Just in case anyone is wondering…I’ve been busy at births and studying for my exam in neonatal resuscitation. I’ll be back posting soon!
I attended a mama being induced last week, and it reminded me that this post was still waiting to be written. So here it is, finally! I’m discussing medical induction here – if you are interested in ‘natural’ induction, the midwife Aviva Romm wrote an interesting piece last month.
Birth can be induced for all kinds of reasons. Some are medical – baby too small (IUGR), mama’s blood pressure too high. Some are social – dad only has the weekend off work, for example, or a loved or trusted care provider is only available at a particular time. Some reasons are better than others. The March of Dimes has a campaign to encourage parents to wait until at least 39 weeks before attempting an induction, and ACOG says the same thing. One reason is that, while a baby may technically ‘early pre-term’, he or she may not quite be ready for earthside life yet. Both the linked pages above note the increased likelihood of NICU stays for babies born between 37 and 39 weeks. Once a pregnancy reaches 41 weeks, many if not most care-givers prefer to induce, citing an increase in the likelihood of still birth as the key rationale: taken together, various studies have suggested that one still birth will be avoided for every 369 women induced between 41 and 42 weeks. The first key questions, then, when confronted with the option to induce, are ‘why?’ and ‘why now?’
Apart from the need to wait to at least 39 weeks, a factor to consider is that the mama’s body (or rather, the mama-baby partnership) may not quite be ready for labour yet, so that ‘failed induction’ is a big cause of cesarean section, especially in first time moms. If you are confronting a possible induction, it’s a good idea to ask your care provider about your ‘Bishop Score’. The Bishop Score is a number between 0 and 13, calculated by assigning points for cervical position (posterior, middle, anterior), dilation (in centimeters), consistency (firm, medium, soft), effacement, and the extent of your baby’s descent into the pelvis (from -3cm above the ischial spines to +3cm). There is a Bishop Score calculator here. With a score of 8 or higher, an induction is likely to be successful – a doctor or midwife may be able to give you a percentage likelihood. 7 or below means that an induction is unlikely to be successful. If you want to be induced, or are feeling pressure from some source to induce, this information is useful to have. It helps to answer another key question, ‘Will it be likely to work?’ It’s good to know your options if it doesn’t work ahead of time – can you go home, and try again another day (likely not if you have agreed to have your waters broken) or will you be facing a surgical birth?
Once the decision to induce is taken, there are several different options (‘how?’). Some involve causing the cervix to soften (prostaglandins) or dilate (a Foley balloon or certain types of seaweed), while others induce contractions (most commonly Pitocin, an artificial form of the oxytocin that your body naturally produces in labour). Often, artificially rupturing the membranes – breaking the water – is an option. Pitocin and rupturing the membranes can also be used to augment a labour already in progress, usually because it is considered to be going to slowly for some reason. Sometimes, if a mama is very near her time, the merest hint of induction can trigger natural labour: a ‘whiff of Pit’, as it is often known, may be given to set things in motion, but then the mother’s own body takes over and no more Pitocin is needed. For others, a combination of all these factors may be used to try to bring labour: first cervical softeners are applied, then Pitocin is started, then later the membranes are ruptured until finally, hopefully, a good labour pattern is established. Or not. What is your care provider’s preference for you? What is his or her preferred timeline?
What do we need to know about these and other methods of induction and augmentation in order to make our own best decisions? In other words, what information do we need to consider before giving or withholding consent? Please note: I am not a care provider and I have no medical advice (or advice of any other kind) to give. That said, I think we need to have, as best we can, both personal, physiological information (how will my body likely respond?) and provider information (if I dilate to 4cm with a Foley bulb, but contractions do not start, what is your plan?). For example, the cells of the uterus are equipped with oxytocin receptors that cause them to contract when that hormone is present, but they are not switched on until labour is imminent – otherwise you might have contractions every time you make out with your honey. If your labour is not imminent, and those receptors have not been activated, what effect will Pitocin have? Or, if you had plans for an unmedicated labour, but Pitocin causes the intense contractions (and sometimes fetal stress/distress) for which it is well known, how will you manage the resulting
agony discomfort or fear? If you planned to move through labour, but must have continuous fetal monitoring due to Pitocin, and be in or near the bed, what will you do? If your care provider asks you to come in and have your waters broken, with the plan to ‘see what happens’, how will you, in the hospital, inform yourself sufficiently to make your best decisions when subsequent steps are suggested? If you are labouring naturally yourself, but your care provider wants to augment your labour, the same kinds of questions apply. Why do you want to do this? Why do you think I need to do it now? What effect will it likely have on me? And on my baby? What are the risks of doing it? And of not doing it? Are there other options? How long do I have to decide?
