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Preparing For Labor

Inductions- Your just about complete guide (better than any single book!)

Inductions

The info in here is designed to fully inform you about what the risks, benefits and *options* are with inductions.

Included in this post: the different induction methods and the possible complications; questions to ask before an indution; how to have a safer induction experience; how a normal induction usually takes place; natural labor induction methods; tests for fetal well being you should have prior to inducing; inducing for size and how it impacts the c-section risk; why inductions don't have to be that bad (with special advice for moms with high bp); why they want you to wait till at least 39 weeks if you and baby are healthy.

I hope that anyone considering induction or needing one reads this.

At present time the American College of Ob/Gyns takes the position of using labor inductions (including membrane stripping, cervical ripeners, artificial rupture of membranes and Pitocin) only when medically necessary. Pregnancies that have exceeded 42 weeks and situations where the risks of continuing the pregnancy for mom or baby outweigh the risks of inducing are medically necessary.

While everyday women get induced or augmented without incident, it doesn’t mean that the risks aren’t real. Even if you have had one labor that was induced and perfect remember that every birth and situation is unique. It is important to make informed decisions about things that affect you and baby.

Remember that every intervention you let into your birth increases your risk of the biggest intervention of them all- a c-section.

“Patients need information during prenatal visits about the possibility of labor induction. When women are presented with the perceived benefits of an induction for a nonurgent indication, a balanced discussion should include the risk of additional procedures and cost.”
http://www.acog.org/.....wrapper.cfm?document=2002/ong13567fla.htm


12 questions you shoud ask BEFORE you are laying in a a hospital bed hooked to an IV, monitor and BP cuff!
1. Why are you being induced? Are you overdue or are their some health concerns?

2. Would they be opposed to following the ACOG's stanadards and monitoring you till 42 weeks then inducing?

3. How favorable is your cervix? This can affect how they induce and how likely the induction is to be successful. Ask for your Bishop's Score.

4. How do they plan to induce? Are they going to use a cervical ripener to soften your cervix? Are they going to go right to Pitocin? The answers should be tailored to how favorable your cervix is.

5. Ask what they would do if you don't go into labor? Do they send you home and wait it out? How do they manage things?

6. Will they let you eat and drink?

7. Will they let you move about, use water, change positions...?

8. Do they require continuous monitoring or do they do intermittent?

9. Can you have pain meds? When can you have them? What narcotics do they have standard orders for? What dose? Is there a cut off point to recieving painmedications (if you are 8+cm, will you be able to get anything?)

10. If labor is progressing well can we turn OFF the pitocin for a while and see if my body will take over? I would like to have the opprotunity to have the kind of contractions that are perfect for my body and I would like to be able to get off of the monitor for a while so I can walk and change positions easily. I know that this will help ensure proper fetal alignment, more so than laboring in bed. What reasons are there that I couldn't have the pitocin turned off?

11. Is there a time limit on my induction before it is considered a failed induction or turns into a c-section? Do you follow active management? Do I have to progress Xcm in X amount of time? If I am well and the baby is well, can we take it slow and steady instead?

12. Can I decline having my amniotic sac ruptured as part of the induction process? I know that I can reconsider later, like if I get stuck at 8cm for a few hours, but as a matter of routine I would rather not have it ruptured. I worry about the added stress baby could face with the pitocin contractions if they don't have the benefit of the cushion. Fetal malpresentation, cord prolapse and cord compression are other concerns, as well as infection.


Pitocin- Synthetic from of body’s natural oxytocin. Unlike natural oxytocin, the dosage is not perfectly designed for your body and labor. Some labors are meant to be fast while others are meant to be slow. Some babies come at 38 weeks others are ready at 42 weeks (still term).
Risks:
-Fetal distress caused by the contractions being too strong- hyperstimulation of the uterus (blood flow to baby can be compromised as a result of the compression)
-Contractions that give mom and baby no breaks and increase the desire for pain meds (which have their own pros and cons)
-A contraction that doesn’t end (tetanic contraction)- they have medicine that can end it though
-Increased risk of c-section due to fetal distress along with the other interventions that are common in an induced labor
-Increased risk of postpartum bleeding
-Baby may be born premature if the due dates aren’t right
-Increased risk of newborn jaundice

Artificial Rupture of Membranes (aka amniotomy, AROM or “breaking your water”)- This protective cushion serves many important functions for you and baby. Sometimes Dr.s or midwives do this as a matter of routine which just might not be right in every situation. Also, the popular wisdom that it speeds up labor isn’t always the case.
Risks:
-The fluid acts as a cushion for baby. It keeps the cord from getting compressed. Cord compression can reduce the blood and oxygen flow to baby.
-The fluid makes the contractions easier on mom and baby. Having your water broken can really intensify labor contractions.
-A lot of caregivers put you on the c-section clock to deliver. If labor doesn’t pick up then other interventions (like pitocin) might be necessary. 24 hours is the norm though it might be longer or shorter depending on mom and baby’s condition and signs of infection.
-The fluid protects the baby from infection. Frequent internal exams after AROM increases the risk.
-Fetal malpresentation- If baby wasn't engaged the AROM can push them into the pelvis at a bad angle (posterior, sideways). This can lengthen labor and make delivery more difficult
-Rare but possible is cord prolapse (the cord comes out before the baby). This is an emergency situation.

