I've noticed that hospital births seem to be more "medical" than they used to be. This observation became even more apparent when I saw Ricky Lake's film, The Business of Being Born. In one scene, the residents are all standing around the labor board, a list in the labor and delivery unit with the name of each patient, their cervical dilation, and any medical issues. The residents are going down the list: Pitocin, Pitocin, Pitocin.

You may know already that Pitocin is a medication that we use to induce or augment labor because it causes stronger contractions. My views on Pitocin are not exactly in line with that of the natural childbirth community -- I don't think it is evil unto itself. But I have been wondering why, these days, almost every labor eventually "needs" Pitocin.

So here are the factors that I think are playing a role in the increased use of Pitocin.

1. More labors are being induced. This comes from:

• diagnosing medical conditions that lead us to believe that the baby is better off coming out, than staying in (such as intrauterine growth restriction, gestational diabetes, hypertension).
• going for convenience as the due date gets close.
• starting to get nervous as the due date passes and choosing induction now, rather than waiting until a full two weeks past the due date (with appropriate fetal monitoring).
• having newer medications, from a family of drugs called prostaglandins, that can get labor going even when the cervix starts out unfavorable for labor. So induction is more possible than in the past, even when the woman's body isn't showing signs of being ready.

2. Pitocin is often given to augment a labor that isn't progessing well. Research done in Ireland, and repeated in Chicago, indicates that once a woman is in active phase (which begins around 3-5 centimeters dilation), you can decrease the chance of cesarean by jumping in with Pitocin if labor starts to stall.

So why are so many labors stalling out? Here are some possibilities.

• Women are gaining too much weight and their babies are too big.
• Diabetes is on the rise and those babies can be extra big.
• Obesity may interfere with the course of labor, and more U.S. moms are overweight than ever before.
• Our routine of continuous fetal monitoring keeps moms in bed. Maybe this lack of mobility makes labor take longer.
• Anxiety interferes with the course of labor. Maybe some routine birth practices are making moms more nervous, or maybe women are just less emotionally prepared for the challenges of labor.
• Although research doesn't show that epidurals cause labors to be longer, as one resident said to me about 15 years ago, "I have seen epidurals screw up perfectly good labors."
• Maybe older moms are more likely to meet our medical criteria for Pitocin, and women are having babies at older ages.
• Maybe our definition of normal progress in labor is wrong.

So what is the problem with a medical approach to birth? If everyone is happy with this, I suppose it is just a different way to approach the birth process. But some moms-to-be don't want a medical experience, and it is hard to believe that a process as normal and time-tested as labor requires medication and surgical intervention so often.

We don't want to go back to the maternal and newborn mortality of the nineteenth century. But you'd think with good hygiene, prenatal care, better nutrition, and our ability to check on the baby during pregnancy and labor, that we ought to be seeing great improvements -- without a 35% cesarean rate or universal use of labor augmentation.

Are moms and babies changing (obesity, excess weight gain, prevalence of diabetes, maternal age)? Has the medical team's tolerance for deviations from "normal" changed? Are we doing things to moms in labor that are making the process require medical interventions? Or is it some combination of all these factors that has lead to, what seems to me to be, an even more medical approach to labor than I have seen in my 25 years of obstetrics?