. It’s the main force behind things like “39 week rule”, “baby friendly”/mom miserable hospitals, refusal of induction until way too late postdates, and the push to force VBAC and lower CS, even at the expense of babies. This isn’t even mentioning the damage done by NCB liars.

    Also, Moms do NOT have any of this info, which is to be expected. Problem is, all of their “advisors” do not have it either. These are people out there either pretending to be experts, giving advice, and otherwise influencing others. All over, bad info, and no place to easily find refutations. (This site is great, but its hard as hell to search, even when you know what to look for. It is also good to have more voices against this scourge. The more anti NCB sites, the better!)

    • Young CC Prof
      April 30, 2014 at 12:46 pm #

      Yes, I think the NCB movement is doing a lot of damage outside of homebirth. I totally agree.

      • Renee Martin
        April 30, 2014 at 12:48 pm #

        Its is also the intro to HB. I cannot think of a single HBer, other than maybe someone avoiding the authorities, that doesn’t choose HB for NCB reasons. So, fight the NCB, take a bite from the support of HB.

        • Young CC Prof
          April 30, 2014 at 1:15 pm #

          I wouldn’t say those are the only reasons. Sometimes people actually do choose home birth for financial reasons, and then you have religious fundamentalists who like to, well, do things their own way.

        • yugaya
          May 4, 2014 at 9:18 am #

          But I do not want to fight natural childbirth or breastfeeding at all. I want to fight the backwards and blind ideological dogma that promotes them as the only moral and right thing to do. I want to fight the over value that is being assigned to one single aspect of womenhood – childbirth. I want all people who attend births to be properly trained and educated and licensed and I want them all to practice legally within clear and formalized guidelines for what is the scope of care that they can safely provide and what is not, and I want them to suffer legal and professional consequences when they fail to do so, and I want them all to carry malpractice insurance.

          And I probably want to smack hard every person daft enough to dare tell any woman what her body was meant for.

      • The Bofa on the Sofa
        April 30, 2014 at 1:12 pm #

        I agree and all, but you know what happens. The instant you try to do something to refute a lie of the NCB crowd, all you get is “why are you against natural birth” and “stop trying to convince everyone to get an epidural.”

        And even if you don’t, you still get the “Yeah, but not all the things of NCB are bad” strawman attackers.

        The whole discussion gets distracted into a pissing match of having to explain the same thing over and over, that it isn’t against NCB, it is against the LIES that are being told.

        • Young CC Prof
          April 30, 2014 at 1:19 pm #

          My default answer to the epidural question when discussing the evils of radical NCB is that it is absolutely none of anyone else’s business whether you get one or not. (The more complicated answer is that I’m bothered by people pressuring women NOT to.)

          And yes, not all NCB things are bad! Of course, the good parts you can get in a hospital if you want.

          Kind of like herbs that way. The most effective ones have already been tested, purified, measured and packed up in little amber bottles.

          • The Bofa on the Sofa
            April 30, 2014 at 9:50 pm #

            Fine, you go with your default answer. And now the discussion is about not criticizing those who don’t have epidurals and away from the original focus of the lies of the NCB movement. Derail successful.

            This is always what happens if you try to address the problems caused by NCB.

          • Busbus
            April 30, 2014 at 9:56 pm #

            I am interested in this thread, because I do think that NCB ideology is at the core of all of this. I don’t know if it’s possible to address that in a way that actually gets heard, but I’d sure like to find a way to.

          • The Bofa on the Sofa
            April 30, 2014 at 10:00 pm #

            I wish there was a way to get it heard, too. But you see it hear all the time. Dr Amy has a post about something really annoying done in the name of lactivism, and the responses are all, “Why do you hate breastfeeding,” which means the followups have to focus on the fact that no one hates breastfeeding.

            Until the next one comes along.

            This martyr-attitude that unless you are going over the top in promoting it then you must be against it prevents any meaningful progress.

          • Busbus
            April 30, 2014 at 10:23 pm #

            KInd of reminds me of the “War on Christmas”… ;-p

          • Young CC Prof
            April 30, 2014 at 10:27 pm #

            How dare you not celebrate Christmas in every possible public space! You’re oppressing my religious freedom!

          • Young CC Prof
            April 30, 2014 at 9:57 pm #

            Yeah, that’s why I say, “none of anyone else’s business” whenever epidural are mentioned and change the subject back to medically appropriate or necessary interventions.

          • Busbus
            April 30, 2014 at 9:53 pm #

            I always think the problem isn’t NCB itself, the problem is *promoting* NCB as the best option for all. There is nothing wrong with an unmedicated delivery, but organisations that “promote natural birth” are highly suspect. Why do you need to promote that? What’s the agenda?

            I actually think the same about breastfeeding promotion: It’s great to have lactation support for mothers who have already decided they want to nurse. But in my opinion, it’s highly problematic to promote breastfeeding (ie, programs to raise breastfeeding rates) because it’s all about ideology. And whenever public funds are used, it’s just about the biggest waste of tax payers money ever. Use these funds to do something that *actually* helps disadvantaged children and families, or that *actually* has an effect on public health.

          • Young CC Prof
            April 30, 2014 at 10:00 pm #

            Or, in certain public health care systems, using NCB propaganda to justify slashing maternity care funding, or divert resources from real maternity care to provide woo and out-of-hospital birth.

          • OBPI Mama
            May 3, 2014 at 6:31 pm #

            I love this comment.

      • Hannah
        May 3, 2014 at 5:38 pm #

        Especially in medical systems that rely heavily on midwives. I harp on this point a lot but the UK has appalling figures and outcomes in maternity and, surprise, surprise, it is a system infected with woo midwifery despite the fact that said midwives are university educated. The same thing is happening in Canada and Australia.

    • Arwen
      May 2, 2014 at 12:47 am #

      Yes. Because there are plenty of docs who also buy into a lot of this NCB crap and that is just not smart.

  10. Busbus
    April 29, 2014 at 11:05 pm #

    Hm… and now I think of how in NCB circles, women are constantly admonished to virtuously wait it out and “let the baby decide” instead of “giving in to their own desires” to get it over with. Getting an induction without dire medical need is kind of painted as something only”bad mothers” do who “can’t even wait another couple weeks”. Well, go figure.

    • Mac Sherbert
      April 30, 2014 at 1:54 pm #

      Yes. They demonize the mother for wanting to get it over with. I think the appropriate response to that is…Hey, it’s the mother’s instincts telling her the baby needs to come earth side.

    • Guest
      April 30, 2014 at 9:39 pm #

      “Lady, will you let the baby decide to touch a hot stove?”
      “Lady, will you let the baby decide to run across a busy street?”
      “Lady, will you let the baby make the decision on the most dangerous day of their life?”

      • The Bofa on the Sofa
        April 30, 2014 at 9:52 pm #

        “Lady, should I build a wall”

  11. Jessica S.
    April 29, 2014 at 8:44 pm #

    Thank you so much for highlighting this, Dr. Amy!

    • Sue
      April 29, 2014 at 9:39 pm #

      Hardly a valid study, though, is it? Where’s the data on Castor Oil? Or Black Cohosh? And not even a word on visualisation!

      • Sue
        April 29, 2014 at 9:41 pm #

        Oops – they’re there – my mistake.

        • Renee Martin
          April 30, 2014 at 12:38 pm #

          They are all mixed together, but it doesn’t include cohoshes.
          I am not surprised that they don’t have a downside, as they do nothing (homeopathy?), but if there is ONE thing that NCBers will take from this, its that their induction methods are evidence based and better than the others.

  12. Elizabeth Nelson
    April 29, 2014 at 8:17 pm #

    Looking at the breakdown by method of induction, alternative methods (acupuncture, breast stimulation, sexual intercourse, homeopathic preparations, castor oil, bath or enema) have a much lower relative risk of c-section than inductions by oxytocin (0.66 vs 1.03) And induction via oxytocin does not show a decreased risk of cesearean. Footnote states that “values less than 1 indicate a decreased risk of cesarea delivery” and the value for oxytocin inductions is 1.03. I’d also be curious to look more closely at the 58 studies excluded from this meta-analysis.

    • C T
      April 29, 2014 at 8:25 pm #

      I thought it was interesting that “membrane sweeps” count as inductions. I’ve had them and they seemed to help get labor going…a couple of days or a week later……I would classify that as “preparing the body a little more for labor” rather than actually inducing it.

