Induced Labor and Informed Consent in Canada
by Gail J. Dahl
"It is apparent that the overwhelmingly redundant message of the...literature...is that there is absolutely no study, no evidence whatsoever, that routine induction at any gestational age improves perinatal outcome." Nichols 1985a
I began to be interested in induced labor shortly after I experienced a birth induction, also known as induced labor, forced birth, scheduled childbirth, daylight obstetrics, Vitamin P, and also described as "a little something to get you going". My daughter was born in a large Canadian city hospital in 1995. Nearing the end of the last trimester, exactly one week after a 40 week due date, I was told by my obstetrician that my baby was overdue, my baby was starving, weighed only five pounds, and that my placenta was aging. He also mentioned it was hospital policy to induce labor at 41 weeks gestation. Reasons given on hospital records for induction were recorded as low weight and fetal distress. Although I had read many books during my pregnancy I did not find any references on induced labor, or its relatively high risks and possible side effects. After thinking it over during the weekend I had difficulty coming to terms with the suggested route of care. Weight gain throughout pregnancy was normal, the mother was healthy and the baby was healthy during the previous ten prenatal visits. However I resigned myself to the obstetrician's advice and arrived at the hospital on Monday morning, highly concerned with the health of my baby.
As the prostaglandin gel, (also known as Dinoprostone, Prostin E2, PE2, or Prepidil) was inserted I began to have serious misgivings about the procedure. I asked if I could leave the hospital to move about during labor. He looked at me and said, as this procedure was still relatively new they could not be sure of its effects, so I would not be allowed to leave. My labor started with a bang and I was soon overwhelmed with violent, unceasing contractions. Consumer research shows that women who have had their labor induced or not will always prefer a normal labor to a forced/induced labor. Only because of the tremendous emotional support and technical support from the nurse-midwives and others on my team was I able to give birth normally and avoid an emergency cesearean operation as I began to experience a hypertonic reaction to the drug.
The Compendium of Pharmaceuticals and Specialties, Thirty-Fifth Edition, Copyright 2000 details the adverse effects and risks of induced labor including fetal distress, failure to progress, failed induction leading to episiotomy and forceps delivery or emergency cesearean operation, hypercontractility, and fetal heart rate abnormalties. Contraindications include: Patients with a history of cesarean section, major uterine surgery; patients with cephalopelvic disproportion; patients with a history of difficult labor and or traumatic delivery; grand multiparae and six or more previous term pregnancies. Patients with suspected or clinically evident pre-existing fetal distress, patients with overdistention of the uterus, multiple pregnancy, polyhydramnios; patients with pre-existing uterine hypertonus; circumstances that make it impossible for a responsible physician to be present. Also contraindicated are patients with ruptured membranes, engagement of the head has not taken place; patients with unexplained vaginal bleeding during this pregnancy, patients with fetal malpresentation; patients with gynecological, obstetrical or medical conditions that preclude vaginal delivery.
During the labor I often felt as though my womb was being torn from within me as I began to hemorrhage during labor. It took months and months for the bleeding to stop and the pain in my womb to subside. When my daughter emerged from my womb and was placed on my breast a refrain was wispered throughout the room, "there is nothing wrong with this baby". As I gazed into her eyes I began to feel the white-hot rage of betrayal. She had obvious signs of prematurity including a covering of soft down-lanugo, vernix and other signs. This was not an overdue baby, but a premature baby. Her medical records record her at barely 40 weeks. She could have easily been two or three weeks premature. We were both out on the sidewalk two hours after her birth on an early-release program. Within 24 hours she began to cry for a pattern of three or four hours consecutively in the evenings for months after the birth. She soon developed excema covering her entire body. That was only the beginning. Soon we found out at the hospital that she had multiple allergies some of which included dairy, soy, eggs, Tylenol, and various environmental triggers. This became noticeable after breastfeeding was stopped. Then her asthma started. After that we dealt with her brain seizures. The emergency ward doctors at the Children's hospital suggested a daily treatment of drugs for her to prevent seizures. Unfortunately the drugs had the potential to cause more side effects than the seizures. It was decided to look for other ways to assist her in reclaiming her health.
