Your Pregnancy

The first thing a woman does after she gets a positive pregnancy test is fantasize about the day the baby will be born. Most of us wish that the baby will make it to term but will be born early, somewhere between 37-39 weeks gestation to be exact. Pregnancy can seem to last forever and the excitement you have to meet your little one can be overwhelming. Many women become miserable towards the end of their pregnancy and will do anything to be “done.” It’s important to remember that in hindsight your pregnancy will go fast and your little one will be in your arms before you know it.

“To all the mamas who are waiting patiently (and sometimes anxiously) for labor to begin: remember that this is your first act of selflessness as a mother. There will be many more. But for now, this acceptance of your child’s unique journey, this willingness to trust your baby, will set the tone for your future relationships.”   -Lauralyn Curtis

Sometimes medical induction is necessary to prevent risks from complications that arise during pregnancy. Induction of labor should be offered only for certain medical complications that are supported by scientific evidence and prove the benefit outweighs the risk of induction [1]. These medical indications include disorders like gestational diabetes, gestational hypertension, intrauterine growth restrictions, and cholestasis [2]. Your midwife will communicate the current evidence-based guidelines and provide counseling in helping you make the right decision for you and your partner. Through education and valuable discussions with your midwife, she or he can assist in helping you make an informed decisions regarding induction.

Midwives strongly support the normal physiologic process of birth. We believe that spontaneous labor offers substantial benefit to the mother and her newborn. Disruption of the normal physiologic process of birth without an evidence-based medical indication represents a risk for potential harm[1]. Elective induction has been noted as contributing to late pre-term births and should never be offered to any woman prior to 39 weeks gestation. Elective induction before 41 weeks gestation can increase the chance of having cesarean if the cervix hasn’t softened or there is minimal dilation [1].

The goal of a midwife is to empower women to have normal physiologic labor–this is characterized by spontaneous onset and progression of labor. Induction of labor interferes with the normal physiological processes of spontaneous labor; the full extent of the disruption is not well known [1]. Research related to the long term effects of induction is emerging but is still insufficient to determine the full impact of newborn effects. Current studies are finding disruption in fetal brain development and increased risk for Autism Spectrum Disorders and behavioral concerns. Evidence also suggests that some critical processes, such as lactogenesis, attachment, and parenting are interrupted by induction of labor [1].

The decision to induce labor requires consideration of the potential for harm verse benefit, including short and long-term complications for the woman and her baby. Ask your midwife to discuss these risks with you. Remember midwives promote choice—you always have CHOICES. Your decisions and requests are always valued so never hesitate to talk openly with your midwife.

Induction Methods

If induction is recommended it’s important to request to have cervical ripening agents if your cervix is unfavorable. Unfavorable means your cervix is not dilated or barley dilated, firm, and still high in your vagina. Cervical ripening agents decrease the chance of needing a cesarean. Cervical ripening agents can take between 4-24 hours or even longer in some cases. Cervical ripening agents include the following:

• Cervidil: This medication is a prostaglandin that is placed in your vagina for 12 hours—it releases 0.3mg of medication an hour. It kind of looks like a small tampon with a string on it. This medication works by softening your cervix (the opening of your uterus) and helps with dilation. One benefit of this medication is you can take it out at anytime. One risk is that this medication can cause your uterus to start contracting to frequently, the good news is if this happens it can quickly be removed. A downfall is that this medication works for over 12 hours, so it can take a long time.

• Cytotec: This is another prostaglandin medication used to soften your cervix and encourage dilation. This medication is not FDA approved for cervical ripening but is standardly used throughout the US as a cervical ripening medication for induction. It can be dosed every 4 hours for 3 doses—you can place it in your cheek and it will dissolve, you can swallow it, or it can be inserted into your vagina. This medication has the same risk of Cervidil in causing frequent contractions and it cannot be removed once administered. The benefit is that this medication only takes 4 hours but it is possible that you will need another dose or two.

• Low-dose Pitocin: Pitocin also known as “Oxytocin,” is a synthetic hormone of a naturally occurring hormone we normally produce in our brain. This medication is given in a IV. This hormone helps the uterus contract effectively during labor. Low-dose Pitocin can be used as a cervical ripening agent. This means that the dose of Pitocin will never go above 4 milliunits per hour. The side effects of this medication are that the baby will not tolerate the medication or it might cause contractions too frequently. This is rare when administered at such a low level. The good news is it can quickly be turned off.