      • Stacy21629
        April 29, 2014 at 8:40 pm #

        I think it’s more interesting that for NCB types and CPMs the amount of things they promote that they DON’T count as induction:
        acupuncture, chiropractic, herbs, breast stimulation, sex, walking, castor oil, spicy foods, pineapple, etc etc etc.

        There’s a HUGE list of things that CPMs will advance to try and “get labor going”. Of course they never call it “induction” because it usually doesn’t work…

        But all those things are A-OK but actually going to a hospital to have AROM and pitocin are EVIL because you’re “rushing” the baby and “baby’s come when they’re ready”. Much like the nitrous vs epidural thing, I think it just boils down to “what I can do at home is good and what the OB can do at the hospital is evil”.

        • C T
          April 29, 2014 at 9:11 pm #

          Breast stimulation actually is included in the chart above as an alternative method.

          • Stacy21629
            April 29, 2014 at 9:18 pm #

            I wasn’t commenting on this paper so much as the NCB/CPM mindset. They’re ok with a whole slew of things to “get labor started” but not at all with induction. What exactly is the difference????

          • Anj Fabian
            May 3, 2014 at 7:54 pm #

            How many techniques do hospitals use to “get labor started”?
            balloon foley
            membrane sweep

            That’s the ones I can remember. It’s a short list.

    • mostlyclueless
      April 29, 2014 at 9:39 pm #

      I wonder if it’s some kind of population difference — people who are unwilling to consent to traditional methods of induction may also be less willing to consent to c-section.

    • Jessica S.
      April 29, 2014 at 9:48 pm #

      I suspect that it would having something to do with the likelihood each woman has of ever reaching spontaneous labor in the first place. Meaning, if you only need a nudge, then you would be less likely to need a CS. If you need all the tricks in the book, including the book, thrown at you, it’s unlikely vaginal delivery would be easy in any event. So it’s like sorting out the women, who are now in post dates, might have a shot at vaginal delivery before waiting until the last minute, where the baby is less likely to tolerate labor, even if the body is willing.

    • mostlyclueless
      April 29, 2014 at 10:00 pm #

      I just took another look. Note that the alternative methods also have a very high I2 value. This is a measurement used in meta-analyses like this one that describes how consistent the findings were in the studies being analyzed. The high value indicates that the studies in this category had a lot of disagreement between them — suggesting that maybe the evidence in this category is not high-quality evidence, for whatever reason.

      More on the I^2 statistic:

    • theadequatemother
      April 30, 2014 at 9:23 am #

      It’s also important to note that if the CI crosses 1, the effect is neutral. another way to look at it would be that inductions that use oxytocin or AROM+oxy don’t increase the cs rate.

      Also look at the authors’ they are MBBH and have a focus in their intro on the importance of reducing the cs rate and promoting “normal” birth. Whatever that is.

      • Young CC Prof
        April 30, 2014 at 11:27 am #

        So, you’re suggesting that the babies who just need a little nudge, medically, are more likely to come out vaginally if nudged in a timely fashion. Babies who need a giant shove to get started and still won’t come weren’t going to come anyway.

    • CanDoc
      April 30, 2014 at 3:45 pm #

      Most of the reaction to this in the Canadian OB community is to take it as an affirmation of what we already know – if you ripen the cervix (misoprostol, vaginal prostaglandins) as a form of cervical preparation for labour, then active labour itself (i.e. often induced by oxytocin) goes much more smoothly. In Canada we’ve really moved away from the traditional dogma of, “Rupture membranes and start oxytocin as soon as you are able to”, to “Use ripening agents (sometimes repeatedly over 1-2 days) until labour starts, then use oxytocin if needed to augment labour.” (Note that the UK has been doing this for years.)

      • Dr Kitty
        April 30, 2014 at 5:43 pm #

        Yep, in the UK hospital where I trained if you had a low Bishop score you came in after dinner, get clerked in about 8pm, got vaginal prostaglandin at 10pm, and a sleeping tablet if you wanted one (!), then a cervical check at 6am and either another dose of prostaglandin, or AROM if things had progressed, then whatever was necessary to keep things moving along nicely.That way, by midday you knew if the second dose had failed and you could have a CS before 5pm.

        The ladies with high Bishop scores just came in at 6am and skipped the first dose and the overnight stay.

        It was quite civilised.

        • CanDoc
          April 30, 2014 at 10:33 pm #

          Funny, this is almost exactly what we do in our centre now, too! 🙂 Although we do our evening check at 8 pm and morning check at 8 am… we can’t keep late night ours or rise early in the morning like those of you on the other side of the pond.

          (Well, except we will give up to 6 doses of vaginal ripening agent before discussing a failed induction, which usually takes 2-3 days.)

          • Young CC Prof
            April 30, 2014 at 10:37 pm #

            I suppose that’s one advantage to doing an induction BEFORE getting the baby out becomes urgent. You can do it gently, let it take a few days, let the woman rest during the process and probably see fewer failed inductions and fewer emergency c-sections.

          • Mer
            May 3, 2014 at 1:34 am #

            That’s the protocol my hospital follows, and after each dose baby gets a NST or BPP since patients aren’t admitted until labor starts or it’s decided the induction is a failure.

  13. SarahSD
    April 29, 2014 at 7:46 pm #

    Can someone unpack/explain/evaluate the differences in C-section risk reduction for different induction methods? It appears that induction with pitocin or AROM + pitocin does not show a decrease C-section risk while other methods do. If this is the case, any ideas why?

    Since pitocin inductions are so widespread and are most often the target of NCB rage, I think the specificity matters and it may be misleading to claim induction lowers the C-section rate when most people think induction = synthetic oxytocin but the study only shows significant reduction with these other induction methods including ambiguous categories like “mixed method” and “alternative method”. What are these?

    • Dr Kitty
      April 29, 2014 at 7:57 pm #

      Foley catheter, membrane stripping, laminaria would be my guesses for “alternative methods”. I assume they don’t mean cohosh and reflexology.

      “Mixed methods” would be Foley catheter and AROM or laminaria and pitocin or some other combination other than AROM and pitocin.

      • Young CC Prof
        April 29, 2014 at 8:04 pm #

        Nope, the footnote says they actually mean alternative-medicine methods like herbs, acupuncture or sex.

        • SarahSD
          April 29, 2014 at 11:30 pm #

          Well that’s interesting.

    • mostlyclueless
      April 29, 2014 at 9:42 pm #

      I can think of a couple possibilities. Maybe, even when the cervix appears favorable, some kind of cervical ripening is before pitocin augmentation creates optimal conditions for labor.

      Or it may reflect some kind of underlying difference in the populations — if doctors tend to choose prostaglandin inductions for X reasons and pitocin for Y reasons, maybe people in Y group were more likely to end up with a c-section anyway. I don’t know enough about what causes doctors to choose different induction methods to do more than speculate though.

    • theadequatemother
      April 30, 2014 at 9:29 am #

      I think some of it could be selection bias. Many of our inductions are begun with a prostaglandin. It’s inserted and after a period of monitoring you can be discharged. Women who then begin to labour are different from women who need a second dose, and then some pitocin and then an arom…I think the other commenters have bit the nail on the head, once the induction begins the less you need is probably a reflection on how well the labour is progressing.

      As for those alternative methods forgive me if I’m wrong but are any of them actually effective at starting labour? I thought there was evidence that sex didn’t work. So if you engage in alternative methods and go into labour, that is likely a coincidence and you are in the same category as a woman in spontaneous labour in terms of CS risk. Seems unfair to compare that to women who are being induced.

  14. fiftyfifty1
    April 29, 2014 at 7:36 pm #

    Slightly off topic:
    I wonder about cervical ripeness. Why are some women super ripe by 37 weeks and some still High, Hard, Closed, Long and Posterior at 42 weeks? Obviously parity plays a part. But what else? Is this just a run of the mill genetic biological distribution, with some bodies betting that Natural Selection will reward a near-preemie while other bodies bet on avoiding a preemie at all costs? Or is something else going on here such as a biologic malfunction due to something about our current lifestyle? Could something be making some women “deaf” to the normal signals that tell the cervix to ripen? And has the “best” gestational age to be born changed with technology? In the past, being born at 37 weeks might have caused a big increase in death due to being undersized and mildly immature. Now with the NICU, it’s seldom a problem. Maybe in the past, the better strategy was to avoid borderline preemie at all costs, even if that meant some of your offspring might go postdates and experience stillbirth.