Although I did not realize it at the time we would both experience many side effects from an adverse reaction to the induction drug. I experienced bleeding during labor and prolonged bleeding for months after the birth, blood pressure problems, prolonged and severe postnatal depression, reduced immune function, and persistent pelvic pain. My daughter experienced reduced immune function, which contributed to excema, asthma, allergies to foods and environmental substances, and brain seizures. Pharmacia & Upjohn report the following adverse effects with this particular prostaglandin, vomiting, nausea, diarrhea, fetal heart rate changes, uterine hypertonus, headache, hypertension, postpartum hemorrhage, fever, dizziness, chills, hiccough, flushing tachycardia dyspnea, bronchospasm, rash. There is a reported case of seizure with this product as well seizures from the other prostaglandin drugs used to induce labor. This drug is also used as an abortant.
I believe we have yet to see the results in the health of babies forced out of the womb prematurely in order to schedule childbirth. There are no studies currently available on the long-term effects of this drug on mothers and babies. One of the reasons for the high failure rate is the drugs inability to completely mimic the hormones in a woman's body that creates both muscles of the uterus to work together to squeeze baby out. Instead only one set of muscles are activated causing the baby to be pounded out, rather than squeezed often with the head of the baby smashing against an incomplete pelvic floor. This action can cause irreparable damage to the baby's brain, this action also places stress on the baby's heart and oxygenation to the brain. These ineffective and incomplete contractions create a longer labor, tiring the mother out often causing the mother to ask for pain relieving drugs to counteract the intense and unending artificial contractions.
Inductions often fail because of an error in the due date. Ultrasound determined due dates are not accurate. Kramer et al. 1988. Even first trimester measurements have an error bar of +- days increasing to + - 8 days in the second trimester and +- 22 days in the third trimester. Otto and Platt 1991. Nichols (1985b) points out that 70% of women classified as postdates in his study were incorrectly dated. All clinical dating methods, including the LMP, have margins of error of more than 2 weeks He also reports that studies of management have not found that tests accurately identify postmature babies or that routine induction improved perinatal outcome. Epidemiological studies have found that much of the excess perinatal mortality in the postdates population is due to other factors like congenital anomalies, infection or IUGR. Postmature syndrome is now shown to be derived from one doctor's subjective evaluation of 37 babies estimated to range from 285 to 325 days gestation. Clifford 1954. He observed no control infants and gestational ages widely overlapped each other within grades. His signs are objective and have not been shown to have clinical importance. Shearer and Estes 1985 show postmature syndrome neither associates exclusively with postdates pregnancy nor do its signs have no clinical importance whatsoever. Another problem with setting a due date is that research is showing a first-time mother to require a longer gestational period, from 38 to 42 weeks and longer. Mittendorf et al. 1990. Sheila Kitzinger reports that over 70% of first-time mothers normally give birth 10 days after an estimated due date. Inducing an unripe cervix leads to long, hard labors requiring additional pain relief. Arulkumaran et al. 1985a. Devoe and Sholl (1983) found that 30% of fetuses testing normal developed fetal distress when labor was electively induced and the cesearean rate was 15% versus 2% for spontaneous labor. Ahlden et al. (1988) found that the most likely scenario to end in an induced labor was a mother who was induced, had an amniotomy, internal electronic fetal monitoring, many vaginal exams and whose labor ended in cesarean section and an infected baby. This treatment works best on those who need it least, treatment does least for those who most need it. Whether the process has gone awry or the mother simply is not as far along as her doctor thinks, if her body is not ready for labor, induction will likely fail. Study after study shows us routinely inducing labor creates more problems that it solves.