Providing yourself with good, evidence based information on options for induction and augmentation may help to make some decisions ahead of time. It may give space and time to think and make decisions. Childbirth Connection has a good article on considerations in induction. Henci Goer wrote a great article on elective induction. Evidence Based Birth has a good one on induction for ‘big baby’. And the now quiet blog ‘Birth Sense’ had an interesting series on due dates and inductions, here (click ‘next’ for the two following posts). Many of these articles have links to medical journal articles where you can read cutting edge research – and sometimes, if you feel you need to, present it to your care provider.
I thought I would cover induction of labour and augmentation of labour at the same time, since similar techniques can be used for each and similar risks and benefits may apply. In order to talk about induction, however, we first need to think about how human beings gestate. It turns out that this topic requires a post all of its own!
Left alone, pregnancy normally lasts for between 37 and 42 weeks (counting from the first day of the last menstrual period or LMP – 35-40 weeks counting from ovulation/conception). This range explains the ‘E’ in ‘EDD’ – estimated date of delivery. Gestation varies more in humans than in any other mammal: it varies between women, and it also varies among the pregnancies of any given woman. It varies partly because cycle length varies in both directions from the average of 28 days. Usually, a woman ovulates about 14 days before the onset of her period. However, the number of days between the onset of the previous period and ovulation can vary a great deal. One woman’s cycle might be 20 days (with ovulation around day 6) while another’s might be 45 days (with ovulation around day 31). Calculating an EDD based on the LMP would be inaccurate for these hypothetical women, and considerably inaccurate in the second case. Of course, ultrasounds are often used to confirm fetal age, and when taken early in a pregnancy, these can be helpful. Later in pregnancy, however, they are considerably less accurate, and can be wrong by perhaps as much as 2 weeks in either direction. Here is an article that goes into greater depth.
The other aspect of an EDD is the normal variation in human gestation. An article published in the journal Human Reproduction in August this year found a variation in pregnancy length of 37 days, even after excluding pre-term births and pregnancies with complications. You can read the abstract online, although you need a subscription for the full article. A woman might have short gestations or long gestations, or vary between pregnancies. Imagine, then, two women. Betty has short cycles and a short gestation. Pam has long cycles (let’s say 35 days) and a long gestation. If both conceive today, August 25, 2013, they get the same due date of 1 June 2014. The error in estimation doesn’t affect Betty so much – she might just be surprised to go into labour in early May next year. However, in most people and very many care-practitioners’ eyes, Pam will be ‘due’ on 1 June and ‘post-dates on 14 June. Living in the United States, she will almost certainly be pressured to induce her baby long before that bundle of joy is ready to make his or her entrance. By her cycle length alone, she would not be 40 weeks pregnant until 8 June, and not post-dates until 22 June. A normal 42 week gestation would put her delivering then – 3 weeks after the due date suggested by her LMP. Conversely, if she induced at 39 weeks from LMP (for whatever reason) her baby would not only be really a 38-weeker, but could be as much as four weeks ‘under-done’.
Why does it matter? Surely in late pregnancy the baby is ready anyway? You know loads of women who have had their labours induced and they and the baby have been just fine? Why do doulas, midwives and natural birth advocates talk about ‘letting your baby choose his or her birthday’? The next post will address these questions.
I haven’t posted for a while, and it’s because I have been rather busy being a doula. Lots of lovely clients, many pre- and post-natal meetings, a looooooong birth and an interview (successful at my new higher fee – yippee!) as well as the never-ending small jobs of daily life with a young family have together taken all my time over the last couple of weeks. I plan to continue my series of posts on ‘interventions’ though, so stay tuned.
The birth I attended this week was very hard. It will take a lot of thinking about and I certainly learned a great deal. The end, though, was beyond worth it. Here’s Baby N (shared with permission):
If you are having a hospital birth, one of the first interventions you will face is an IV. Most commonly, a doctor might want to give you antibiotics if you have tested positive for Group B Strep* (in the US at least) or if you have another communicable illness; pitocin to induce or augment labour or to help prevent hemorrhage in the third stage of labour; or fluids to help keep you hydrated or in preparation for surgery. The downside to having an IV is that it tethers you. If you plan to have an epidural, that doesn’t really matter, but if you seek a natural birth it can make things harder. It doesn’t make movement impossible, but it does make it more difficult – just turning over from a side-lying position to being on all fours in bed is trickier, because you get tangled.