• Foley balloon (Cooks catheter): This is the most common method of mechanically dilating the cervix [3]. Your midwife will use a speculum or his or her fingers to insert a small balloon into your cervix; she will then insert some sterile water to inflate the balloon, about 30 cc’s. This will put mild tension on your cervix. The balloon will fall out on it’s own when your cervix dilates to a 3 cm—this usually takes between 6-12 hrs. The benefit of this procedure is that it ripens the cervix in a natural way using no synthetic hormones. This is the most “natural way” to ripen the cervix. The risk is that it can cause your bag of water to break and in rare cases the cord can prolapse. This is uncommon and rarely occurs but it is a risk to be aware of. The procedure can also be a little uncomfortable and cause some cramping but once it is in place the discomfort usually goes away.

When you start active labor there are other methods to help encourage continual dilation of your cervix and adequate uterine contractions to promote the birth of your baby. These two methods are listed below.

• Breaking bag of water: Your midwife will use a tool called an “amniohook” to break your bag of water. This can be uncomfortable but it is not a painful procedure. This helps the baby engage in the pelvis and put pressure on the cervix increasing dilation + progression of labor. The risk of this procedure is that it can cause the baby to become malpositioned, the cord can prolapse, and there is always an increased risk of infection if your bag of water is broken for a long period. This method of induction can shorten the period of labor by 2 hours or more [1].

• Pitocin: Pitocin also known as “Oxytocin,” is a synthetic hormone of a naturally occurring hormone we normally produce in our brain to stimulate labor. This hormone helps the uterus contract effectively during labor. This hormone can also help the uterus contract down to its prepregnancy size after you delivery your baby. This medication is administered IV during labor and your baby’s heart rate is continuously monitored to ensure they are tolerating the medication. Risks of this medication include that your baby will not tolerate the medication, it can cause your uterus to contract too much, your blood pressure to drop, and there is a chance of increased blood loss after the delivery of your baby. Your midwife and nurses will be monitoring your baby closely to ensure you and your baby are tolerating this medication. This is a very common medication and used frequently on the labor & delivery unit.

Expected Time Frame

Induction can take anywhere from 6 to 72 hours or longer. Usually, women who are having a baby for the first time have a longer induction than women who have already had a baby. The most important thing to remember is that it can take time, so have patience and bring some movies to watch or games to play with your husband while you wait for active labor to begin. Your midwife will be by your side every step of the way—she or he will give you thorough education regarding risk, benefits, and alternative options. Just remember you always have CHOICES.

Resources

1.http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000235/Induction%20of%20Labor%2010.10.pdf

2.http://www.acog.org/Womens-Health/Labor-Induction

3.http://transform.childbirthconnection.org/2013/02/choosing-wisely/

Recently, a woman explained that during delivery of her baby she pushed for 3.5 hours on her back, in the “dorsal lithotomy” position, using an epidural for pain relief. Dorsal lithotomy means the woman is laying on her back with her legs in stirrups. She explained that she was diagnosed with “failure to progress” and this resulted in an emergent cesarean. Now there is no saying for 100% sure that if she changed positions the baby would have been born vaginally but I will say that I have witnessed the many benefits of position changes. Frequent position changes during pushing helps the baby engage and move down into the mother’s pelvis. Some positions can open the mothers pelvis 20-50% more making it easier for the baby to be born.

Did you know you can still change positions in bed with an epidural? Just ask to have your epidural low dosed so you can still move your legs. How cool is that? After all, women were not meant to have babies on their back in bed. If you decide you want to go natural you will learn that it is very uncomfortable to be in bed on your back during active labor. Not to mention changing positions acts as pain relief, helps the baby move down and engage in the pelvis, and it helps labor progress by utilizing gravity and helping the mother relax. Don’t worry your midwife has you covered—she is trained not only to provide you with support during labor, she can deliver your baby in almost any position that is comfortable for you.

The following labor positions can be used during labor to act as pain relief + open up the mother’s pelvis:

• Squatting: Squatting helps widen the pelvic opening for baby to come out. It relieves back pain, it speeds up labor, relaxes the perineal muscles so you are less likely to tear, and improves oxygenation to the baby. It also helps promote delivery of the placenta after the birth of your baby. Practice this position during your pregnancy. Remember it can help open up your pelvis 20-30% more, making it an easy pathway for baby.

• Hands and Knees: This position looks how it sounds. The laboring mother kneels on both knees and leans forward onto her hands or leans on other support devices like pillows or a birthing ball. Personally, I have found that the woman loves the lean over the birthing ball as it helps her relax. You can do this position on the floor if you have a soft surface like carpet or a yoga mat or it can be done in a bed. This position is very comfortable for a mother going natural but it can also be done if the mother has an epidural—as long as she has excellent support from a doula, nurse, and midwife.