It took both my daughter and I over three years to regain our health and during that time I began to study induced labor. I was very concerned about what had gone wrong during the birth so I asked for an investigation by the College of Physicians and Surgeons. Two years later it was discovered that an error had been made in her due date. I talked personally to the Registrar of the College of Physicians and Surgeons about this hospital policy to induce labor and about informed consent on the procedure. During this time I had spoken to hundreds of women across Alberta and had heard from many women who had the experience of having a preterm baby forced from their womb or who had undergone an emergency cesearean operation because the induction drugs failed. Recently in one Alberta hospital there were four scheduled induced labors wherein all four immediately went on to an unplanned emergency cesearean operation. A waste of resources and health for both the mothers and babies involved in these scheduled births.
I began to write a book for my daughter that would give her guidance when dealing with her own childbirth. My book, Pregnancy & Childbirth Tips began gaining prominence in the health community and great attention from media as I began a cross-Canada tour to promote the book and the concept of having a faster, easier and safer childbirth. I joined a local birth association but soon became frustrated with their lack of concern for women giving birth in hospitals. During this time the seeds for the Canadian Childbirth Association began to be formed. This association would work towards informed consent on birth inductions in Canada and work to see that all women, regardless of birth setting or chosen caregiver, would have the opportunity to have a faster, easier and safer childbirth.
New research shows that by reducing the numbers of induced labor we can also reduce the numbers of episiotomy and unplanned emergency cesearean section. A new study, First Births - A Continuous Quality Improvement Project with the British Columbia's Women's Hospital shows that by reducing labor inductions in first- time mothers by 22% there was a corresponding decrease in unplanned emergency cesearean section by 21% with no change in newborn outcomes. Also included in the study was a reduction in early admission, reduction of electronic fetal monitoring and a reduction of epidurals offered in the first stages of labor. Also observed was a difference in the number and timing of epidurals in induced compared to non-induced labors. The input of over 80 clinicians went into creating this manual of improved maternity results for first-time mothers.
The Canadian Childbirth Association contacted the Calgary Regional Health Authority, hospital legal departments, and head of the obstetrical department for the province, various governmental officials including the Minister of Health and the Alberta Medical Association to set up informed consent on induced labor in Alberta. Eventually we were connected to the Committee on Reproductive Care for the Alberta Medical Association. After our initial submissions were sent we were invited to review and provide them with our feedback from a consumer perspective for their proposed Patient Information Sheet on Induction of Labor. We returned with the new research showing the importance of establishing due dates without ultrasound and the new gestational range for first-time mothers. We also asked that women be informed of the risks and possible side effects of the drug used in this elective procedure. Previous AMA Clinical Practice Guidelines for Induction of Labor for 1993 did not include any mention of informed consent, it had been completely left out.
On February 16th, 2000, the Canadian Childbirth Association received a letter from the Alberta Medical Association as follows. "I'm happy to report to you that the clinical practice guideline for the induction of labor includes a strong recommendation that informed consent take place before the procedure is initiated." Dr. Robert A. Burns, Executive Director, the Alberta Medical Association. As the new guidelines have not yet been released to the physicians we do not have observations on the reaction to this precedent setting move by the Alberta Medical Association. The AMA Clinical Practice Guidelines are expected to be released shortly. It is our hope that the AMA will also include a sample of informed consent, including risks, side effects and natural alternatives to the physicians when they send out the new guidelines.
The Canadian Childbirth Association is now lobbying to have informed consent in place across Canada. The book, Pregnancy & Childbirth Tips is now a national bestseller and it has shown thousands of Canadian women how to have a faster, easier and safer childbirth regardless of their chosen birth setting. The Canadian Childbirth Association will be creating an audio-visual program to provide basic pregnancy, childbirth, breastfeeding and newborn care and newborn crying information at the high school level throughout Canada.
By Gail J. Dahl, Executive Director of the Canadian Childbirth Association, Childbirth Researcher and Bestselling Author of "Pregnancy & Childbirth Tips". Available across Canada at bookstores, drug stores, and health food stores.
Induced Labor and Informed Consent in Canada
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