Prostaglandin Gels (Cervidil, Prepidil)- Used to ripen your cervix and make it more favorable for induction. Usually used before pitocin though it might be enough on its own. It is inserted vaginally. Mom and baby need to be monitored for any signs of uterine hyperstimulation. If mom shows signs of trouble, the drug can immediately be stopped.
Risks:
-Fetal distress as a result of the uterine hyperstimulation.
-Postpartum hemorrhage
-Upset stomach (especially diarrhea because the prostaglandins that ripen the cervix can irritate the bowels)

Cytotec (Misoprostol)- The only advantage to this drug is it is time and cost efficient. The drug comes in pill form and a portion if the pill is inserted into the vagina. This is usually used independent of pitocin. **If your Dr. suggests this drug, just say “no” because there are much safer alternatives**
Risks:
-Uterine hyperstimulation and possible uterine rupture. Unlike Cervidil it can not be stopped if the medicine is too much for you and baby.
-The medicine was formulated for the treatment of stomach ulcers. It is acknowledged by the medical community as a possible labor inducer but the drug manufacturers actually don’t support its use as a labor induction drug.
-The fact that labor is sometimes shorter with Cytotec is not worth the potential risk to mom or baby.

Here are some links to read. They are some of my references.
Pitocin
http://childbirth.org/articles/pit.html

Amniotomy
http://childbirth.org/articles/amnio.html

Cytotec:
http://sheknows.com/about/look/143.htm
http://dir.salon.com/health/feature/2000/07/11/cytotec/index.html

The ACOG's website is acog.org. The links can not be posted per their guidelines and copyrights.

Elective Inductions: This includes important information on how to have a safe induction- elective or not
http://www.hencigoer.com/articles/elective_induction/
http://my.webmd.com/content/article/26/1728_58677.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348}

Mothering Magazine article on labor Induction:
http://www.mothering.com/11-0-0/html/11-2-0/11-2-babydecide105.shtml

Inducing for size and the c-section factor(Henci Goer):
http://www.parentspl.....ru/articles/0,10335,243385_234322,00.html


Books:
The Thinking Woman’s Guide to a Better Birth by Henci Goer
Planning Your Pregnancy and Birth by the American College of OB/ Gyns

Tips to having a safer and easier induction for yourself AND baby:

Write a birth plan. There are many choices available to you, even in a highly medicalized setting. If there are no complications then there are always alternatives and options. You just need to know to ask for them. So, write up a birth plan that includes some of the below tips as well as postpartum and newborn procedures (don't neglect these- the health and safety of baby is in your hands after that baby is on the outside- not all procedures are desirable or necessary in all situations).

Discuss your birth plan with your Dr. or midwife ahead of time. Make sure that you know how they plan to induce. Speak up if it isn't what you want (like if they want to use Cytotec). Find out what they do if the induction doesn't take. If they don't break your water and the induction isn't necessary for health reasons then do they give up for the day? Or do they break your water this necessitating a c-section? Take a copy of the plan to your place of birth so they know what you would ideally want.

Finally make sure that your partner understands your birth plan and why you have made the requests you have made. They can help you advocate for yourself.

-Cervidil not Cytotec if ripening needed

-Lowest possible dose of Pitocin

-Turn Pitocin off once labor is established. Either your oxytocin will continue labor or you can always go back on Pitocin. Natural contractions will be easier and it is worth a shot.

-Don't have your membranes ruptured. If you do, wait till you are in a well established labor and around 5-6cm (usually you can feel ok that labor will progress and not stall out at this point).

-Avoid pain meds (especially the epidural) till at least 4-5cm because they can stall out labor and lead to more interventions.

-Eat lightly and drink. Yes, the i.v. can keep you hydrated but your stomach still might growl. You need energy- birth is like a marathon. They have the means to keep you from aspirating if you go under general anesthesia.

-Stay active and mobile as much as possible. Even if you are connected to an external monitor you can still pace, use a birthing ball, rock in a chair or simply change positions. They can bring out longer cables for the external monitor, just ask.

-Use the bathroom at least once an hour to allow baby more space to come down and the walking and squatting might help bring baby into better position.

-Don't set time limits on your birth. You don't have to progress at any rate. Sometimes a slow pace is just right. Unless there are signs of trouble, take your time. Remember, your baby wasn't quite ready yet so be patient with them.

-No time limits on pushing. It takes a while to get the hang of it. So long as mom and baby are well then 3+ hours is ok according to the ACOG.


There are more tips in this link:
Elective Inductions:
http://www.hencigoer.com/articles/elective_induction/

Common interventions and risks/ benefits:
http://www.lamaze.com/birth/choices/articles/0,,167805_240720-2,00.html#npo

How a normal induction takes place

A lot depends on the condition of your cervix. This link here helps you determine your Bishop's Score and what method of induction is normally recommended:
http://pregnancy.abo.....dbirth.org%2Finteractive%2Finduction.html

If your cervix is not ready, or ripe, then they will administer a drug to help soften your cervix. Most commonly this drug is Cervidil. If ripening is necessary then they often begin the induction process at night. Your body is naturally more receptive to oxytocin at night. Cervidil is a vaginal suppository.

Once the Cervidil is placed then they will require external fetal monitoring for 1-2 continuous hours. This may or may not require you staying in bed.

After this initial monitoring they may let you go home is all is well. If baby or mom to have a bad reaction to the prostaglandin gel then it usually happens in the first 1-2 hours. It is generally considered safe to go off of the monitor and go home to await labor (assuming mom and baby are healthy). I would say that about 50% of moms are given the opportunity to go home.

Less than 50% of the time Cervidil alone is enough to push mom into labor. It may cause cramping but not active labor. Some women complain that the waiting is the hardest part. The drug is usually kept in place for 8-12 hours.