    • Dr Kitty
      April 29, 2014 at 8:04 pm #

      My mum was a failed IOL at 42 weeks after SROM with a low Bishop score and an unengaged presenting part and no sign of CTX for almost 24hrs after ROM.Minimal dilation despite pit high enough to produce tetanic contractions and a foetal bradycardia, crash CS.

      Me, long, closed, posterior cervix at 39 weeks with an unengaged head…of course I opted not to roll the dice and went for a CS, but I suspect an induction would not have been successful.

    • Young CC Prof
      April 29, 2014 at 8:13 pm #

      You know, there are a lot of examples in nature of where the “average” trait is most desirable. Got a really solid cervix? Baby might never come out, and you die with your first offspring still inside you. Got a really soft easy cervix? Your babies are at risk of prematurity, real prematurity that’s almost always fatal without medical care.

      So, natural selection is aiming for an “average” cervix that softens around 39 weeks and lets go at 40, but a few individuals will always fall to one side or the other.

      That’s my armchair speculation, anyway.

      • Trixie
        April 29, 2014 at 9:12 pm #

        Except, people go different lengths of time with different pregnancies. I was talking to a woman the other day who had 6 kids at 38 weeks and the 7th at 42. So there must be other stuff going on.

        • Kristie
          April 30, 2014 at 7:23 pm #

          Perhaps the baby itself? I went longest with my last, and he was more than a pound heavier than any of my other babies. During labor, he took forever to move down, and in the end CNM who delivered him was surprised he fit through my pelvis at all.

          • Trixie
            April 30, 2014 at 7:53 pm #

            I don’t know. My kids were basically the same size, but one was 38 weeks and one was 41 weeks.

    • Laural
      April 30, 2014 at 9:22 am #

      If it was evolution would there be a familial ‘labor pattern’ or at least cervical ripeness similarities among closely related females?

      I’ve been honored to have five babies… all within the 37-38 week timeframe, and my cervix is soft/ripe/early advanced dilation. A couple were technically induced… to avoid an accidental homebirth.

      My last doc suspected I have something wrong with my placentas to make me have this chronic ‘borderline prematurity’ which surprised me as I always was told 37 weeks was term- it is the 39 week culture now, though I guess. My last baby has two true knots in her cord; another one had one true knot, the doc wondered if that had to do with a bad placenta as well..

  15. meglo91
    April 29, 2014 at 7:33 pm #

    I too have an N of 1 and 100% success rate. My first birth started with SROM and, 17 hours of agonizing and mostly unmedicated labor later, ended with the birth of my first child. The second time around I had PIH and a soft diagnosis of preeclampsia (which I probably had had with baby #1 as well). The docs induced at 38 weeks with a foley catheter and pitocin, I labored comfortably in bed with an epidural for about 12 hours, and my second child was born after about a half hour of pushing. I did not feel any pain. Even with the somewhat panicky induction, I’d take the second experience over the first any day.

    • Stacy21629
      April 29, 2014 at 7:06 pm #

      Surprise! NCB followers are blinded by their biases.

      • Young CC Prof
        April 29, 2014 at 7:16 pm #

        Science. If you don’t make mistakes, you’re doing it wrong. If you don’t correct those mistakes, you’re doing it really wrong.

        If you engage in fight-or-flight when contradicted, you aren’t doing it at all.

    • Young CC Prof
      April 29, 2014 at 7:09 pm #

      I especially like the comment consisting only of “BS.” No, you don’t have a knee-jerk reaction to anything that interferes with your preconceived notions, not at all.

      • Dr Kitty
        April 29, 2014 at 7:53 pm #

        31,000 women can’t be wrong…unless they don’t support the NCB party line, in which case, obviously, they are.

        • Young CC Prof
          April 30, 2014 at 1:10 pm #

          If you thought your hospital birth was awful, you must be right, and anyone who tries to explain that the doctors were just trying to help is a tool of Big Pharma. If you thought your hospital birth was basically fine, you need your consciousness raised.

    • Life Tip
      April 29, 2014 at 7:52 pm #

      Maybe a dumb question, but is this article saying that the drug oxytocin and rupturing membranes is ineffective in general? Or just ineffective in reducing c-sections?

    • PrimaryCareDoc
      April 30, 2014 at 1:00 pm #

      That’s some mighty deep sand that they’re sticking their heads into. All those comments basically boil down to them saying, “Nah Nah Nah, I can’t hear you!!!”

  16. fuck dr amy
    April 29, 2014 at 6:05 pm #

    wheres the actual study? this just lists their assessments and results.

    • Dr Kitty
      April 29, 2014 at 6:15 pm #

      Dude, it’s a SYSTEMATIC REVIEW.
      Which means it is a meta analysis of lots of studies.
      Which means it is probably the most definitive answer we’ve got at the moment.

      If you don’t even understand the difference between a RCT or cohort study and a systematic review, you have no business critiquing the findings.

    • Guest
      April 29, 2014 at 6:22 pm #

      Try the little blue link.

      With such powerful observational skills (and eloquent language, I might add), I’m sure you’ll have no problem proving the review of 157 papers wrong. *snark*

    • Box of Salt
      April 29, 2014 at 6:22 pm #

      Did you click on the blue text in the third paragraph down? Then the yllow box marked “Full Text”? It’s not even behind a paywall.

    • Stacy21629
      April 29, 2014 at 6:45 pm #

      Ah, an open-minded and unbiased commenter. Refreshing.

    • Jessica S.
      April 29, 2014 at 9:34 pm #

      A wonderfully open-minded screen name. Do you always put your best foot forward?

    • Carolina
      April 30, 2014 at 10:32 am #

      Do you have trouble following links? Follow the link above, and that page has another link. Amazing, this internet. Are you Tara? The punctuation and language are very similar to the troll on the facebook page

      • Hannah
        May 3, 2014 at 5:55 pm #

        I am finding similarities between a few derailers and commenters here, at the moment. The ‘voices’ are very similar.

    • Renee Martin
      April 30, 2014 at 12:47 pm #

      But you probably cannot read well enough anyway.

  17. moto_librarian
    April 29, 2014 at 5:38 pm #

    I had prodromal labor for ten days before one of the CNMs at my practice took pity on me and offered to strip my membranes (I was 38 + 5). Contractions finally started causing dilation to progress, and I went to the hospital at 5 cm. Got an epidural, felt relaxed and comfortable, and proceeded to stay at 5 cm. for about 10 hours. CNM on call started pitocin, which baby did not like. She finally broke my water around 3:00 am, and baby was born at 4:29 am. To this day, I’m not sure why she didn’t just do AROM to begin with, but I remember being so grateful for what amounted to a “soft” induction after being so miserable for so long.

  18. mostlyclueless
    April 29, 2014 at 4:35 pm #

    Great article. Have any of the NCB blogs/advocates commented?

    • The Bofa on the Sofa
      April 29, 2014 at 5:20 pm #

      As Maguire writes in Wicked, when asking if the Wicked Witch has returned…

      “Not yet…”

  19. Aki Hinata
    April 29, 2014 at 4:27 pm #

    Holy cats! NCBer’s heads will explode whey they see that “eevil” Cytotec induction reduces C/S risk.

    • Medwife
      April 29, 2014 at 5:06 pm #

      I KNOW! And it’s been established for some years now that cytotec is the method of induction with the highest rate of vaginal birth. I find that the people most wanting to avoid c/s are vehemently against using cytotec and pitocin, but they’re fine with AROM, which does not do a whole lot for primips. *shrug*

      • lawyer jane
        April 29, 2014 at 7:11 pm #

        I dunno, if the FDA didn’t approve Cytotec for inducing labor, I think I’d skip it.

        • fiftyfifty1
          April 29, 2014 at 7:16 pm #


        • Jessica
          April 29, 2014 at 7:18 pm #

          Maybe one day Dr. Amy or a guest commenter could explain to the masses how FDA approval is obtained for drugs and why off-label use isn’t necessarily a bad thing….

          • Sue
            April 29, 2014 at 9:49 pm #

            Jessica is right. Adding a new indication for a drug costs a lot more time and money – manufacturers often won’t go through that once their product is out in the market.

            As a clinician, I don’t feel constrained by these processes – we use what is supported by the literature as effective and relatively safe. Lots of medications are therefore used ”off label”.

          • Stacy21629
            April 29, 2014 at 9:57 pm #

            I’m a vet. Nearly EVERY medication I use is “off label”, especially for cats. We extrapolate from human indications and literature and use our own studies to determine dose ranges and treatment strategies.

