"If I recall correctly that the body of research for the last five years supports intervention if the pregnancy goes to _41_ weeks.  There is a significant increased risk of problems to the baby after that."

Not true, according to this June 2003 meta-analysis:

Sanchez-Ramos L, Olivier F, Delke I, Kaunitz AM.
Labor induction versus expectant management for postterm pregnancies: a systematic review with meta-analysis.  Obstet Gynecol. 2003 Jun;101(6):1312-8. Review.

"OBJECTIVE: To compare routine labor induction with expectant management for patients who reach or exceed 41 weeks' gestation....

Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99).  Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), ***THIS DIFFERENCE WAS NOT STATISTICALLY SIGNIFICANT***.  Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores."  [emphasis mine!]

(Note: the conclusions of this analysis with respect to perinatal mortality and morbidity are being incorrectly described in some online articles; that is, the article is being incorrectly cited as concluding that perinatal morbidity and mortality *were* significantly lower in the induction groups, "significantly" meaning statistically significant, of course.)

As far as the 1.9% lower rate of caesareans in the induction groups, the cynic in me thinks this: since Caesarean sections are very much in the discretion of the physician, I think they got tired of waiting for the women in the expectant groups (natural labour) to deliver and therefore chose C/S more often.  At 3 am it is certainly more tempting and is a more known and finite option than waiting for a child to arrive naturally.  Something about natural birth also makes them nervous - they just don't feel as in control as when those contractions are regularly clicking along with the assistance of the drip - and indeed, they aren't in control and I think they hate that.

Note the perverse conclusion in the abstract:

"CONCLUSION: A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes."

Needless to say, there are other, less physically/socially/emotionally/financially costly ways to reduce caesarean rates.

A very recent study on the increased risk of caesarean section associated with inductions (the breastfeeding part is coming!):

Johnson DP, Davis NR, Brown AJ.
Risk of cesarean delivery after induction at term in nulliparous women with an unfavorable cervix.
Am J Obstet Gynecol. 2003 Jun;188(6):1565-9; discussion 1569-72.

"RESULTS: Among 4635 women (63.7%) in spontaneous labor, the cesarean delivery rate was 11.5% versus 23.7% among the 2647 (36.3%) patients who underwent induction. An important variable that affected the delivery route was the Bishop score at the initiation of the induction. The cesarean delivery rate was 31.5% among patients whose Bishop score was <5 at induction versus 18.1% for patients with a score > or =5(P <.001). CONCLUSION: The induction of labor in nulliparous patients, especially those women with an unfavorable cervix as measured by Bishop score, is associated with a significantly increased risk of cesarean delivery."

And another (there are more still):

Seyb ST, Berka RJ, Socol ML, Dooley SL.
Risk of cesarean delivery with elective induction of labor at term in nulliparous women.
Obstet Gynecol. 1999 Oct;94(4):600-7.


To bring the circle back to breastfeeding, note the many studies in which caesarean deliveries have been found to negatively affect breastfeeding initiation rates, time until initiation, duration, exclusivity, or all of these.  Some of these studies are:

Rowe-Murray HJ, Fisher JR.
Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding.  Birth. 2002 Jun;29(2):124-31.

Perez-Escamilla R, Maulen-Radovan I, Dewey KG.
The association between cesarean delivery and breast-feeding outcomes among Mexican women.  Am J Public Health. 1996 Jun;86(6):832-6.

Leung GM, Lam TH, Ho LM.
Breast-feeding and its relation to smoking and mode of delivery.  Obstet Gynecol. 2002 May;99(5 Pt 1):785-94.

Weiderpass E, Barros FC, Victora CG, Tomasi E, Halpern R.
[Incidence and duration of breast-feeding by type of delivery: a longitudinal study in southeastern of Brazil]  Rev Saude Publica. 1998 Jun;32(3):225-31. Portuguese.

Shawky S, Abalkhail BA.
Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia.  Paediatr Perinat Epidemiol. 2003 Jan;17(1):91-6.

Ever-Hadani P, Seidman DS, Manor O, Harlap S.
Breast feeding in Israel: maternal factors associated with choice and duration.
J Epidemiol Community Health. 1994 Jun;48(3):281-5.

Mathur GP, Pandey PK, Mathur S, Sharma S, Agnihotri M, Bhalla M, Bhalla JN.
Breastfeeding in babies delivered by cesarean section.
Indian Pediatr. 1993 Nov;30(11):1285-90.


While this is not exactly the same as being able to show that oxytocin inductions *per se* negatively affect breastfeeding, I think perhaps these studies collectively say something broader and more important: that inductions at term (or before) elevate the caesarean rate, which in turn negatively impacts breastfeeding.

As for the lower caesarean rate seen with *post-term* inductions (Sanchez-Ramos et al, above),

- the absolute difference between the expectant groups and the induction groups, although statistically significant, was minor: 20.1% (induction) versus 22.0% (expectant) = 1.9% difference; ie. only 2 out of 100 women benefited from being in the induction group (by avoiding a caesarean she would otherwise have gotten),
- the caesarean rate in *both* groups was very high (caesarean rates of 2 to 5% are achievable), and
- the caesarean rate in the expectant groups likely could have been lowered to match or undercut the rate in the induction groups simply by greater physician patience and/or less nervousness.

A rather roundabout way of trying to answer the induction/breastfeeding question ....

Barb Strange

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