Applying medical research to clincial realities

by | Oct 19, 2015 | Hospital birth, Inductions, Using statistics, VBAC | 4 comments

Isabel recently asked over on Uterine rupture rates after 40 weeks:

“I wonder however if there are studies that compare the method of induction. My Doula said that the increase rates of uterine/ scar rupture was due to using high dosages of Pitocin, but now the induction uses lower dosages and administered at longer intervals. Do you know something about this?
Thank you”

Isabel,

Great question.

A few factors to consider:

1. Induction protocols can vary by provider, including some providers who don’t induced planned VBACs at all.
2. Induction guidelines can vary by hospital.
3. Women can react to the same drug/dose differently.
4. Some studies do compare the uterine rupture rates among spontaneous, induced, and augmented planned VBACs.

Medical studies on induction are only relevant to your situation if your provider follows the same protocol outlined in the study. However induction protocols are often not spelled out in detail unless that is the focus of the study.

When reading medical research, make special note of the sample size. We need ample participants in order to accurately capture and report the incidence of uncommon events such as uterine rupture. I typically like to see at least 3,000.

Also remember that it’s ideal to have a experimental group (who receives the induction protocol) and a control group (who does not receive the induction protocol) in order to measure the difference in outcomes, such as fetal distress, uterine rupture, hemorrhage, cesarean hysterectomy, etc. Ideally, we would have a couple thousand, at least, in the experimental and control group.

In terms of the trend that induction now uses lower dosages and is administered at longer intervals, that may be true in some practices, but I would always confirm and not assume.

Anecdotally, I have heard a wide range of induction protocols reported just as research has identified similar variations among cesarean and episiotomy rates that are not linked to medical indication. This California Healthcare Foundation infographic clearly illustrates how hospitals differ:

Tale of Two Births

In terms of specific studies comparing the method of induction, the first resource that comes to mind is the Guise 2010 Evidence Report.

Search for the word Cytotec and there is a discussion comparing rates of rupture by Pitocin, prostaglandins, and Cytotec.

Pitocin is associated with the lowest rate of rupture among the chemical agents which is likely why ACOG (2010) recommends Pitocin and/or Foley catheter induction in planned VBACs when a medical indication presents. (Learn more about what the Pitocin insert actually says.)

There may be more recent studies out there. Google Scholar is a good place to start. You can often obtain the full texts of medical studies at your local library, university, or graduate school.

Also, if you subscribe to Evidence Based Birth’s newsletter, she will email you a crash course on how to find good evidence.

I hope this helps!

Jen

What is the induction protocol at your facility? Does it differ for those with a prior cesarean? Let me know in the comment section.

Resources Cited

American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463, http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

California Healthcare Foundation. (2014, Nov). A Tale of Two Births: High- and Low-Performing Hospitals on Maternity Measures in California. Retrieved from California Healthcare Foundation: http://www.chcf.org/publications/2014/11/tale-two-births

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Friedman, A. M., Ananth, C. V., Prendergast, E., Alton, M. E., & Wright, J. D. (2015). Variation in and factors associated with use of episiotomy. JAMA, 313(2), 197-199. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=2089343

Kozhimannil, K. B., Arcaya, M. C., & Subramanian, S. V. (2014). Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database. PLoS Med, 11(10). Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1001745

What do you think? Leave a comment.

4 Comments

  1. Hi Jen, I’m not seeing the infographic referred to in the article. I’m viewing this on my phone, if that helps.

    Reply
    • Heidi,

      Thank you so much for bringing that to my attention. I have added the infographic.

      Best,

      Jen

      Reply
  2. I am a nure in a cardiac unit and had to have an emergency cesarean 2 yrs ago. Our policy is you have to go into labor on your own, there is no induction. They also make you sign a waiver (I just looked around on our elctronic forms) that could kind of scare you into another cesarean. I’ve even asked around to some of the L&D nurses I know and all frown upon VBACs The LC there I talked with said she thinks it’s a great idea and worth the try if I wanted. Her daughter has had two vaginal deliveries after her first baby (who was a c-section). So I am doing my personal research too.

    Reply
    • Hi Stephanie!

      You might want to contrast the information you received from your nurse colleagues with what ACOG states. ACOG is clear: VBAC is a safe, reasonable, and appropriate option for most women so the fact that those nurses frown upon VBAC is disconcerting for three reasons.

      First, it’s not consistent with the evidence. ACOG states that women should be counseled about VBAC and candidates should have the opportunity to VBAC. (Note that very few women are truly not candidates per ACOG guidelines.) ACOG is clear that the ultimate decision regarding mode of delivery rests with the patient and that regardless of restrictive VBAC policy, women should not be forced into cesareans.

      We also have to be cognizant that both VBAC and repeat cesareans carry risk. Few women are actually counseled on how the rate, response, and outcomes of placenta accreta compare with uterine rupture. I write extensively on this subject here.

      Second, what would it be like to labor with a nurse who is not really supportive? Imagine managing each contraction with nervous energy in the room. Now imagine laboring without it.

      Third, their perspective likely mirrors the tone of providers and administrators at that facility. You deserve better. Life is easier when we have support. And being supportive of VBAC is consistent with the evidence, ethical obligations, and national guidelines. So, nurses frowning upon VBAC is a huge red flag.

      If you are interested in VBAC, I encourage you to investigate more supportive options in your community. Also, subscribe to my newsletter and receive a one-hour podcast where I compare and contrast what ACOG says versus what women are told. Also, check out my online workshops for more in-depth information.

      To continue the conversation, I shared your comment here. A couple nurses have already replied.

      Best,

      Jen

      Reply

Submit a Comment

Your email address will not be published. Required fields are marked *

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.