          • KarenJJ
            April 29, 2014 at 10:37 pm #

            I use a drug that’s “off-label” – it’s mostly used and tested for Rheumatoid arthritis and my issue is “close-enough”. It’s awesome – it works better for what I have then it does for RA.

          • Deborah
            April 30, 2014 at 12:46 am #

            There is another very specific problem with the labeling on cytotec, above and beyond the fact that it’s not FDA approved for any obstetric use. The manufacturer issued a letter in the early 2000’s completely divorcing itself from any non- GI use of the med. However, this letter was issued about a week after one of the major papers presenting the mifepristone/cytotec medical abortion protocol. I always took it as a political move for the manufacturer to distance themselves from being the makers of an abortion drug, but the letter reads like you aren’t supposed to use it for anything obstetric. So that’s floating around out there making people uncomfortable about the obstetric uses of cytotec, when it’s really all abortion politics. (When that letter came out, I was TERRIFIED they’d take it away from us for PPH’s. That stuff saves lives!!!)

        • Young CC Prof
          April 29, 2014 at 7:19 pm #

          Here’s the thing. The package insert on a drug reflects the best known science at the time of approval, usually for only one indication in one specific group of patients. Package inserts are rarely updated, except possibly to add warnings if a serious risk or side effect is discovered in postmarketing surveillance. Adding a new indication to the approval requires going through the FDA process all over again, which is super expensive.

          So sometimes the “FDA approval” can be pretty darned out of date.

        • C T
          April 29, 2014 at 7:31 pm #

          Agreed. I think there are enough indications in the medical studies that misoprostol is likely associated with an increased risk of uterine hyperstimulation and rupture. Without FDA approval, I wouldn’t allow it to be used on me for induction unless nothing else worked.
          That said, NCB educators need to stop demonizing misoprostol so thoroughly. Once the baby is out, it is a cheap, fast way of stopping PP hemorrhage and getting the uterus to clamp down quickly (I just don’t feel comfortable with that clamping action starting while the baby is still in me). I bet homebirth midwives would use it themselves for PPH if they legally could.

          • Jessica
            April 29, 2014 at 7:37 pm #

            But dose matters, as does previous mode of delivery. Misoprostol is contraindicated for IOL in someone who has had a C-section. But for someone who’s never a C-section, a 25-50mcg dosage is shown to be both safe and effective. Given the cost of the medication it’s hardly surprising the manufacturer hasn’t sought FDA approval for IOL. So practitioners and hospitals continue to use it with quite a bit of success.

          • C T
            April 29, 2014 at 8:10 pm #

            I understand why they use it, but I personally don’t feel comfortable with the pre-birth use of it on me. Pitocin, fine, it’s synthetic oxytocin and easily controlled as to dosage in the midst of administration. Misoprostol cannot be controlled so easily and it does more than just ripen the cervix. I don’t want it used on me until the baby is out. I know that scientific knowledge advances over time, and I wouldn’t be surprised to see that they eventually find out that certain induction methods, especially prostaglandins and specifically misoprostol, are associated with AFE, rare as it is. (Please see this month’s Obstetrics, Gynaecology & Reproductive Medicine study by Tuffnell & Slemeck finding that AFE risk factors from five countries only have two items in common – induction of labor and maternal age, and even maternal age is only true for some ethnic minorities.) I’d rather err on the side of caution before uncontrollably clamping my uterus down on a live baby.

          • CanDoc
            April 30, 2014 at 10:39 pm #

            Actually, misoprostol has been proven again and again to be a SUBSTANDARD treatment for post-partum hemorrhage. It is a second-rate harm-reduction strategy in developing countries without refrigeration and safe injection supplies to give oxytocin. But oxytocin, ergot, carbeprost are all choices with better evidence. Even tranexamic acid.

          • C T
            April 30, 2014 at 11:06 pm #

            Cool. Thanks for giving me new drugs to research. I never even heard of tranexamic acid before. I just remembered that when I started to hemorrhage after #4 was born, they gave me Pitocin and misoprostol and massaged my uterus (ow! but worth it), and darned if my uterus didn’t have the easiest recovery that time out of any of my four hospital natural childbirths; I had much less in the way of uterine cramping while breastfeeding and less scary lochia clots. I think that primarily relying on natural oxytocin from breastfeeding to shrink my uterus postpartum didn’t do the job as well after my previous deliveries. But I’m just one person, and I wouldn’t expect everyone to have the same results.

        • CanDoc
          April 30, 2014 at 10:38 pm #

          The brief version of the reply to this, is that FDA approval simply reflects if a company has gone through the incredible expense of petitioning and amassing scientific evidence to prove its efficacy and safety to the FDA, ostensibly with the view that the company will be able to use it’s (brand-new, name brand) drug for inordinate profits during the interval until the patent runs out and it goes generic. But misoprostol is ALREADY generic, so there is no incentive for any company to try to make money on it, hence no petition for FDA approval.
          The SOGC (Canadian OB/Gyn Society) already has a clinical practice guideline about the safe use of misoprostol for induction of labour.

    • Jessica
      April 29, 2014 at 5:31 pm #

      Even non-NCBers are terrified of Cytotec, if you read pregnancy/parenting forums. “I would NEVER let my doctor use Cytotec on me…it’s not FDA approved for inductions! The manufacturer even says it shouldn’t be used in inductions!”

      When my OB discussed the use of Cytotec vs. Cervadil with me, he went over efficacy, cost, and most importantly, the long track record of no problems at the hospital where I was delivering. I was very reassured by his explanation. The drug did not cause me to go into labor and my cervix was only a bit more dilated after a couple of doses, but after a few hours on pitocin and AROM (and an epidural), my labor really got moving. From the time I was 4cm (at which point AROM was performed and I got the epidural) to pushing was about 3.5 hours, IIRC. I pushed the kid out about 40 minutes after that.

      • Hannah
        April 30, 2014 at 4:16 am #

        I always found “But it’s off-label use!!!!!” to be the weirdest of all arguments against it. Stuff is used off-label all the time. I have lupus, and I was on chemo seven years ago (geeze that long?) for a bit. That use was off-label, it’s not technically approved for lupus. Same with Plaquenil, it’s approved for malaria, not lupus, yet it’s one of the best maintenance medications out there. I’d be screwed if it weren’t for off-label use of medicines. Not to mention use of birth control for acne and the thousands of others that I don’t even know about. If it works, it works, that’s the part that really matters.

        • Mac Sherbert
          April 30, 2014 at 2:04 pm #

          Off label meds finally made my ovaries work!! There’s a difference between off label use and don’t ever use this drug for this purpose.

        • Hannah
          May 3, 2014 at 5:57 pm #

          My mother has lupus, too, and Plaquenil literally changed our whole family’s life. Off-label, FTW!

          • yugaya
            May 4, 2014 at 7:41 am #

            My mom has inoperable Tarlov cysts. Her country’s FDA did not approve morphine patches to be used for people with her condition, but that is the only thing that keeps the pain subdued enough for her to still be walking upright.

    • CanDoc
      April 30, 2014 at 3:55 pm #

      I love EEVIL Cytotec! Of of the best tools ever to land in the hands of modern obstetricians. Had a patient this week who wanted minimal intervention/pain medication with her induction after her water broke. One small dose of cytotec, beautiful labour, and gorgeous delivery. No IV, no oxytocin.

  20. Carolina
    April 29, 2014 at 3:18 pm #

    Again, I wish I had found this blog pre-baby. I blamed my induction for my c-section, because everyone (including my “birth education” class at the freaking hospital) said inductions increase the risk.

  21. Coraline
    April 29, 2014 at 3:12 pm #

    LOVE this. LOVE this so much. Thank you for posting this!

  22. Mariana Baca
    April 29, 2014 at 1:53 pm #

    So going post dates increases stillborn rate and inductions reduce c-section rate. Who would have thunk it? Babies don’t magically know when to come out.

    • Arwen
      May 6, 2014 at 8:28 pm #

      Babies don’t know how to do much of anything. I rather think someone with years of medical training is better equipped to handle birth than a person who can’t even say the word “school,” much less go to one.

  23. mom of 2
    April 29, 2014 at 1:43 pm #

    Also want to add–as an OB nurse, I have always suspected this might be the case. Most inductions go swimmingly. And if they don’t, spontaneous labor probably wouldn’t have worked out either.

    • Young CC Prof
      April 29, 2014 at 2:25 pm #

      I think many people who work in obstetrics have long suspected it, which is why these studies are being done. People don’t (or at least shouldn’t, NCCAM!) waste money testing hypotheses which are wildly implausible.