Once the first dose of Cervidil is done then things are reassessed. If things have become more favorable then they will start Pitocin in the morning. You may be given a "break" following the Cervidil in which to walk around and eat. If the initial dose of Cervidil wasn't enough then they may apply another course of it. You can request repeated applications if you would rather avoid Pitocin.

If they start the Pitocin then they usually start it at the lowest possible dose. It will be increased preferably every 30 minutes until a good labor pattern is established. You will most likely be required to have continuous external monitoring but you should not be restricted to the bed. Move within the confines of the tethers or ask for a telemetry monitor (some hospitals have them).

Once labor is active and established you can request that the Pitocin be turned off so as to allow your body to labor under its own oxytocin. If labor stalls then you can try nipple stimulation, walking, relaxing in a tub, or position change before having the Pitocin turned back on.

Many Dr.s will want to break your water at some point. They either do this at a predetermined time (right before their lunch hour) or when you hit a certain dilation. Read over the risks of AROM. It may very well not be in your best interest to have this done as a matter of routine.

That is pretty much the average induction.

If Cytotec was used then it changes things. The Cytotec is a pill that is inserted behind the cervix. It may be used alone or followed up by Pitocin. Cytotec is so new that there really isn't a clear way to administer it. I do not encourage you to use this drug because there are safer alternatives. If you feel that it is in your best interest to use it then follow the ACOG's guidelines which is 25mg. Many Dr.s use too high of a dosage. It should also not be repeated any closer than 3 hours from the last dose and pitocin should *never* be given unless 4 hours have passed since the last dose.

This is one example from one nurse at one hospital. Protocols and practices vary from hospital, nurse, situation and care provider. But it should give you a realistic idea of what to expect.
1)PG Gels: 20-30 min of monitoring prior to insertion of gel, on the monitor for 1 hour post gel then up to walk for 45-50 min, Repeat X2 (total of 3 rounds of gel) then monitor and recheck cervix 1 hour or so after last gel, if baby is okay, mom is okay and labor has not started, go home. (no IV required)

2)Cytotec (misoprostil): monitor 20-30 min prior to dose, get dose either by mouth or vaginally, monitor for 1 hour post dose, up to walk for 1 hour then monitored for 20 min out of each hour. Doses are given every 4 hours to a maximum of 6 doses, although some docs do 4 total doses. If labor has started, great, continue on by yourself. If contractions are to numerous to give next dose and cervix is changing, continue on. Sometimes pitocin is started when cervix reaches 3-4 cms and contractions are not regular.
We require an IV access for Cytotec inductions.

3)Pitocin: Continuous fetal monitoring, okay to get up to bathroom. You don't have to stay in bed and can use a rocking chair, birth ball, stand, squat, etc at bedside as long as we can monitor the baby you don't have to be in bed.

4)AROM: no explanation needed intermittent monitoring (20ish minutes out of every hour)

Set realistic expectations for an induction

If you are inducing labor it most likely means that you are trying to get your body and your baby to do things before they are ready. Be respectful and patient with the process.

Don’t expect immediate results. Especially if you are a first timer.

Some moms do react to prostaglandin E2s very readily- and sometimes they react strongly and aggressively. But, the majority (70+%) don’t have any major changes during this process. That’s normal.

If you are being induced with no signs of labor already and an unfavorable cervix then it could be a long process. Expect to have contractions for 12-24 hours (yes, hours!) before your cervix really starts t change. Don’t expect progress of 1cm/ hour as soon as they start the pitocin. That’s an unrealistic expectation. (Actually, that 1cm/ hour thing is unrealistic in any labor and that theory is quite flawed when used in the US- it is called the Friedman Curve and it is used with regards to Active Management of Labor).

So, take things slow and steady. A common thing I hear is when given the choice between Cytotec or Cervidil moms are told that their Dr. or mw prefers Cytotec because it is faster. Who said faster is better?

Inductions are already stressful for mom and baby because they are trying to imitate a process that wasn’t ready to be initiated. Slow and steady isn’t a bad thing.

Your induction may progress very quickly but don’t go into the induction expecting that- even it isn’t your first baby or first induction. Every birth is different.


Tests for Fetal Well Being

Non-Stress Test:
Simple procedure involving an external fetal monitor. You will be hooked up to the monitor. You will hit a button when you feel the baby move. They will look to see if baby's heart rate reacts to the baby's activity (it should). They are looking for several good reactive heart rates.

Sometimes baby is uncooperative so you will have to try and wake the baby up.

ALWAYS drink and eat before the test. If the results are borderline, get something to eat and try again. Usually the problem is solved by eating and drinking.

Bring a book or partner with you to the test b/c it can take btw 20 minutes and an hour depending on baby.

Bio-Physical Profile:
This is an ultrasound that is used to measure a few things; baby's body mov't, muscle tone, breathing, heart beat and amniotic fluid levels.

It is important to drink plenty of water before the test (and throughout pregnancy!) b/c even slight dehydration will negatively and falsely influence test.

"Each of the five components — body movements, muscle tone, breathing movements, amniotic fluid, and heart beat — is assigned a score of either 0 (abnormal) or 2 (normal). These scores are added up for a total score ranging from 0 to 10. In general, a total score of 8 or 10 is normal, 6 is considered borderline, and below 6 means that your baby is probably not getting enough oxygen. If all the ultrasound scores are normal, your practitioner may forgo the heart-rate evaluation. But if the amount of amniotic fluid scores a 0, then your baby may need to be delivered right away — even if the other components seem fine."
http://www.babycenter.com/refcap/1276703.html

I had both tests done twice. Even at 41 weeks 5 days baby received a 9 on his bpp.

