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Home > Pregnancy & Birth > VBAC Induction

VBAC and Pharmaceutical Induction: Help or Hindrance?
Part 2
by Jennifer Jamison Griebenow, ICAN of the Bluegrass

part 1

Going "Overdue"

Care providers may suggest or encourage induction of labor because a mother is past 40 weeks. However, medical evidence does not support induction if your pregnancy is postdates. Membrane sweeping has been shown in some studies to reduce the length of pregnancy, (33)(34) but it is difficult to find current studies which address the outcomes for the fetus and the rates of cesarean section. In other words, membrane stripping does make the pregnancy shorter, but it does not necessarily lower your chance of a cesarean.

It is also wise to evaluate your due date. If your menstrual cycles are longer than 28 days, your pregnancies will necessarily be longer, because you did not ovulate and conceive until later in your cycle.

Risks of membrane stripping are infection, inadvertent rupture of the membranes, and problems due to an undiagnosed placenta previa.(35) While there is evidence that the risks for the baby increase somewhat after 41 or 42 weeks,(36)(37) you still have to weigh the risks and benefits of the induction versus the risks of waiting for labor to begin spontaneously. "Postdates pregnancy is far from cut and dried. Testing in order to induce selectively introduces risks. Routinely inducing creates more problems than it solves. Letting nature take its course is generally best, although that is not risk free either...The reality is you pay your money and you take your choice."(38)

Uterine Rupture

Finally, there is the issue of uterine rupture. The facts are clear: pharmaceutical induction increases the risk of uterine rupture.(39) The rate of rupture in a VBAC labor which is not induced is only 1/2 of one percent, less than your risk of experiencing several other major childbirth complications. However, when you add induction to the picture, the risks increase. A recent study which gained a great deal of media attention showed that in VBAC labors induced with Pitocin, the risk of rupture was .77%. With prostaglandin inductions, the rupture rate increased to 2.45%! (40)

Almost every study verifies the risk of induction in VBACs, although some report no increase in rupture rate with induction.(41) In a study which included 752 women, 12 uterine ruptures occurred, 11 of which were associated with the use of induction or augmentation or both. The authors stated that VBAC is safe, but VBAC with induction is not.(42) In a study quoted above on the efficacy of induction, uterine scar separation was found to be 7% in the induced labors.(43)

A review of almost 115,000 births in Canada confirmed that induction and augmentation of labor (using chemical agents to stimulate greater uterine activity in a labor which began on its own) are definite risk factors for uterine rupture.(44) Although augmentation of labor may be less questionable an option than induction because labor has already begun, the risk of rupture remains. A study from Israel concluded that using oxytocin and prostaglandin added to the risk of rupture.(45) Another study confirmed that spontaneous labors had a low (0.45%) risk of rupture, but that using prostaglandin gel increased the risk by 6.41 times.(46)

Alternatives to Pharmaceutical Induction

Should one require an induction for a medical reason, what are the options? There are several options addressed, albeit briefly, in the medical literature. Sexual intercourse is cited by many midwives as effective, but there is little in the medical literature addressing its efficacy. Nipple or breast stimulation with an electric breast pump has been found to be as effective as oxytocin to start labor,(47) although it could have similar side effects and should be undertaken under the supervision of a provider experienced in it.

Acupuncture appears to increase the number of contractions.(48)(49) Mechanical dilation, including the use of balloon catheters, is another non-pharmaceutical option that appears to be effective.(50)(51) Using non-pharmaceutical forms of induction may have a higher failure rate than simply awaiting spontaneous labor if the baby is not ready to be born because it may not yet be positioned optimally, and without the bag of waters, may not be able to reposition. Data on the success of induction with non-pharmaceutical agents is difficult to come by. Should you wish to pursue information on the safety and efficacy of induction with these agents, and castor oil, cohoshes, and the like, you may refer, however, to the Midwife Archives at http://www.gentlebirth.org/archives/natinduc.html in order to make an informed decision.

Conclusion

In general, pharmaceutical induction as currently practiced in hospitals does not do what it promises. Instead of increasing your chances of a successful VBAC, it decreases them, and it does so at the same time that it makes your experience and your baby's more dangerous. In case of medical need, induction can be a useful option, but it should not be chosen lightly. Should induction be required, it is important to ripen the cervix as much as possible before the induction to maximize your chances of success. Choose your care provider carefully and discuss your choices fully with him or her before you agree to induction of labor for a VBAC.

11/17/01

References

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