    • Karma Kidney Stone
      April 29, 2014 at 3:06 pm #

      But the current climate in OB residency is against inductions, especially early inductions. I had a hell of a time with the residents during my last pregnancy because they believed so firmly that all inductions before 39 weeks are bad, even when there is a clear medical need, like there was in my case. Several years ago there was a serious push to reduce the delivery of near pre-term babies, to the point that residents who are currently being taught are very fearful of near preterm babies. I had ICP and 2 different MFM’s I saw both recommended delivery at 36 weeks (I have other conditions as well), and the residents told me that they were against the induction and were not going to allow it to happen. The whole thing was crazy cakes. I mean seriously, the stuff they pulled to try to nix the induction, such as pretending to make me sign legal forms absolving them of responsibility, taking me off the schedule that day, accusing me of drug seeking (?), telling me that I talked the MFM’s in to a 36 week social delivery, and on and on. It was nutso. All cause they have been taught to be afraid of 36 weekers.

      Baby was wonderful, by the way. He was healthy, vigorous, chubby, and did not require any NICU time and didn’t even have jaundice requiring phototherapy (I’m isoimmunized as well and my titers were rising). He’s a rambunctious adorable toddler now and an absolute joy. But I still get mad when I think about what a bunch of jackanapes those residents were. I think things have changed in residency programs. Anyone work in OB residency seeing a shift?

      • moto_librarian
        April 29, 2014 at 4:16 pm #

        I know that residents are still training, and since I receive care in a university medical center, I know that they will be part of my care team. BUT…I am amazed by the difference of opinion regarding treatment that I see when compared to what their attending actually does/recommends. I have noticed a trend to be more aggressive about treatment in the case of the residents (including one who wanted to take out a wisdom tooth that was causing me no issues during surgery to remove the crown of one that was abrupted; he was overruled). I am unhappy to hear that residents were not reigned in by the MFM and attending OB in your case, and very disturbed that this campaign by the MOD has swung the pendulum back too far. Did you file a complaint? I would, if you can.

        • Karma Kidney Stone
          April 29, 2014 at 8:25 pm #

          I’ve thought about it. There was a lot more going on that I put in my post, too.It was a major cluster. But at this point, I don’t even know who I’d complain to. Thankfully I had the specialists and my husband behind me advocating for me (he was a fellow at the time), or else I don’t know how things would have ended up. ICP is very much misunderstood and is often blown off as it is, then you add in some residents with major hubris going on, and it is a potential disaster. I remember one time a resident came in and told me point blank to my face not to listen to my MFM because all the residents thought he was an idiot. My husband and I had a good laugh over that one, especially since he was considered the best MFM in the area. The residents just didn’t like him because, as my husband put it, he made them actually work. So, based on that, they undermined him to his patients faces.

          • Sue
            April 29, 2014 at 9:56 pm #

            I think there may be something generational happening. As I become a cranky older clinician, I am constantly amazed at how judgement and experience are being overlooked, and risk-aversion prevails.

            Many policies that are alleged to be about risk-mitigation are simplistic ways of showing that something was done, without considering all the ramifications. (We’ve discussed various examples here – stubbornly avoiding ”early delivery” is one of them).

            But this seems to be happening everywhere – not just in health care. The twenty-something management consultants, the junior clinicians who feel they’ve seen and done enough and move into management. This is leading to avoidance of ”doing”, but ignoring the adverse effects of ”not doing”.

            In moments of self-reflection I have to wonder if my frustration is just age, and whether every generation feels the same about the next, or whether things are changing in a real way. I suspect a bit of both.

          • Busbus
            April 29, 2014 at 10:27 pm #

            I always love reading these discussions between the medical professionals on this blog and getting a little bit of a feel for how your work looks from the inside!

        • Stacy21629
          April 29, 2014 at 8:51 pm #

          “.I am amazed by the difference of opinion regarding treatment that I see when compared to what their attending actually does/recommends. ”
          Ah, experience. 🙂
          I’ve been practicing just 3 years now (veterinarian) and I know I am (slightly) less cautious than I was as a new grad. Without a prior caseload to refer back to and know how x patient did with y disease treated with z drug all you’ve got to go on is your lectures and notes and textbooks and what you’ve been taught. Which usually says “work up x patient this way, treat them with this drug”. Very black and white. Learning nuances comes with time and experience. Plus you are so scared to make a mistake based on your inexperience that you tend to err on the side of caution and do more testing or more procedures. I’ve backed away from that a bit…though now I’m in ER so I know little to nothing about most of my patients so I recommend more than I would in day practice with a regular client.

      • Arwen
        May 2, 2014 at 12:30 am #

        I wanted my baby out at 37 weeks because my health was going to pot. My OBs and one MFM refused and blew off my symptoms–symptoms which turned out to be signs of auto-immune disease. I remain extremely angry about how I was treated and admittedly have little faith in the field of obstetrics, just for the complete opposite reasons NCB zealots do. It seems that far too many OBs want to pat you on the head and say there’s nothing to worry about, women have been doing this for thousands of years, and send you on your way than actually admit you might be that patient whose hoofbeats really do indicate a zebra, not a horse.

  24. mom of 2
    April 29, 2014 at 1:39 pm #

    I LOVED being induced at 39 weeks with my daughter. I got a good nights sleep had a good breakfast, went in at 7 and had a baby at 2. Got an epidural before I even felt a contraction. I enjoyed the afternoon relaxing with her and my husband. My son came to meet her, then I got a restful night of sleep, occasionally interrupted by breastfeeding. And apparently i reduced my risk of cs, which being a VBAC, obviously mattered to me. What is there to complain about?

    Contrast that to my older child’s delivery at 41+ weeks. I labored all night, he was born (by stat section–prolapsed cord) early in the morning. I was an exhausted mess and it took quite a while to feel even remotely rested. Yeah, I’ll take the scheduled, straightforward induction any day of the week.

    • Coraline
      April 29, 2014 at 3:12 pm #

      Thank you for sharing your story!

    • Lottie
      April 29, 2014 at 4:41 pm #

      Sounds exactly like my baby’s birth. He is my first baby. I was in at 8.30-baby born by 2.15. I was 39 weeks exactly. Had been dilated to 5cm at 37 weeks, 6cm at 38. Had a BPP score of 6 a couple of days before his birth, the test was done as I felt decreased movement. OB was all for inducing then and there but let me have the weekend with strict instructions on doing regular kick counts and to act on a decrease in movement immediately.

      I was terrified because the NCB brigade had brainwashed me to believe that induction was a ‘violent’, ‘irresponsible’ way to give birth. In fact, it was the most wonderful day of my life! Had an epidural half way through and from then on it was plain sailing :). Only difference was I absolutely did NOT sleep the night before from nerves and excitement!

      When I read some of the posts a about women who are blinkered to anything but their birth experience at the cost of their baby’s life, my emotions run the gamut from anger, disgust and pure despair; at them and at those who brain wash women into the orgasmic, natural, healing birth nonsense. A healthy baby and mom are all that matter-I have respect for all mums no matter how they have birth and no matter how they feed their baby. We all just do our best.

    • AmyP
      April 29, 2014 at 5:33 pm #

      Very true. My last baby was an induction at exactly 39 weeks. It was on a Wednesday. My husband dropped me off at the hospital in the AM, took the kids to school and came back to be with me (he wasn’t teaching that day). There was some suspense over the progress of the induction–it was slow, slow, slow, then go time, but the baby was born at around 4:30 PM, my husband was able to go collect our big kids from friends, have dinner, and then bring the kids to see the baby and then take them back to our very own home. Then we were released lat in the morning on a Friday and I had my husband available the whole weekend. So civilized! The big kids only had to be with our friends for less than 2 hours (I think) and there was no need to pull them out of bed in the middle of the night, worry about school uniforms, or get them to friends in the middle of the night. Also, my previous labor had been only 4 hours and I had had a lot of trouble getting an epidural (I think I was in transition by that point and the anesthesiologist was really struggling), so it was very nice to have no problems at all getting one. If things had gone “naturally” this last time, there’s a real risk that we would have spent so much time getting big kids to friends that I’d miss out an epidural entirely, not to mention the risk of delivering on the way to the hospital.

      An induction is so nice when you have older kids at home to plan around.