Insist on tests for fetal well being before consenting to induction. Your Dr. should be doing this as a matter of routine after 41 weeks.


Inducing for size has really become a common occurrence. But it is not an exact science. And inductions can increase the risk of a c-section.

Barring a medical concern like Gestational Diabetes then the odds are in your favor that you will deliver a baby that is just the right size for your body. It might take a bit more effort on your part and your care provider's but a large baby does not have to turn into an emergency if handled well.

True CPD can only be diagnosed following a fair trial of labor and delivery. The real rate of CPD is 3-5%. Many more moms are diagnosed with CPD. Many times it is more a Failure to Progress (or failure to wait or try new positions).

Fundal Height Measurements
1. In your pregnancy, if your due dates are pretty accurate then your fundal height and week of gestation should match up beginning around 20-22 weeks.
2. A few readings here and there that do not match should not be a cause for concern. If they are consistently off then further consideration should be taken.
3. Measurements can fluctuate for a variety of reasons:
-Baby's position
-Baby's position within your uterus (ex. if baby has dropped then the fundal height might be lower than in previous weeks)
-Amount of amniotic fluid
-Growth spurts can affect some readings. Not all babies grow at exactly the same rate. Things usually even back out.
-Due date discrepancies. If the fundal height has always been off then this might be something to address. The most accurate edd is derived from Last Menstrual Period. Second most reliable is a first trimester u/s. Any u/s beyond the 1st trimester is not accurate enough to date the pregnancy. Each trimester that goes by, accuracy falls off dramatically (8 days in the 2nd trimester and 22 days in the 3rd according to one study).
-Uterine Growth Retardation
-Other rare complications

"My Baby is just going to get to be too big if I continue the pregnancy"
-Babies do continue to grow as the pregnancy continues. But, where the baby will grow is another story.
-Babies gain about .5lbs per week.
-Baby could actually get longer, not necessarily heavier.
-That .5lbs isn't guaranteed to end up on baby's head or shoulders. Odds are good that it will get evenly distributed to places that aren't going to be a major factor in delivery (like on their feet, on their calves, their arms...).

The Accuracy of Ultrasounds for sizing the pregnancy
-In the 3rd trimester the margin of error is +/-2lbs.
-You will always find people whose results were dead on. But you will also find people whose tests were really, really far off. Base decisions on facts, not anecdotes.
-The skill of the person doing the u/s and the equipment used can play a role in the accuracy of the test.
-Even if you have been having u/s weekly to measure growth, the results could still be off.
-There are many Dr.s and midwives who will not do a 3rd trimester u/s to check the baby's size. Mine was one who said that they are too unreliable (which was a major surprise b/c he was very heavy into interventions!). Just hold that in your mind that if you were with a dif't care provider this issue of size might never be brought up.

The Importance of Position
1. A poorly positioned 6lb baby can have a hard delivery. A well positioned 10lb baby can slide right out.
2. Position is very important. This issue is often neglected but it is very important and you have a lot of control over this situation (and little over baby's size). Many c-sections today are based on Failure to Progress and some of those are directly related to baby's position. A poorly positioned baby can make for a longer labor. Labor might also stall as baby slowly makes progress. Delivery, particularly of a posterior baby, can be a slow affair.
3. There are many things that you can do to help this situation.
-Before the baby comes, spend time on your hands and knees. Do pelvic tilts. Sit Indian style. No squats! Use a birthing ball. Stand up and pretend that you are using a hula hoop to help shimmy baby into a good position. Climb stairs. Keep on walking!
-When you are in labor, do the things listed above.
-When you are in labor stay out of bed as much as you can! Even if you are in a situation that requires continuous monitoring, you can still use a birthing ball or change positions. Ask for a telemetry monitor or longer cables for the external monitor (just ask, it can't hurt).
-Once an hour, get up to use the bathroom. The walk to the bathroom can help the baby descend nicely into the pelvis. Squatting to use the toilet is a good labor position. Emptying your bladder can make more room for the baby to come down.
-If your labor stalls focus on *position* before reaching for the pitocin or rupturing the amniotic sac. Get out of bed if labor stalls. Great things can happen!
-Hold of on breaking the amniotic sac. When it is broken the baby can be thrust into the pelvis at a bad angle. They can wedge themselves in a way that makes it harder for you to move them. With the amniotic sac in place it makes it easier for the baby to float into a good position.
-Don't deliver on your back with legs in stirrups!! This constricts your pelvic bones and narrows the baby's passage. Think upright, like squatting or all 4s. If delivery is slow then before consenting to a c-section, episiotomy or assisted delivery try a new position (provided all is well with you and baby).
-It is OK for pushing to take a long time!!! The American College of OB/ Gyns has no problems with it taking 3+ hours. Some Dr.s and midwives give you far less time with that. For no good reason. Stand up for yourself.

If you already think that the baby is going to be too big, that can really affect the outcome
-If labor stalls or is slow (which is OK!!) and someone hints that it is probably because the baby is too big for your body then you will probably believe them. No effort will be made on any front to work on position.
-If delivery is taking a while, you are more inclined to face an intervention if the thought is already in everyone's mind that the baby will be big.
-If size hadn't been brought up then that could change the outcome.