Many docs and midwives in hospitals will at least consider inserting an IV lock, which gives you freedom of movement but allows for the speedy administration of an IV if it becomes necessary. For my own last birth, I would have preferred not to have one at all – I was GBS-, labouring fast and hard, and kept drinking throughout. I had decided it was a ‘battle not worth fighting’ though, and agreed to the IV lock when I was admitted. It took five goes (five BIG bruises) to insert the lock and perhaps 10 minutes of trying. I have lovely big blue juicy veins too – except when I’m in labour. They vanish during contractions. That made me understand more fully why a care provider might feel more comfortable with a labouring mom who agrees to an IV-lock!
* In the US, mothers who are GBS+ are routinely administered 2 doses of antibiotics via IV during labour. GBS is a bacteria that colonises the vagina, just as other kinds of bacteria colonise the gut or the skin. It is not harmful to the mother, and it is rarely transmitted to the baby. However, when it IS transmitted, it can cause a very serious illness and death. Medics treat GBS+ mothers differently in different countries. You can read more about GBS over at Evidence Based Birth.
Interventions are something I talk about with every mama with whom I work, so I thought I would write a series of short posts covering some of the oft-raised issues and questions. I’m going to try to go chronologically through labour and birth – although of course, since every woman’s experience is different, things happen in different orders for different mamas.
Many women are met at the doors of the hospital by a nurse offering a wheelchair. Some women sink into it gratefully and are happily wheeled to L&D. Some women plonk their hospital bag into it and stride along next to it, pausing to contract along the way. Some women say no. As with every intervention I plan on discussing here (and barring medical necessity) it doesn’t matter what your choice is, as long as it is your choice. Some women like the comfort of being wheeled: it signifies arrival at a safe place, where professionals will take care of them. Others feel as though accepting a wheelchair labels them as a patient, rather than a woman in labour, and prefer to walk. Also, choices change. If you planned on striding in but find yourself exhausted from labouring at home as long as possible, sit on down. If you hoped to ride in style but sitting feels like you are on a bowling ball, congratulations, there’s a baby in your pelvis, you’re going to have to walk. This is a small thing, but like everything in birth, it matters. It affects how you feel, and how you feel affects how you labour.
A second small choice is what to wear to labour. A hospital gown carries the same ‘I’m a patient’ label as the wheelchair, but no one cares when it gets messy and it also unsnaps brilliantly to allow for easy skin to skin when the baby is born. A special t-shirt (sometimes a partner’s t-shirt) can convey home and comfort and familiarity and not really be in the way. Apparently you can get fancy labouring gowns on the internet, but I’ve never seen one used. A bra might be helpful to keep pregnant boobs comfortable, or be in the way, or difficult to get off when necessary. How do you want to be in labour? What makes you feel comfortable and safe? Note: in the births I have attended or participated in so far, almost everyone ends up naked. The two who didn’t laboured so fast that they didn’t have time to get naked. So perhaps in the end this small choice is a less important one? Unless it is important to you.
If there’s a particular intervention or birth choice you would like me to discuss, please let me know in the comments.
The wonderful website Improving Birth posted an article recently on informed consent in childbirth. It concludes by saying,
‘With a national cesarean rate of over 32%, all women have an interest in ensuring that they have the right to make an informed decision about the risks of cesarean for their own births, and that every intervention offered—up to and including surgery—may be freely accepted or freely declined. Many patients freely choose to say, “Doctor, tell me what to do.” But that, too, is an autonomous choice to follow a practitioner’s advice, and must be recognized as such. A “yes” is not meaningful unless you also have the right to say “no.”’
