Induction is wrong, wrong, wrong… wait, what?
I hear all the time how induction in VBAC is contraindicated. This is false. This is the kind of misinformation that materializes when we demonize all induction rather than specifying between elective and medically indicated inductions.
It’s important to use clear, specific language when we talk about birth because there is a lot of confusion among moms, advocates, doulas, and health care providers about VBAC and induction. When I point out the lack of clarity many people have on the topic to “anti-induction advocates,” some respond that their focus is warning moms about elective inductions, which is absolutely needed. They genuinely believe that people are aware of the distinction between elective and medically-indicated inductions.
However, that has not been my experience. In fact it’s been quite the opposite. There are many people who don’t understand the why, when, and how of inducing VBACs and that is impacting the abilities of women to make informed decisions and exercise their right of patient autonomy.
First, you can induce VBACs
To be clear, medically indicated induction in a VBAC is not contraindicated. Yet, many people persist that it is citing ACOG (1) and the Pitocin insert (2). ACOG clearly says in their latest VBAC guidelines (3) that “induction remains an option” in a mom planning a VBAC via Pitocin or Foley catheter. The Pitocin drug insert (2) does state, “Except in unusual circumstances, oxytocin [Pitocin] should not be administered in the following conditions” and then lists “previous major surgery on the cervix or uterus including cesarean section.” However, despite conventional wisdom, a prior cesarean is not listed under the contraindications section. Further, the drug insert recognizes the value of individualized care:
The decision [to use Pitocin in a woman with a prior cesarean] can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.
This is in line with ACOG’s latest VBAC recommendations (3) where they say, “Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk.” This is information a woman can use to make an informed decision if she is faced with a medical condition that requires her baby be born sooner rather than later, but not in the next 15 minutes. To induce, have a cesarean, or wait for spontaneous labor when facing a true medical issue is a decision for the mom to make in conjunction with her supportive heath care provider based on the evidence of her risks, benefits, and options.
If you just read bits and pieces of the Pitocin insert, or a few key quotes from an anti-induction article, you are going to miss the full story; much like how reading the full text of a study gives you context and details that you lack by just reading the abstract.
Yet, misinformation persists
Ok, so now you know that induction remains an option per the Pitocin insert, ACOG, and respect for patient autonomy. Now check out these quotes, from the last couple days, from six different people. If I were to keep a list of comments like these, just referring to induction and VBAC for a month, I would literally have dozens if not hundreds. Misinformation is rampant:
“pitocin is CONTRAINDICATED for vbac bc the risk of uterine rupture”
“I thought it was unsafe to use pitocin with a vbac.”
“vbac should never be induced!”
“It is unsafe for prev surgical births. It says so in the PDR, or at least it did.”
“Not supposed to induce with a VBAC.”
“Never never never have an induction, especially with any kind of vbac!! Oh my goodness. it drastically raises your chances of uterine rupture!! Holy toledo. If you don’t know the risks involved with inductions, especially in vbacs, don’t offer the advice! Smh. Pitocin is completely contraindicated for vbacs, I’m pretty sure it even says that on the insert.”
“Are you actually trying to argue that induction of labour on a VBAC is OK???WOW…that is not evidence based AT ALL. Every study that has been done comparing the two shows a clear rise in risk associated with induction of labour and rupture. I am ALL for choice no matter the case, but I think every women has a right to INFORMED choice and you clearly are not. UNLIKE.”
Note the tone of these comments. There is no room for negotiation. Do you get the sense that they are just referring to elective inductions or all inductions?
More risk than what?
But the key question is: More risk than what? That is always what women should ask.
More risk than remaining pregnant with preeclampsia? Ok, let’s say that is true.
Then when a woman with a prior cesarean is diagnosed with preeclampsia, or another medical condition itemized by ACOG (4), and they agree that remaining pregnant has higher risks than delivering the baby, they should have a cesarean, right? Even if vaginal birth remains an option, albeit via an induced labor? Those moms shouldn’t have a choice, they shouldn’t have a say, they should just go straight to cesarean?
How is that preserving choice for women and honoring their right to make their own medical decisions?
Don’t misrepresent the facts
That is what anti-induction advocates don’t understand: induction has its place. As does every other medical intervention. If you want to go straight to cesarean, rather than having a medically-indicated induction, that is your choice to make with your body.
But don’t misrepresent the truth to other women.