Your body is capable of amazing things with regards to childbirth. Have faith in it.
"Q: My doctor told me my pelvis is too small to vaginally deliver a baby over eight pounds. Is this true?
A: No, the pelvis and the baby's head are not fixed bone structures. During labor the pelvis opens, allowing room for the baby, whose head molds to fit. The pelvis will actually open up 33% larger than it's pre-pregnant size with a squatting position. There are several factors that contribute to this. First a hormone called relaxin is released during the latter part of pregnancy which soften the ligaments and cartilage surrounding the pelvis. Also different positions assumed during labor will change the dimensions of the pelvis such as walking, climbing stairs and squatting. This combined with the flexibility of the baby's head gives ample room for babies to move through the pelvis. The baby's head is made up of five plates that are connected with soft tissues that allow it to mold during the birth process as the baby travels through the pelvis. These bones return to their pre-birth state within hours of birth."
http://www.ican-online.org/resources/faqs.htm

If my baby gets too big then they could get stuck (shoulder dystocia)
-Shoulder dystocia is very scary. But, it can not be predicted ahead of time.
-Shoulder dystocia is a complication where baby’s shoulder(s) get stuck after the head is already out. It happens in about 1% of births.
-Contrary to popular sentiment, babies of all sizes are prone to shoulder dystocia. More than 25-50% of shoulder dystocia cases are for babies of small or average size. (This is one of the many reasons that I emphasize the importance of position).
-“Approximately 2-3 or every 1000 newborns” will be affected by an injury from shoulder dystocia called Brachial Plexus. Of the babies born with shoulder dystocia there is approximately a 30% chance of baby sustaining this birth injury.
-There was a 7 year study conducted that tried to determine the main cause(s) of shoulder dystocia. The study reviewed more than 100,000 births so it is pretty statistically significant. It found that size was not the leading factor of s.d.. The top 3 contributors to s.d. were Epidurals, Inductions and Forceps.
http://www.ncbi.nlm......&list_uids=12648177&dopt=Abstract
-Your care provider’s skills and expertise with regards to shoulder dystocia can make all the difference in the world to how you and baby do. I suggest talking to your Dr. or midwife about how they would handle a shoulder dystocia. These are several options, the Gaskin Maneuver coined for the famous midwife Ina May Gaskin and her record for handling s.d. with this method is very successful:
• “Suprapubic Pressure: This pressure is at the pubic bone, not at the top of the uterus. This might allow the shoulder enough room to move under the pubis symphysis.
• Gaskin Maneuver: Get the woman into a hands and knees position. This will also change the diameters of her pelvis, though is not always possible with epidural anesthesia.
• McRobert's Maneuver: Flex the mother's legs toward her shoulders as she lays on her back, thus expanding the pelvic outlet. One study showed that this alleviated 42% of all cases of shoulder dystocia.
• Woods Maneuver: This is also known as the corkscrew, the attendant tries to turn the shoulder of the baby by placing fingers behind the shoulder and pushing in 180 degrees.
• Rubin Maneuver: Like the Woods maneuver, two fingers are placed behind the baby's shoulder, this time they are pushing in the directions of the baby's eyes, to line up the shoulders.
• Zavanelli Maneuver: Pushing the baby's head back inside the vagina and doing a cesarean. This is the mostly frequently asked about method, but also one of the most dangerous.”
http://pregnancy.about.com/cs/laborbirth/a/aa081801a.htm
-The position that you birth in matters with regards to s.d. The lithotomy position (legs in stirrups, mom on her back) is more likely to cause s.d. because it constricts the sacrum and pelvic bones. Baby has a harder time descending.
How inducing for size increases the C-Section rate. The Cascade of Interventions.
-Some hospitals still don't let you eat and drink in labor. This can affect you physically as you might feel worse (light headed...) and you might begin to loose the energy necessary for delivery.
-You will usually require continuous monitoring. If your hospital doesn't have telemetry units then that means you are tethered to the machine. You can still change positions, use a rocking chair, bounce on a birthing ball but it is a little less convenient.
-If you let them break your water there is a good chance that baby could wind up in a bad position (sideways, backwards) and that will make things harder. Plus you are on the c-section clock b/c of the infection risk.
-Pitocin contractions are not natural. They can never entirely mimic oxytocin. There is no real gradual build up- more like hit you over the head. This can make the contractions harder for you and baby. This increases the likelihood that you will use an epidural (which is fine but it can impact the progression of labor).
-If you have an epidural then your options with regards to delivery are usually limited unless you turn it off for pushing (it still takes a while for it to wear off). The best delivery positions for any baby, especially a larger one, include squatting and hands and knees. Very hard to do with an epidural in place. You can request that it be turned down or off for the pushing stage.


Well, this was me playing Devil's Advocate to just point out some issues with inducing for size. Take it for what it is, one person's well researched opinion. Use it as a staring point for your person research and talking points with your Dr. or midwife. Make the decision that feels best for you. But, please make it an Informed Decision. :)


Oh, and be aware that in the past 2.5 years I have noticed many more "big babies" around all the major holidays. I don't think this is a concindence....I think that it is a reason Dr.s can try and get their patients to induce.


Foley catheter for induction:
They seem like a really good option, imo. My only hesitations are that they often result in your water breaking and there is an increased risk of infection since there is a foreign object in there. But, from what I can tell the amniotic sac tends to break around 4+cm, which is usually a fine time- you are far enough along that labor should progress before they would consider a c-section. And as for infection, that isn't that high of a risk.

I posted on the Childbirth Choices debate board trying to get info from the L&D nurses about this but I only got one reply from a mom who used this method and liked it.