  25. Ardent
    April 29, 2014 at 12:40 pm #

    My N of 2 is 100%. I have been induced at 38 weeks twice due to PIH/preeclampsia. The first time, my son’s head turned out to be something like 97th percentile and he was posterior and barely barely fit. If I had gone into labor at term I bet I never would have delivered him vaginally. For that one I had a foley catheter and Pitocin, for the 2nd just Pitocin. I was very happy with both inductions and if I had a 3rd with no PIH/preeclampsia I would have an elective induction at 39 weeks. (That was the plan for #2 before my blood pressure climbed and I started seeing flashing lights.)

  26. OldTimeRN
    April 29, 2014 at 12:39 pm #

    I was only induced once and I wasn’t a fan. I was 2 weeks overdue, closed, think and high. Showed up, pitocin started and nothing. Sat there for hours while the pit when in and I didn’t feel a thing. The pit went up and up till it finally kicked in and I felt like I was having contractions one on top of the others. There was no gradual 0 to 20, 30 for 50, 60. It was 0 to 60 with no relief. Kicker being I was only 1-2 centimeters. Couldn’t have an epidural until I was 3 cms. Finally got the epidural or for it not to work very well.. Then came the MSAF. I ended up hrs later with a section, only for my epidural to not work and I was knocked out after my baby was born.

    So not to great of an experience. Including my post partum stay. Looking bad and now working where I work I realized how things should have been different. I should have been induced earlier, right around 40 weeks. I should have have cervidal to soften my cervix. And the big one? I should have delivered at a different hospital. But I really didn’t focus on that. I had a beautiful baby and I was a Mom!!! A few years later with #2 I wasn’t going to go back there.. Starting with the doc who delivered at a different hospital. I opted, with his advice to schedule a section if I didn’t go into labor by my due date. I had a scheduled section, all went beautifully well and I LOVED my “experience”. I felt like I had been treated like a princess. Which is a far cry from what I felt like the 1st time around.

    • Allie P
      April 29, 2014 at 2:10 pm #

      Sounds like a mishandled induction. Closed and thick should have been an indicator for Cervadil, yes? All I had at my induction was cervadil, no pitocin at all.

  27. The Bofa on the Sofa
    April 29, 2014 at 12:28 pm #

    When we looked at risk of cesarean delivery by gestational age, we found statistically significant reductions in risk with labour induction in term and post-term pregnancies, but not in preterm pregnancies.

    What is the definition of “term” applied in this work?

    • Rebecca
      April 29, 2014 at 3:13 pm #

      Based on Fig 3, “term” means 37 to <42 weeks.

      • The Bofa on the Sofa
        April 29, 2014 at 3:19 pm #

        OK, so much for the 39 week rule, right?

        I am not concerned about conclusions based on induction <37 weeks. You are only doing that if their is a damn good reason, so you aren't questioning whether you should induce or not.

  28. Ellen Mary
    April 29, 2014 at 12:28 pm #

    I am still glad I did not induce at term, because their plan was Misoprostol, that cannot be switched off like Pitocin & even VERY low dose Pitocin augmentation produced distress due to my baby’s double knot. I already sorta knew that induction was considered preventative of Cesarean postdates.

    Maaaaybe if I had chosen to accept Misoprostol my labor could have proceeded with membranes intact & that could have reduced the cord compression, but that is really unlikely, since AROM is considered a more ‘natural’ way to induce & that probably would have been offered to me alongside the Misoprostol.

    In any case, I am glad we could just turn off the Pitocin when my baby’s readings on the monitor were not reassuring.

    • Jessica
      April 29, 2014 at 1:28 pm #

      Maybe someone can correct me if I’m wrong, but misoprostol doesn’t necessarily induce contractions the way pitocin does. I received misoprostol vaginally the night my induction started – a quarter tablet at 11 PM and another quarter tablet at 3 AM. It did not cause contractions or do much of anything to my cervix.

      • Ellen Mary
        April 29, 2014 at 2:07 pm #

        That is super low dosing. Inducing with Misoprostol is 800 mcg, more than 2 whole tablets.

        • Jessica
          April 29, 2014 at 2:09 pm #

          Not at my hospital!

          • KT
            April 29, 2014 at 3:22 pm #

            I was going to say, 800 mcg is I think the doseage usually prescribed for a missed miscarriage. I had 600 mcg at 9 weeks for a pregnancy lost at 5 weeks since I’m smaller and react strongly to medicine.

          • Dr Kitty
            April 29, 2014 at 6:30 pm #

            During pregnancy the uterus has receptors to prostaglandin. These increase as the pregnancy progresses.
            So you need higher doses for medical management of first and second trimester losses than you need for induction at term.

            Misoprostol is a cheap, temperature stable synthetic prostaglandin, which mimics the effects of natural prostaglandin. It is not the unsafe, evil, experimental drug NCB paints it as.

          • Sue
            April 29, 2014 at 10:04 pm #

            I was a medical student tester (voluntary, paid $25) for one of the PGs in the late 1970’s. It was being tested for Gall Bladder contraction (I now don’t recall which PG). I was the first female in the trial, and couldn’t lie still to have my GB ultrasound because I was getting very severe uterine contractions. “Great”, they said, ”at least we know you’ve absorbed it”. I wasn’t pregnant, though, so no baby afterwards. Just $25, and an apology from the Prof of Pharmacology.

          • Young CC Prof
            April 29, 2014 at 10:43 pm #

            Yikes! Another excellent reason why medical research needs to involve both men and women.

          • Dr Kitty
            April 30, 2014 at 4:48 am #

            Misoprostol was originally designed as an ulcer drug- prostaglandins protect the stomach lining.
            Then pregnant women miscarried after taking it and people realised that it also caused uterine Ctx. Then people worked out dosing regimes for medical abortion and miscarriage management, IOL and PPH through trial and error.

            Arthrotec (misoprostol+diclofenac) is an excellent pre-procedure analgesic if you’re getting an IUCD removed BTW, because it slightly softens the cervix. Worked like a charm for me.

        • mom of 2
          April 29, 2014 at 2:43 pm #

          No no no you would NEVER induce with that much. Induction dose is 25-50 mcg q 4-6 hours. 800 mcg is for post partum hemorrhage and works quite well.

        • Medwife
          April 29, 2014 at 5:10 pm #

          WHAT??? No. Not unless you are inducing with a dead baby.

      • areawomanpdx
        April 29, 2014 at 3:54 pm #

        Technically misoprostal and cervidil are for ripening the cervix and pitocin is for inducing contractions. It is possible for the ripening to start contractions, too, though, and some women never end up needing the pitocin. Cervidil is not as potent as misoprostal, but it is designed for use in labor (right now, miso is used off label for inductions, although I believe they are working on getting FDA approval for a form that is), so you can put it in, and it has a string so you can pull out if need be. (bad reaction, contractions too close together, etc.). Once you use the miso, you aren’t getting it back out.

        • Jessica
          April 29, 2014 at 4:00 pm #

          That is what I understood. 🙂

        • Ellen Mary
          April 29, 2014 at 5:32 pm #

          Misoprostol does both. Cervadil is (mostly) only for ripening. At my hospital Cervadil was not an option: it was not offered.

        • mom of 2
          April 29, 2014 at 6:56 pm #

          I’ve always wondered why we couldn’t have miso in a form like cervidil! Really, the only downside to it is that you can’t pull it out. I’m glad to know they are working on it.

  29. Guesteleh
    April 29, 2014 at 12:22 pm #

    My induction was amazing. I feel bad for first time mothers who are terrified of being induced. I try to reassure them but it’s hard to counter all the noise.

    Also, a question: are inductions now done with a lower dose of pitocin than in the past? I ask because I read so many horror stories about painful pitocin contractions and that wasn’t my experience at all.

    • Sullivan ThePoop
      April 29, 2014 at 12:46 pm #

      It wasn’t mine either. I was induced twice and augmented once with pitocin.

    • Laura
      April 29, 2014 at 12:56 pm #

      They start with a low dose, but for me, the contractions were still brutal. However, my body really wasn’t ready for labor but they wanted baby out before my liver killed her.

      • Laura
        April 29, 2014 at 12:58 pm #

        And honestly, I was making no progress with the pitocin sans pain relief. If I had continued the way I was, I would have ended up with a c-section for failure to progress. It was the epidural that made my cervix actually dilate.

        • Guesteleh
          April 29, 2014 at 1:59 pm #

          I got an epidural at 4 cm. My contractions weren’t terribly painful at that point but I figured we had nowhere to go but downhill from there, so better to get pain relief sooner rather than later.

          • Laura
            April 29, 2014 at 3:28 pm #

            Got the epidural after being at 2 cm for several hours. Yup.