Don’t misrepresent the risks of Pitocin by listing a mish-mash of complications with no rates or citations.
Don’t say things that can be disproved with a single mouse click like inducing VBACs is against evidence based medicine.
Don’t undermine a woman’s legal right to autonomy (5) by perpetuating the myth, that all induction, including when medically indicated, is wrong.
Don’t dictate specific actions while withholding facts that would enable women to make their own decisions, even if they are different than what you would prefer.
Medically indicated induction = choice
People don’t appreciate that standing for medically indicated induction is standing for women to have a choice: induction vs. repeat cesarean. Without induction, there is no choice when a valid medical reason presents. By eliminating the option of induction, women are mandated to the increasing risks (6) of repeat cesarean. And yet people who persist in their agenda say things like this to me (naturally, the following was asserted after I shared my article (4) and they didn’t read it),
Does inducing a VBAC increase the chance of rupture??? YES. Does a women, and should a women have the right to choose that irregardless of that FACT??? YES. Is the most important thing informed consent?? I believe it is.
Women can make informed decisions only when they are informed
To provide information supports choice and informed consent. To dictate a specific action while misrepresenting the evidence eliminates choice and prohibits informed consent . I advocate for the former.
If you read my article (4), you will see that I list the reasons for medically indicated induction as well as provide an extensive review of studies illustrating the increased risk of uterine rupture. I do this rather than simply saying, “the risk of rupture is higher and thus you shouldn’t do it” because providing facts with context puts the choice in the hands of the mom, rather than me (or anyone else) dictating to her what she should do.
Some women will accept that higher rate of uterine rupture that comes with induction in order to have a vaginal birth and avoid a cesarean. Others will choose to avoid the increased risk of uterine rupture in an induced labor and accept the risks of a repeat cesarean section. Those are choices for women to make for themselves based on facts, not on misrepresentations of what other women (incorrectly) think is contraindicated.
“Induction is wrong” & patient autonomy
People who advocate that “induction is always wrong” don’t understand the implications of their assertions. By arguing against inductions, which in the minds of many include medically indicated inductions since no distinction is made, they are effectively advocating for more cesareans and against informed consent and patient autonomy. Just like others who exaggerate or minimize the risk of uterine rupture. (Click here to download a free report on the top 5 uterine rupture myths.)
My mission is to increase access to VBAC. I advocate for informed consent and patient autonomy and that is why I share evidence rather than dictating what others should do. I only hope that this reasoning and evidence based position spreads because there are far too many people out there who persist in the inaccurate philosophy that inductions in a VBAC are always wrong even in the face of a valid medical reason. This does not support choice, women, or birth.
1. Kamel, J. (2010, Jul 21). ACOG issues less restrictive VBAC guidelines. Retrieved from VBAC Facts: https://www.vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/
2. JHP Pharmaceuticals LLC. (2012, Sept). Pitocin official FDA information, side effects and uses. Retrieved from Drugs.com: http://www.drugs.com/pro/pitocin.html
3. American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology , 116 (2), 450-463. Retrieved from Our Bodies Our Blog: http://www.ourbodiesourblog.org/wp-content/uploads/2010/07/ACOG_guidelines_vbac_2010.pdf
4. Kamel, J. (2012, May 27). Myth: VBACs should never be induced. Retrieved from VBAC Facts: https://www.vbacfacts.com/2012/05/27/myth-vbacs-should-never-be-induced/
5. Kamel, J. (n.d.). Legal stuff. Retrieved from VBAC Facts: https://www.vbacfacts.com/category/vbac/legal-stuff
6. Kamel, J. (2012, Dec 9). Why cesareans are a big deal to you, your wife, and your daughter. Retrieved from VBAC Facts: https://www.vbacfacts.com/2012/12/09/why-cesareans-are-a-big-deal-to-you-your-wife-and-your-daughter/
7. Kamel, J. (2012, Dec 7). Some people think I’m anti-this/ pro-that: My advocacy style. Retrieved from VBAC Facts: https://www.vbacfacts.com/2012/12/07/some-people-think-im-anti-thispro-that-my-advocacy-style/
What do you think?
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What do you think? Leave a comment.
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 a hospital, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. Even more have accessed her trainings online. 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 the Secretary for the California Association of Midwives and the California Association of Licensed Midwives. Her favorite flavor of ice cream is peanut butter chocolate. And mint chip. And coffee.