A lot of the links I have read discuss using the Cervidil or Cytotec (yuck) with the foley catheter- I guess to give it more of a nudge?
Foley catheter and Cytotec vs foley catheter alone- comparison in success and risks:
http://www.findarticles.com/p/articles/mi_m0689/is_8_50/ai_77275980
http://www.findarticles.com/p/articles/mi_m0CYD/is_7_38/ai_100131461


There is less risk of uterine hyperstimulation with the foley catheter than the Cervidil or prepidil. It is more gradual. It will dilate the cervix slowly then it will tend to fall out when you reach 4-5 cm or your water breaks. From there you can decide to try a wait and see for a few hours (position change, nipple stimulation or walking may be employed). Or you can go with the breaking of the water or pitocin based on how everything is going.

It is similair in time to the prostaglandin gels- about 5-12 hours. I don't know if you have to stay the whole time it is doing it's thing or if you have to stay in bed the whole time either.

I really don't know why it isn't used more often.

Good links that I have found:
http://www.aafp.org/afp/20030515/2123.html
http://www.gums.ac.ir/MAGAZIN/39-40/abstract80aw_13.htm

Make sure the baby is well positioned and down low into the cervix before proceeding b/c of the likelihood of the water breaking. Cord prolapse and cord compression are bigger risks if baby is high. Malposition is a risk regardless.

Inductions do not have to be that bad! I know I might sound all gloom and doom about them. But that is more a result of how the typical induction tends to play out...not how it actually has to be!

There is also some info for moms being induced due to pre-e.

Inductions do not have to be that bad

Inductions do carry risks so it is a good idea to know some good strategies to help make things safer. Inductions do tend to get a bad rap and most of the time those cases are more because the induction was mismanaged.

By mismanage I mean this...
If you recieve pitocin they can almost play "Mother Nature." Do they have a lunch date or other patients close to delivery? Well, they can tweak your pitocin levels to speed up or slow down your progress. They can make things stronger and faster which can appeal to some Dr.s that like to work 9-5. The better way to induce is to be slow and patient. The very best technique is one that isn't often used unless requested. That is to establish contractions with pitocin, get mom progressing. Once she is in active labor turn OFF the pitocin. From there mom has a very good chance of continuing labor all on her own. The benefit is that the contractions are natural. They are as weak or as strong as HER body and baby need them to be. Sometimes they get obsessed with labor needing to have a particulair pattern to be effective (contx every X minutes, consistent and lasting X seconds). However, not all moms and babies want or need a labor like that. Even at the very end of my labor contractions were 1-7 minutes apart! I staill gave birth in a normal amount of time. I just didn't fit the textook version of how labor is supposed to be.

Now, there is a chance that they would turn off the pitocin and labor would stall. That's ok. There are other things to try. I would ask for an hour to walk, change positions and/or try nipple stimulation (releases nature's own pitocin). All you have to lose is some time. All you have to gain is a gentler, safer, easier birth for you and baby. It may help the bp too b/c you might not be working as hard.

So, that is my pitocin advice. At the very least only let them increase it every 20-30 minutes (not closer) and don't let them keep cranking it up to adhere to some textbooks. Ask for time to just see how your body tolerates one level of the drug. The contx may not be picture perfect but they may be effective. kwim?

Another major mismanagement is breaking the water. This has become so common that most moms don't even realize that it is a bad or risky thing- and that keeping it intact has many benefits to mom and baby. We have been led to believe that breaking the water dramatically speeds things up. Studies have shown that it does speed up labor but not by very much (an hour or less). Yes, an hour less of labor may sound like a good thing BUT when compared to the risks it may not be worth it.

What are the problems with breaking your water? One thing is the pain factor. That amniotic sac works as a cushion for mom and baby. It takes some of the impact of the contractions off of mom and baby. Over and over again I hear moms say that they were handling the pain OK till their care provider broke their water. Or that their care provider told them that they should get an epidural before they break the water. Well, why break the water if it is going to increase the pain that much??? It doesn't need to be done.

Other risks include infection, being on the clock to deliver, possible limitation on activities, malpositioned baby (a situation that can really through a good birth off course), fetal distress, cord compression, and more interventions.

There is a time and place for AROM. But, it shouldn't be routine in your induction. Maybe if you are stuck at 6cm for 4 hours it would be a good option- assuming you haven't tried position change, walking, nipple stim, relaxation or water since they have the potential to speed things up too.

I would say "no" to Cytotec.

Cervidil or a foley catheter are good, safer options.

I know with the high bp you may have limitations that most moms wouldn't. If they put you on meds for the bp odds are you won't be out of bed much. You can still request sitting up, sitting in a rocking chair, or sitting on a birthing ball. All can help labor progress- and help the pain factor.

Magnesium Sulfate is commonly used to lower the bp if things get out of hand. It has nasty side effects though and can affect you, baby and labor. If you can avoid it it really would be beneficial. So, ask questions about ALL your options before consenting to this drug.

I don't know if you are planning an unmedicated birth or not. If you are then a lot of the advice I already gave should help (turn off the pitocin, use it wisely when used, hang onto that amniotic sac, change positions...). If you aren't, know that the epidural can lower your bp so if magnesium sulfate is mentioned talk about this option first.

Why 39+ weeks if mom and baby are healthy?

Remember what I said before that the ACOG lumps ALL induction things (even membrane stripping) in the "avoid unless the risk of continuing the pregnancy exceed the risk of inducing" category.

The ACOG discourages non medically necessary inductions prior to 39 weeks. And if labor is induced they agree that the cervix should be 3+cm, well effaced (70+%) and baby should be low and in the correct position.

Why 39 weeks?

Due dates are just estimates.

They can be off by 2 full weeks.

At 38 weeks baby may only be 36 weeks mature, as a result of the due date discrepancy.

36 weeks is not full term. There are babies even at 38 weeks who are not ready.

At 39 weeks you can feel better that baby is at least 37 weeks mature, which is considered term.

