Induced Labor and Informed Consent in Canada
Part 2
by Gail J. Dahl

part 1
I believe we have yet to see all the results to the health of babies forced out of the womb prematurely in order to schedule childbirth. No studies currently available show the long-term effects of this drug on mothers and babies. One of the reasons for the high failure rate is the drug's inability to completely mimic the hormones that cause 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 out, 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 and often causing her 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 +or -5 days increasing to + or - 8 days in the second trimester and + or - 22 days in the third trimester (Otto and Platt 1991). Nichols (1985b) points out that 70 percent of women classified as postdates in his study were incorrectly dated. All clinical dating methods, including the last menstrual period (LMP), have margins of error of more than two weeks He also reports that studies of management have not found that tests accurately identify postmature babies or that routine induction improves 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 that neither associates exclusively with postdates pregnancy nor do its signs have any clinical importance whatsoever.

Another factor to consider when setting a due date is that research shows 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 percent 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 percent of fetuses testing normal developed fetal distress when labor was electively induced, and the cesarean rate was 15 percent versus 2 percent for spontaneous labor. Ahlden et al. (1988) found that when labor is induced, other interventions are also likely to be part of the scenario including amniotomy, internal electronic fetal monitoring, many vaginal exams with a labor ended in cesarean section and an infected baby.

Induction works best on those who need it least, and it does least for those who need it most. 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 that routine induction creates more problems than it solves.

It took my daughter and myself 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 my daughter's 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. Meanwhile I had spoken to hundreds of women across Alberta and had heard from many women who experienced their preterm baby being forced from their womb or who underwent an emergency cesarean because induction drugs failed. Recently in one Alberta hospital there were four scheduled induced labors that ended in four unplanned emergency cesareans, a waste of resources and health for all these the mothers and babies. These babies were taken out on schedule, the objective was accomplished as though the feeling of being physically raped of your baby would have no effect on your emotional health or your ability to bond with your baby. The adverse physical side effects of the drugs used for labor induction can last for years after the birth, as it has in my own case and that of my daughter. It is time to stop this dangerous, unnecessary intervention in childbirth.

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 cesarean 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 percent, there is a corresponding decrease in unplanned emergency cesarean section by 21 percent 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 (AMA) to set up informed consent on induced labor in Alberta. Eventually we were connected to the Committee on Reproductive Care for the AMA. After our initial submissions were sent we were invited to review and provide the association 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 AMA 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," signed by 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. 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. Pregnancy & Childbirth Tips is now a national bestseller and 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.

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Gail J. Dahl is the Executive Director of the Canadian Childbirth Association, childbirth researcher, educator, media advisor and best-selling author of Pregnancy & Childbirth Tips (1998), Innovative Publishing, ISBN 1896937-00-4, $18.95. Available at bookstores, drug stores and health food stores. International Toll Free Order Line 1-888-999-2080.



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