Recently I was asked to be a part of a prime time special on the risks of inductions. The camera woman, Leona came out to tape me teaching a group of students on the risks of inductions and the real reasons they were sometimes necessary. She ended up also interviewing four of my students and then spent another hour interviewing me. I had also given them the names of another student and one of my doula clients who had been induced previously and wanted to share the ramifications it had caused the child that was the induced birth. Shannon and Tinika did a great job sharing their stories. The show was originally supposed to be a full hour but then it was whittled down to a half hour. I ended up getting two sound bites… but information was shared and that was what was most important. I thought I would share the link with you here so you can watch it and gather some information as well!
Patience: –noun
“One of my favorite stories concerns a Buddhist scholar and a Zen Master. The scholar had an extensive background in Buddhist Studies and was an expert on the Nirvana Sutra. He came to study with the master and after making the customary bows, asked her to teach him Zen. Then, he began to talk about his extensive doctrinal background and rambled on and on about the many sutras he had studied.
The master listened patiently and then began to make tea. When it was ready, she poured the tea into the scholar’s cup until it began to overflow and run all over the floor. The scholar saw what was happening and shouted, “Stop, stop! The cup is full; you can’t get anymore in.”
The master stopped pouring and said: “You are like this cup; you are full of ideas about Buddha’s Way. You come and ask for teaching, but your cup is full; I can’t put anything in. Before I can teach you, you’ll have to empty your cup.”
This story is and old one, but it continues to be played out in our lives day-by-day. We are so enamored of our own ideas and opinions and so trapped by our conditioning that we fill ourselves up to the brim and nothing can get in.” http://www.prairiewindzen.org/emptying_your_cup.html Continue reading »
Tips for Clients
(Ana Hill’s CAPPA training topic)
No complaining about normal discomforts to your care provider- complain to your doula or your friends- but the care provider often feels the need to “fix” it for you with an induction.
Adjusting your expectations about your due date- first time moms are usually pregnant for 41 weeks and a few days, and moms who have given birth before usually go 40 weeks and five days… so remember your due date is a guess date based on a 28 day cycle. Only 4% of moms go into labor on their due date.
Correcting suspect due dates with caregiver- do this early if you do not have a 28 day cycle- advocate for yourself if you know how long your cycle is- share it early on so that is taken into consideration.
No horror stories told or listened to… they affect your mind body connection as well as how your care provider sees you. Don’t listen to the stories and don’t offer up any for him or her to project onto you.
Chiropractor care and prenatal massage is great for helping the baby to be lined up properly. Gail Tully’s website www.spinningbabies.com also offers some great guidelines for aligning your baby for optimal fetal positioning. We also offer a great Line Up Your Baby for Labor class.
Sexual activity- those who stayed sexually active tended to not go postdates. The oxytocin and prostaglandins are wonderful ways to get things going.
Prodromal labor is a problem for many moms who have a malpositioned baby- so optimal fetal positioning is important. But often times it is also some issues that are causing fear that will delay labor beginning and sometimes cause labor to become dysfunctional once it does begin.
Some studies are showing perhaps these things can help:
Vitamin D supplementation- 4000 IU daily is recently been linked to more cesareans and malpositioned babies when the Vitamin D is too low… perhaps considered in the way the pelvis is lubed by doing so…
Fish oil- 400 mg DHA daily…matures baby’s brain and helps the mom prevent PPD.
Protein 80 to 100 grams a day.
Rest and hydration go together… don’t over do in the last week as to go into labor and be exhausted. Some say take your current body weight divided by 2 is the number of ounces you may want to drink of water daily.
Consider your expectations and determine if they are realistic with the birth care you have selected. Perhaps a change of venue and care provider will get you the birth you desire.
Keep in mind induction is not the same as labor. Our bodies being pushed into labor is not the same as our body going into labor on its own. Oxytocin and endorphins work very differently than the drugs used for induction- it does not pass the blood brain barrier. It can be more challenging since it brings on a different labor pattern- contractions much closer a lot sooner- transition lasting longer.
Remember what is controllable and what is not. The method of pain relief may not be as effective. The method of birth may be different. Failed inductions does not mean your body failed. The body’s job is to protect the baby from being born too early. So if your body does not think this baby is really ready to be born, your body will try to work against the induction medicine. Some studies show it may increase your cesarean rate by 50% over the normal rate. So understand what happens if it does not work- you may have a cesarean birth.
Find out what your Bishop score is before you go in so you know what your chances are of an induction that may be smoother.
You can consider acupuncture, a competent herbalist, a chiropractor and a massage therapist. There may be some risks to consider when doing herbal or homeopathic or kitchen sink inductions. It is an oxymoron to say “natural induction.” (these are my therapists- my acupuncturist, chiropractor and massage therapist.)
The bottom line is know what to expect and be a great advocate for yourself prior to going to the hospital for your induction.
Consider these sites if your induction does not go as you had hoped. Solace for Mothers and ICAN.
We know that inductions can lead to two problems- babies who were truly not ready and due date guesses that were wrong- leading to a baby who needs help and therefore earns a stay in the nursery or NICU. Or a mom whose body was not ready and her body did not comply with being forced into labor and therefore her failed induction led to a surgical birth by cesarean. I adore the Cochrane Datebase of evidence practiced medicine. And I adore Medscape which reports new guidelines by the medical societies set up by their specialties- the ACOG guidelines have now changed regarding inductions. I wonder if this was due to the ever increasing premature infants that are being born across the US and also the escalating cesarean birth rates.
So read ahead the newest guidelines regarding induction:
July 23, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, “Induction of Labor,” in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.
Benefits vs Risks of Labor Induction
For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.
The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.
“There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut,” coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. “And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home.”
Recommendations Based on Sound Evidence
Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.
The bulletin authors searched the MEDLINE database, the Cochrane Library, and ACOG’s own internal resources and documents to identify pertinent English-language articles published between January 1985 and January 2009. Although articles reporting results of original research were given priority, review articles and commentaries were also consulted, as were guidelines published by organizations or institutions such as ACOG and the National Institutes of Health. However, abstracts of research presented at symposia and scientific conferences were excluded. Expert opinions from obstetrician- gynecologists were used when reliable research evidence was not available.
Indications for Labor Induction
Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.
Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.
When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.
The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.
Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.
Clinical Recommendations
Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:
* For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
* When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
* Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
* For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
* For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
* In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
* The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.
An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.
As a proposed performance measure, the guidelines authors suggest that the percentage of patients in whom gestational age is established by clinical criteria when labor is induced for logistic or psychosocial indications.
“A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn’t successful in producing a vaginal delivery,” Dr. Ramin concluded. “These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus.”
Obstet Gynecol. 2009;114:386- 397.
Authors and Disclosures
Journalist
Laurie Barclay, MD
Laurie Barclay, MD, is a freelance writer and reviewer for Medscape.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