• Side lying: In this position you can lie on your left or right side. Your body is supported with at least five pillows—one or two under your head, one supporting your top knee, one behind your back, and another under the abdomen bulge. This position can be helpful when the mother is tired and needs a rest from being upright. This position can also be done with and without an epidural. This birthing position is very effective for maintaining relaxation. The woman is able to reduce unnecessary muscular effort….this results in less fatigue during a long labor and greatly increases her comfort level.

• Dorsal lithotomy: This is one of the most common birth positions in a hospital. In this position the woman lies flat on her back or at a slight incline with her legs in stirrups. There really are no advantages to this position other than it doesn’t interfere with the urinary catheter, IV line, or fetal monitoring system. It also provides an easy access to the perineum for healthcare providers. If you want to avoid tearing, you want to avoid this position. This position also results in the narrowest pelvic opening and puts pressure on the coccyx. This position increases the need for vacuum and forceps delivery. The woman has to push against gravity in this position. It also increases the risk of having a malpositioned baby resulting in a slower progression of labor.

It’s important to remember there is definitely more than one position you can try during labor and your midwife will help you change positions frequently. Listen to your body and try to practice these positions during your pregnancy. Request for frequent position changes while you are pushing—this can be done with and without an epidural. Now you are on your way to a positive birth experience.

Continuous monitoring (also known as external fetal monitoring) of your baby’s heart rate during labor is the standard of care in hospitals throughout the US today. It is important to understand that there are risks and benefits for continuous monitoring. Continuous monitoring is required during labor induction to ensure your baby is tolerating labor ok. Continuous monitoring is also required if you decide to get an epidural or during the administration of any pain medications.

It is important to note that continuous monitoring is associated with an increased risk of unnecessary cesareans [1]. Research has found that there is no decrease in fetal death or incidence of cerebral palsy with external fetal monitoring. Cerebral palsy is a disease that was originally thought to be caused from lack of oxygen during delivery. If we cannot prevent this disorder with external fetal monitoring, why is it the standard of care? Liability is a big concern for healthcare providers today. A big increase in lawsuits against providers who delivered a child vaginally that later turned out to have cerebral palsy have increased the use of external fetal monitoring [1].

Many studies have shown that a decrease in heart rate of the fetus during labor and delivery are more often the result of a reflex response to changes in the baby’s circulation and such drops are normal and can do relatively little or no harm [1]. Today, we know that cerebral palsy is not caused by a lack of oxygen during delivery. Instead, birth defects, growth restriction, infections, inflammation and other unidentified factors can cause the condition [2].

It has been found that fetal monitoring strips read by experienced obstetricians tend to interpret the monitor reading very differently [1]. In fact, when an obstetrician was allowed to evaluate the same reading twice several months apart, the interpretation differed even more. It’s easy to interpret a good fetal heart rate tracing (cat. I) verses a bad tracing fetal heart rate tracing (cat. III) but everything in between (cat. II) can be very tricky. This type of inconsistency has made the United States Preventive Services Task Force rate electronic fetal monitoring as having the lowest grade of effectiveness possible [4]. So if you don’t want to be tied down to the bed during labor or if the monitoring device is bothering you, ask your midwife about intermittent auscultation. If you have had an uncomplicated pregnancy and are planning to have a natural birth this is likely an option for you  [1].

What is intermittent auscultation?

Intermittent Auscultation is a method of listening to fetal heart tones with a fetascope (like a stethoscope) or a hand-held ultrasound device (doppler). During intermittent auscultation your midwife will listen closely to rate, rhythm, and variability of your baby’s heart rate for at least one full minute before, during, and after a uterine contraction. This process gathers information that is charted by your midwife to represent a baseline rate, presence or absence of accelerations, decelerations, and the presence or absence of variability. The purpose is to ensure the midwife in making information-based, logical management decision during labor and birth of your baby. Intermittent auscultation protect the well being of your unborn baby without exposing the mother to the risks of unnecessary interventions [2].

Using intermittent auscultation you can expect your midwife to listen to your baby’s heart rate every hour during the early phase of labor, every 30 minutes when you are actively laboring, and every 15 minutes while you are pushing. This provides the ability to move freely around during labor and not have devices on your abdomen that can be uncomfortable or irritating.

Remember that the goal of a midwife is to give you the information for you to make an informed decision. It is always your CHOICE what route you decide to go. If you are looking for a low intervention, natural approach, talk to your midwife about intermittent auscultation. Below are a list of links that provide more resources about external fetal monitoring and intermittent auscultation.

Resources

1. https://cerebralpalsynewstoday.com/2016/12/09/electronic-fetal-monitoring-no-benefits-plenty-of-harm
2. http://birthtools.org/Reducing-Primary-Cesareans
3. http://onlinelibrary.wiley.com/doi/10.1016/j.jmwh.2010.05.007/full
4. https://www.uspreventiveservicestaskforce.org