A huge part of a doula’s job is to educate – to find and present evidence-based information on birth-related issues so that our clients can make truly informed decisions. Many care providers bristle at the suggestion that they do not practice evidence-based care, yet statistics for use of methods and interventions from routine rupture of the membranes (breaking the waters) to prone, directed pushing, to episiotomy to immediate cord clamping (the list could go on and on) suggest otherwise. Of course few mamas or doulas have the years of medical education and experience that OBs have, and when there is a difference of opinion it can be hard to negotiate or even to square up against that kind of presence – white coat syndrome. (I could point back to the ‘Choosing a care provider’ post below…). Being able to refer to, or hand over a print out, of a Cochrane Review or Summary (like this brand new one on delayed cord clamping) goes some way to meeting a doctor or midwife on his or her own ground. It gives a basis for discussion and reasoning. It demonstrates to the care provider that a mama is not relying on ‘Dr Google’ or internet chat rooms, but is striving to make truly informed decisions. This is why I am continually e-mailing my mamas links to birth related websites and medical journal articles, and why my learning as a doula never ends.
At the same time, the sentence in bold above, which asserts the right to informed dissent, is also crucial. Parents – and most especially labouring women – must be allowed to say ‘no’ to any given procedure, without being threatened with withdrawal of care (which is illegal), without being bullied, without being treated as anything less than the human beings they are. (This logic, backed by law, must surely result in the overturning of hospital VBAC bans, because of which many women are not free to dissent to surgical birth – but that’s a story for another post). We have to be free to say no, I do not want to be induced at 39 weeks because you think my baby might be big. No, I don’t want routine pitocin: if my labour slows or lulls, I’d like to try nipple stimulation first. No, I don’t want you to break my water right now: please take the time to explain to me why you want to, why you want to right now, what are the risks and benefits of doing it now and what are the risks and benefits of not doing it. No, I’m happy pushing on hands and knees, please catch my baby this way. No, we have no STDs, please don’t put erythromycin in my baby’s eyes.
It’s our responsibility as women, as mothers, as parents, to educate ourselves about options and choices during birth. Doing so is easier for some women than others, free time and access to information not being evenly distributed. Know what makes it easier? Hiring a doula!
ObGyn News has an interesting article this month on how labour progresses. You can read it online. The catchphrase is that ’6cm is the new 4cm’, but the take away for me comes further down the text (is there an online version of ‘below the fold’?): citing an article from The American Journal of Obstetrics and Gynecology, it says, ‘it was common to have very slow progress before 7 cm, there was no deceleration phase, and the slowest but still normal rate of cervical dilation was less than 1 cm/hr, with a wide range of variability‘ (italics added). In this study, going from 6cm to 7cm dilation took 30 minutes on average, but the range was from 12 minutes to 2 hours. For me, this range is the takeaway. Getting rid of Friedman’s Curve, or even moving the start of ‘active labour’ from 4cm to 6cm, makes no sense if it is simply replaced with a new curve that women are ‘supposed’ to follow. I have been at a birth where getting from 4 to complete took 18 hours, and one where 7 to complete took the unit of time known as ‘climbing off the bed and into the tub.’ Women labour and ‘progress’ differently. Changing the circumstances can change the labour. How about that?
Sometimes, this work is very hard. I can be present, and calm, and loving. I can hold hands and rub feet and light candles and whisper: ‘it’s ok, don’t be afraid, everything will be ok.’ But sometimes a mama is broken – physically, mentally, spiritually. Sometimes it’s a dangerous thing to wait for labour and surgery really is the safest thing – that very surgery making it too dangerous for a mama ever to contemplate another pregnancy again. Sometimes a papa is not a safe haven or a hero or a protector or a comforter but a threat. Sometimes breast is not best: it can be deadly, no matter how much the mama wants and needs and yearns to feed her baby that way. Sometimes there is judgement as well as compassion in the eyes of caregivers. Not all, by any means, but enough to add to the hot tide of shame and despair that a broken mama might feel. Sometimes the future looks unremittingly bleak.
I was at an incredible birth this week and it made me reflect again on the ‘care provider’ post below. Healthy mama, healthy baby, low risk pregnancy, hospital-based nurse midwives providing care. With the mama’s permission I’ll post a full story and pictures later, but for now, let me just say this: baby chose her birthday, mama laboured at home as long as possible, arrived at the hospital close to transition and powered through with NO interventions – no wheelchair, no gown, no IV-lock, no epi, no pit, no instruments, barely a moment of fetal monitoring here and there. Supported by people who knew her and loved her and trusted her and her body and her baby, some warm water, some circling hips, some hanging on to papa, some vocalising and moving and shifting and hard, hard, hard work…and a bright, alert, beautiful baby who arrived about an hour after we got to the hospital and nursed about an hour after that.
It doesn’t always go this way, even when choosing this kind of care. But oh my, when it does, it is magnificent.