    • Mishimoo
      April 29, 2014 at 8:48 pm #

      I can’t answer for inductions, but I had augmentation with two. I was expecting it to be overwhelmingly painful, but it was bearable. The contractions got stronger and became regular again, and my pain level went up a point or so. I did only have a “whiff” of it, 23 was the last number that I remember seeing for each before I was pushing. I also have a high pain threshold, so others experiences may vary from mine.

      • araikwao
        May 3, 2014 at 6:26 am #

        Good golly, I had hyperstimulation on 12! And on my ob/gyn rotation, I saw someone on something like 90?

        • Mishimoo
          May 3, 2014 at 6:30 am #

          It’s really weird and kind of cool how different everyone is.

  30. C T
    April 29, 2014 at 12:04 pm #

    Sweet! I already had my OB on-board for an induction between 39 and 40, but she did say “We’ll have to see how your cervix is….” Now she doesn’t even need to worry about that. 🙂 See you in six weeks, baby!

  31. Gene
    April 29, 2014 at 11:52 am #

    I’ve had two inductions (one for ROM without labor, one for size), each times with a very unfavorable cervix. And each ended with a vaginal delivery. So my N of 2 is 100%. So much for the evil cascade…

    • Mary Schreiner
      April 29, 2014 at 11:55 am #

      Me too! Although my Bishop score was pretty good with both. I was so terrified of the “cascade of interventions” with my first induction. And I had nothing to worry about, it all went swimmingly. Thank you, dumb NCB community, for scaring me over nothing.

    • Rabbit
      April 29, 2014 at 12:00 pm #

      My N of 3 is also 100%. First for size, dates, and rising blood pressure, second for size and convenience, third for dates. I had a very favorable cervix for the first two, but not at all for the third – I was 2cm, not effaced, baby high. Labor was 4 1/2 hours for my first, and got shorter each time. If we decide to have a 4th, I’m scheduling the induction for as close to my due date as possible – I like the certainty of a known end date.

      • Medwife
        April 29, 2014 at 5:13 pm #

        Once you have had a few babies the cervix is often not effaced before labor, and baby often stays high until mom is about to push.

        • Sullivan ThePoop
          April 29, 2014 at 8:55 pm #

          Really? With my third I was 80% effaced at 7 months and 2 cm dilated. It was very uncomfortable. My OB was very worried that I would have the baby accidentally at home or on the way to the hospital. Instead I had the most mild steady contractions for 12 hours and then at 6 cm they broke my water and gave me a little pitocin and it was over in 1 and 1/2 hours. I never even needed any pain killers.

          • Medwife
            April 30, 2014 at 5:24 am #

            Classic third timer. Pop a bag, have a baby! But yes, often =! always. That’s why I’m stingy with predictions. Just delivered a full term baby the other day who I could have sworn was going to go 6 weeks ago. OB keeps you humble.

    • Young CC Prof
      April 29, 2014 at 12:20 pm #

      Actually, among the women on my IUGR message board, when inductions do fail it seems to be due to fetal distress more often than “mom’s body not ready.”

      And if a nice gentle induction is causing fetal distress as soon as things get going, that probably means your baby can’t safely be born vaginally, whether your labor is spontaneous or not. With the babies whose placentas are dying early, they try to wait as long as they safely can, to minimize the prematurity-related complications. Sometimes that means waiting so long that the placenta is no longer strong enough for labor.

      But honestly, if I had to choose between, say, a nice quick vaginal birth of a 35-weeker who then needed respiratory support vs a c-section with a 37-weeker who got to come home with me, I’d go with door #2.

  32. Allie P
    April 29, 2014 at 11:49 am #

    I’m not a doctor, but this seems obvious to me. Like putting on a little antibiotic ointment before you get a raging infection. It’s a small intervention that helps defer the possibility of a larger one. Aren’t going into labor naturally? Isn’t a little induction medication better than open-abdominal surgery? I had an induction for a post-dates baby. Worked like a dream.

  33. Young CC Prof
    April 29, 2014 at 11:35 am #

    The authors discuss the effect of induction for “no reason given.”

    How common is it really to do an induction for no reason at all? Postdates is a reason. Reaching the 37 or 39 week mark in a high-risk pregnancy is a reason. Signs of preeclampsia is a reason. Days of unpleasant prodromal labor is a reason. PROM is a reason.

    How common is it for someone to induce labor for a completely nonmedical reason?

    • Amy M
      April 29, 2014 at 11:37 am #

      It said “no reason given”, but does that mean there wasn’t a medical reason, or does it mean whatever the reason, it just wasn’t mentioned? (I don’t know, I am asking.)

      • Rabbit
        April 29, 2014 at 11:51 am #

        When I was induced with my second, I don’t think my doctor listed a reason. The nurses asked me if I knew why I was being induced, and seemed surprised when I told them it was because my first was 9.14, and this baby was estimated to be 9 on the ultrasound. He ended up being 9.5, and I was induced the day before my due date. I shudder to think of how big he could have been if I’d gone a week over, like I did with my first.
        My doctor told me at the beginning of that pregnancy that she was happy to schedule an induction for anytime after 39 weeks for non-first-time moms. I don’t think she had to give a medical reason for the induction, other than giving one would put me higher on the priority list for a room.

      • Young CC Prof
        April 29, 2014 at 12:01 pm #

        I think it could be either way, that it was done for a nonmedical reason, or that it was done for a very good medical reason that just wasn’t listed.

        I know there are sometimes inductions performed for nonmedical reasons, and as long as the baby is full term (and the due date is confirmed) I don’t see any problem with it. I’m just wondering how common such situations actually are.

    • Pilo
      April 29, 2014 at 11:48 am #

      They are sometimes (I don’t know a number) done for psychological or social reasons. Some that have occurred in patients I have cared for: mom had a previous late-term stillbirth for unknown reasons and wants this child out as soon as it is safe to do so, dad is in the armed forces and is deploying soon and they would like him to be there for the delivery, grandparents are here from another country and will be leaving soon, mom is a teacher and wants to have a full 8 weeks of recovery before going back to school–and the semester starts in 8 weeks, mom has severe anxiety, parents have to move across the country to start a new school program next week, have baby before the end of the year for a tax deduction and/or insurance savings because deductible is met, and mom’s sister is getting married next week.

      • Pilo
        April 29, 2014 at 11:53 am #

        And one more I just remembered: to have baby born under a certain astrological / zodiac sign. I’ve seen that one twice too.

        • Zornorph
          April 29, 2014 at 12:04 pm #

          I have to say that’s a peculiar reason, but I guess no harm in it. My son’s original due date was close to the edge between Leo and Virgo and I will admit that I preferred Leo because it just seems a more ‘studly’ birth sign. No worry – he came early and right in the middle of Leo.

          • Siri
            April 29, 2014 at 12:16 pm #

            Haha, I once saw a primip push a baby from up in the gods to out on the bed in what seemed like 20 seconds – she didn’t want her kid born after midnight (next day was MILs birthday, or the wrong starsign, or some such guff). The midwife said, sorry, it’s nearly midnight, you’re not going to make it – one superhuman push later, baby appeared at the perineum and shot out in one contraction. Remarkable.

          • Sue
            April 29, 2014 at 10:08 pm #

            Which all goes to show how meaningless star signs are. You can be pushed one side or the other and it effects your whole personality and life course? I don’t think so.

          • Young CC Prof
            April 29, 2014 at 10:41 pm #

            There was this YA fantasy novel East in which the conditions of your birth really did affect your life and personality. Main character’s mother carefully delivered seven of her eight children exactly the way she planned, then chance intervened on #8, resulting in a daughter who never quite fit in…

          • KarenJJ
            April 29, 2014 at 10:55 pm #

            I know someone who chose their induction date to be a few days earlier because they didn’t want their child to be born on April Fool’s Day.

        • Trixie
          April 29, 2014 at 12:29 pm #

          Okay, that’s kind of dumb, but at least they’re in the hospital!

        • April 29, 2014 at 12:32 pm #

          My mother (half joking, I think) was very concerned I’d go postdates and my son wouldn’t be a Scorpio like her. She was equally concerned that they’d share a birthday. He came 3 days after her birthday (induction that ended in cs, but mainly for fetal distress as I pushed for 40 minutes) and is Scorpio to the Scorpioest degree.

          PS none of us actually believe in horoscopes.