There was a study done on "near term babies"
".."Conventional wisdom has been that babies who were near-term but still premature would do as well as full-term babies. They stay in the normal nursery and usually go home when the mother is discharged," says Marvin Wang, MD, of the MGHC Neonatology Unit, who led the study. "But those of us who take care of these children know from experience that they may have more jaundice or hypoglycemia than full-term infants do. No one had ever studied that assumption, so we decided to start the dialogue and examine whether these babies need additional health services."

The research team examined records of infants born at Massachusetts General Hospital over a three-year period. They randomly selected groups of full-term (37 or more weeks) and near-term newborns for whom adequate information was available and who had no major health issues at birth, ending up with 95 full-term and 90 near-term infants. In addition to reviewing their charts for problems that developed during the infants' hospital stay, they also analyzed the costs incurred.
The near-term infants had significantly greater risk than did full-term infants of being diagnosed with many clinical problems - including jaundice, hypoglycemia (low blood sugar), respiratory distress, the need for intravenous feeding, and difficulty maintaining body temperature. They were also more likely to have multiple problems; 18 of the near-term infants had six or more diagnoses, a situation found in none of the full-term babies.
"Overwhelmingly, the near-term babies performed worse for every diagnosis studied," Wang says. "Another important point is that, for some diagnoses, the treatment is different between premature and full-term infants. For example, respiratory distress usually signals infection in full-term infants; but in premature infants it is more likely caused by lung immaturity. Our results suggest we need to carefully examine how we treat children who are in between those two categories."
Wang also notes that recent news reports have described some mothers - including celebrities - who have chosen to have their babies delivered before their due date by elective Cesarean to avoid effects like muscle tearing or stretch marks and to better fit their schedules. "There can be valid medical reasons for delivering early, but our study calls into question the presumption that elective delivery at 35 or 36 weeks poses no risk to the infant," he says.... "
http://www.massgeneral.org/news/releases/080204wang.html

Many practices will do an amnio if they are on the fence to intervene in that 38 week range to check on lung maturity. Some moms will find that they need to wait to make sure baby is ready. (Visit the c-section board for some anecdotes on that front).

Even if you have delivered before 40 weeks in previous pregnancies there is no guarantee that this baby will be ready then.

Even with a certain conception date you can't know for sure when baby will be fully mature.

There are lots of amazing things that happen in those final days/ weeks. They add more fat so they can maintain their body temperature. The placenta gets more porous to allow for the transfer of iron and immunities. You can't know for sure when those things will happen/ be done. The current theory is that when babies are ready they release a hormone that then tells your body to start labor.


There's just a lot to be said for waiting for labor to start. You know baby is ready. They benefit from starting labor too. They get the right sequence and build up of hormones and chemicals. If you can hang in there it's probably going to be worth it.

NO Cytotec for me! What you need to know about this drug

Cytotec (Misoprostol)- The only advantage to this drug is it is time and cost efficient. The drug comes in pill form and a portion if the pill is inserted into the vagina. This is usually used independent of pitocin. **If your Dr. suggests this drug, just say “no” because there are much safer alternatives**
Risks:
-Uterine hyperstimulation and possible uterine rupture. Unlike Cervidil it can not be stopped if the medicine is too much for you and baby.
-The medicine was formulated for the treatment of stomach ulcers. It is acknowledged by the medical community as a possible labor inducer but the drug manufacturers actually don’t support its use as a labor induction drug.
-The fact that labor is sometimes shorter with Cytotec is not worth the potential risk to mom or baby.

My thoughts:
Of all the induction methods out there, I would personally never use Cytotec. If my cervix was not ready for an induction and I had to be induced for the health and safety of myself or baby I would consent to only Cervidil (or another prostaglandin E2 gel) and or Cervidil/Pitocin combo. I wouldn't even go with having my water broken (maybe I would consider it if I had been stuck at 7cm and labor was active). Based on lots of research I think that these are the safest options.

Cytotec can NOT be stopped if you or the baby begins to have trouble. The uterus can be overstimulated with contractions that are too strong, too long or too frequent. This can diminsh the Oxygen supply to the baby. If you begin having trouble with the contractions then they can administer Terbutaline (or similair) to stop the contractions. Knowing that it can cause this, and much more, I would not take the chance when there are better alternatives.

There haven't been any studies that have proven it to be safe. No induction drug is 100% safe. Ask how he uses it and see if he uses it per the ACOG guidelines (go to their website, acog.org, and type "cytotec" in or do that on google). I really do think that Cervidil is safer. It was designed for ripening the cervix unlike Cytotec. Cytotec is still too new imo to be a good option. I don't really think I would be swayed with the logic of "I use it all the time with no trouble." They probably say the same thing about epidurals but 3 in 100 women will develop a spinal headache and slightly less than 1 in 100 will have a more sever problem. So,yes for the majority of moms they are safe but some moms won't have a good experience. I'd rather not be a statistic. (Yes, uterine hyperstimulation can happen with Cervidil but it is less likely).

If you do just a Google search for Cytotec you will pull up some very scary stuff. Not to make light of the possible serious consequences that can come from this drug but a lot of those stories are more frequently the rersult of the drug being used "improperly." (Remember, the drug has not been approved by it's manufacturer for inducing labor so there is no official way to use it). A wile back the American College og OB/Gyns had info on their website (acog.org) about how to use this drug "safely" for inducing labor. Your Dr. should follow these!

ACOG recommendations:-One quarter of a pill should be the initial dose
-Can be readmisitered every 3-6 hours
-Continuous monitoring is necessary
-Pitocin should not be given any sooner than 4 hours after the last dose of Cytotec has been given


Links:
Elective Inductions: This includes important information on how to have a safe induction- elective or not
http://www.hencigoer.com/articles/elective_induction/
http://sheknows.com/about/look/143.htm
http://dir.salon.com/health/feature/2000/07/11/cytotec/index.html

FDA's advisement that this drug should NOT be used on pregnant women:
http://www.fda.gov/cder/foi/label/2002/19268slr037.pdf
More FDA info:
http://www.fda.gov/medwatch/SAFETY/2002/cytotec_changes.PDF


Books:
The Thinking Woman’s Guide to a Better Birth by Henci Goer

Interesting thoughts:
"Those doctors and midwives using Cytotec for induction of labor off-label need to understand that they are taking very big chances with the safety of the women and babies they serve. Just about everyone in the world, after taking a careful look at the scientific evidence, has concluded we don't yet know enough about the risks to be willing to use it. This is illustrated in the following list of organizations that do and do not recommend Cytotec (misoprostol) for labor induction:

Recommends

American College of Obstetricians and Gynecologists (ACOG)

Does not recommend

U.S. Food and Drug Administration
Best scientific opinion—Cochrane Database
Searle (manufacturer of Cytotec)
Society of Obstetricians and Gynaecologists of Canada
British Royal College of Obstetricians and Gynecologists
All obstetric organizations in Scandinavia
FIGO (International Federation of Gynecology and Obstetrics)
World Health Organization
Obstetric organizations and drug regulatory agencies in many other countries
How can ACOG possibly be willing to stand alone in opposition to the best scientific opinion in the world? Because so many of ACOG's members already use Cytotec induction off-label for its incredible convenience, the organization needs to support its members by recommending this practice. This means ACOG must find a paper published in a prominent U.S. journal supporting Cytotec induction. In ACOG's recommendation on Cytotec induction, the organization leans heavily on a paper by A.B. Goldberg and other authors published in the New England Journal of Medicine (2). Let's take a careful look at the contents of this paper, as it is a superb example of torturing the data until it confesses to what the authors want it to say:


http://www.midwiferytoday.com/articles/cytotec.asp

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Like I said before, if it were me I would stick with Cervidil or another Prostaglandin E2. After that I would use Pitocin on the LOWEST setting and ask that it be turned off once labor was established.

Beth

Watch this. It is from CBS News this past November all about this drug. Maybe it will be more compelling than the articles and my thoughts.
http://www.cbsnews.com/stories/2004/11/30/eveningnews/main658388.shtml

Inducing *because* your cervix is unfavorable is a big recipe for trouble, especially for first time moms.

I have been hearing this "logic" more and more lately. 1st time mom goes in for 39 or 40 week appointment and very little cervical progress is noted. Rather than give mom the full 42 weeks (assuming mom and baby are healthy) the implication is made that obviously mom needs help; that she won't go into labor on her own. I have heard some moms say that they need to be induced (had to be induced with all their babies) because they never go (never will go) into labor on their own. Really and truly? Mom would eventually go into labor.

To induce labor with an unfavorable cervix increases the c-section risk. This isn't my opinion, it's pretty well acknowledged. The Bishop's Score should be used when making induction decisions in cases where induction isn't vital for the health of mom and baby.

I guess induction is at least better than just scheduling a c-section for lack of progress. Unfortunately that trend seems to be growing a whole lot too. I have hosted the board for 2+ years and this trend is really recent.

At least with an induction mom does have a chance of avoiding an induction (50/50 for a first timer with an unfavorable cervix).

Really think hard about inducing before 42 weeks if you and baby are healthy- especially if your cervix is unfavorable. If your body isn't ready that should be a red flag that you need more time not an induction.

A ripe piece of fruit is plucked very easily from the tree. An unripe piece needs a lot more force and could be damaged in the process.

Take the "Am I ready for an Induction" quiz:

http://www.childbirth.org/interactive/induction.html

Evening primrose oil and sex can help your cervix.

A Cervidil Induction

A Cervidil Induction:

Every so often someone says that the Cervidil really hurt. Usually that is because the cervix is pretty unfavorable, maybe even posterior, so it is harder to work with. I don;t think this will be a problem for you because your cervix is favorable.

A cervidil induction can be long. So, if you have to stay at the hospital consider asking for an Ambien or something so you can get some sleep that night. You don’t want to waste energy staying up all night if you aren’t in labor- that would be extrememly counterproductive. I know it is exciting to be at “labor” day but you have to pace yourself. If you can get this done as an outpatient then that would be best. Hospitals aren't exactly the most restful places in the world. Since IIRC this isn't a life or death kind of induction they may be cool with doing the cervidil as an outpatient.

You need to ask what they will do if the first dose of Cervidil does not change your cervix in any way. Will they do a 2nd round or just move on? Ask before then what their procedure is.

Sometimes one dose will send mom into labor. It isn’t that common though- probably 20-30% chance. This wouldn’t be a bad way to go. No IV, no pitocin, shouldn’t be any additional intervetions except *intermittent!!* monitoring.

So, be prepared to have pitocin and that whole ball of wax the next day. Stay optimistic but don't expect the Cervidil alone will start labor. You can certainly say you want to try another dose of cervidil rather than pitocin. The only thing anyone has to lose is time. Is that really a terrible thing? No. Patience is a virtue often lacking in birth. I say go for whatever will make birth easier for yourself and baby!

Sometimes they will take a break from the induction process in the am so you can eat, shower, do all that good stuff before doing round 2 or pitocin.

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