      • Trixie
        April 29, 2014 at 12:29 pm #

        My baby was going to be born on one of my grandmothers’ birthdays, because they’re on subsequent days (not induced, it just happened). It was almost midnight as I was pushing. She wasn’t born until 12:15, so her birthday is the same as my living grandmother’s. I’m sort of glad, because she gets to enjoy sharing a birthday with her only great-granddaughter!

    • Mary Schreiner
      April 29, 2014 at 11:48 am #

      A certain number of women will choose induction for “social” reasons, according to my OB. There are advantages to being able to schedule a date: ability to find a babysitter, ability to choose which doctor delivers, ability to avoid certain difficult dates (like an anniversary of a loved one’s death), etc. All of those reasons are usually pooh-poohed by the natural birth community, and even by others. But they are examples of non-medical reasons for induction.

      • attxm
        April 29, 2014 at 12:01 pm #

        I scheduled an induction because I had no desire to go a week over, like I did with my first baby. Plus my mother-in-law was in town and I didn’t want to waste precious time. It wound up not being needed since my baby came right on time, seven hours before the induction was set to begin. I of course had a homebirthing friend (of a breech baby…) try to warn me against it. Needless to say I think she’s a moron for her choices so it was easy to ignore her dire warnings.

        • KarenJJ
          April 29, 2014 at 10:53 pm #

          Part of my reasoning of scheduling a c-section instead of trying a VBAC is because I could time the birth and fit it in with work schedules as well as a relative flying from interstate to mind my toddler.

      • Lion
        April 30, 2014 at 5:00 pm #

        I requested an induction at 39 weeks because I just couldn’t take another day of pregnancy. Labour started a few hours before we were due to arrive for the induction. I was however augmented with pitocin and membranes ruptured. I was in agony and sobbed for an epidural. Second baby, when I couldn’t take one more day, I thought with relief that baby must be about to arrive, lunch time labour started, I did ask for an epidural at about four cm but nurse refused to call anaesthetist, but after that I managed to cope. Definitely not as sore second time.

    • Mishimoo
      April 29, 2014 at 8:55 pm #

      At my local hospital, they don’t do social inductions. I discovered that when I asked if I could have one so I could have a chance to take the youngest up to meet my dying granddad. We did make it up in time, but he wasn’t lucid by that point. If we have a surprise post-vasectomy baby, I’ll see if I can wrangle a 39 week medical induction based on having mild SD with the last. I have a feeling that anything bigger than 8lb will not fit through my pelvis because he was such a tight fit, and I want to try to avoid an emergency caeserean.

  34. Zornorph
    April 29, 2014 at 11:35 am #

    I certainly didn’t see any ‘cascade of interventions’ with my son’s birth. My Surrogate went in because she had an issue with her leg swelling (it was fine) but then they discovered she was dilated 5cm and that was too much for them to want her to leave the hospital. They were considering Pitocin, but then she went into labor on her own. Things progressed – other than the various monitors, the only ‘intervention’ was breaking her water at a sheduled time and then the baby came out within an hour and a half. It just seemed all so careful and controlled – I was nervy, but to me it just seemed like things were being helped along, not forced. Besides, I couldn’t wait for him to be out and safe. I certainly don’t think anybody there wanted it to end in a C-section.

    • Amy M
      April 29, 2014 at 11:42 am #

      I wasn’t induced, but I did have pitocin augmentation when things weren’t progressing appropriately. I was given a choice (imagine that!) between that and a Csection. I chose the pit (and an epidural) and went on to have a vaginal birth. My “cascade of interventions” prevented a Csection. (don’t get me wrong, I had no ncb ideas at any point, but I did want to avoid surgery if possible…I feared the recovery with 2 newborns to care for.)

    • Young CC Prof
      April 29, 2014 at 12:05 pm #

      Actually, my birth was induced. Mom’s water broke, but nothing much else was happening, so they started a pitocin drip. Worked, I was born a few hours later, perfectly healthy, no further interventions required.

      • KT
        April 29, 2014 at 3:32 pm #

        My daughter had a similar situation, only fetal distress with thrown in (both with the sporadic Braxton Hicks contracts I was having before the pit drip and after the pit drip was started on a low level). Due to the fetal distress I had a c-section. As someone said above, if your baby isn’t tolerating a low level of pitocin, then labor probably isn’t going to happen under any circumstances.

  35. Karma Kidney Stone
    April 29, 2014 at 11:35 am #

    My favorite delivery was my scheduled induction. Maybe because I was so miserable (ICP), but knowing when it was all going to be over was priceless. The labor and delivery were really easy, too, even though I was 36 weeks. I had an emergency induction at 36 weeks, also, for my first baby (oligo, IUGR, and loxenox) and that labor and delivery were quick, easy, and awesome, too. Of course, for us high risk moms, there is no greater joy than having a living baby.

    • Mel
      April 29, 2014 at 12:07 pm #

      My mom says that my youngest brother’s labor and delivery – who seemed to have no interest in being born at the end of the 41st week and needed to be induced twice – was the easiest by far. She didn’t feel any contractions until around 3:30 pm, felt like she needed use the toilet at 5:10 pm, yelled at Dad when he asked if that might be the urge to push, changed her mind half way across the room, and delivered my brother at 5:17pm.

    • Laura
      April 29, 2014 at 1:03 pm #

      Another ICP mom here–I was induced at 37 weeks for it, and was also absolutely miserable. However, my induction was difficult and took FOREVER. I’m jealous you had an easy one. Maybe next time.

      • Karma Kidney Stone
        April 29, 2014 at 3:16 pm #

        I think labor and delivery is just different for every woman, and for every delivery, as well. For some reason, I have very easy deliveries. My pregnancies SUCK, but L&D is just pretty easy for me. I had one tough one out of 4 (my only natural birth, too) because the baby was malpositioned. Maybe that’s my karma for having so much pregnancy trouble. I really envy those cute little pregnant ladies who feel fine. I puff up like a puffer fish, vomit constantly, itch all over, and have issues with pre term contractions, not to mention the health issues that make pregnancy a nightmare of doctor appointments, tests, and praying.

        • Laura
          April 29, 2014 at 3:23 pm #

          I had the itching hell and a not-so-fun delivery. Although I did lose my baby weight very quickly (I’m seriously a walking breastfeeding advertisement) so I guess that was my reward for going through all of that 😉

          My mom had fast deliveries, so I thought I would be like her in that regard, although I believe the fact she had ICP too (undiagnosed back in the day) made it so we wanted to vacate the uterus before her liver had its way with us.

          Everyone tells me that the second delivery is much easier than the first. I sure hope so because if it isn’t, someone’s gonna get it.

          • Mishimoo
            April 29, 2014 at 9:19 pm #

            My second was faster, but required augmentation because I was getting tired. No tearing despite nuchal hand (and cord), and her delivery felt easier than her sister’s even though she was bigger.

      • carr528
        April 29, 2014 at 5:57 pm #

        My one induction was awful and did end in a c-section. However, if you look at the size of my son’s head in his baby picture, you would understand why. My best friend had four inductions and loved everyone of them (all VB). I, on the other hand, really had no problems with any of my c-sections. Everyone goes through pregnancy differently.

    • meglo91
      April 29, 2014 at 7:37 pm #

      I know that you are talking about Intrehepatic cholestasis of pregnancy, but every time you guys talk about ICP my mind goes to Insane Clown Posse, and I giggle.

      • Sue
        April 29, 2014 at 10:09 pm #

        ”Insane Clown Posse”? I think of Intracranial Pressure.

  36. Young CC Prof
    April 29, 2014 at 11:29 am #

    What do you want to bet this evidence WON’T be appearing on Evidence Based Birth? Or make an appearance on Lamaze International’s list of ways to prevent a cesarean?

    • Rabbit
      April 29, 2014 at 11:38 am #

      They’ll just keep repeating that the people with the lowest risk of c-section are those that go into labor on their own, ignoring entirely that you can’t choose to do that. Either spontaneous labor happens on its own or it doesn’t.

      • Young CC Prof
        April 29, 2014 at 1:44 pm #

        You know, that really reveals their agenda. If you’re actually interested in mother and infant health, you’d be in favor of anything that can reduce cesareans WITHOUT increasing death or injury to the baby or other serious complications.

        Burying their heads in the sand on this shows that they aren’t pro mother or pro baby, they are pro natural birth. They are ignoring the mounting evidence that labor induction, augmentation and other “small” interventions can safely prevent some cesareans in favor of decrying the imaginary cascade of interventions.

  37. Busbus
    April 29, 2014 at 11:27 am #

    How interesting.

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