One of my most memorable evenings at Lamaze class went like this.
It was the fifth night of a six week series – so everyone was very pregnant. We were discussing Interventions – everything from IV medications to epidurals to emergency cesareans. Nationwide, one in four women are induced. To start the discussion, I turned to a mom who was due in ten days – and it was almost Christmas.
“So Jane, you go for your appointment tomorrow and the doctor says she would like to induce you on Wednesday. What do you say?”
Without missing a beat, Jane replied, “What time do you want me there?”
We all laughed – but truthfully, my heart sank. Just because something happens pretty often – ie it’s culturally normal – doesn’t mean it’s biologically normal. What did I know about inductions that Jane did not?
The bottom line is – yes, we can make you have your baby. But it may not be pretty. Here’s some of the things to talk to your doctor or midwife about, when they ask about scheduling your induction.
Is there a medical reason we are inducing my labor?
The last four weeks of pregnancy, most of us just want to go into labor (who knew we’d look forward to it!) because we’ve got pregnancy miseries. But the research says we need to be careful. Due dates are not set in stone. Despite our best guesses and all our fancy technology, there’s no way around the fact that we’d all be better off to get a due month rather than a due date. Only 3% of babies are born on their due dates, and if you’re having your first baby, we know you’re more likely to go overdue. (One third of babies are born at 40 – 42 weeks if labor starts on its own.)
Certainly there are good reasons for starting labor with a medical intervention. If you have high blood pressure, or have gestational diabetes, your placenta may be getting old. A nonstress test may be ordered for twice a week in this situation – is the baby still nice and active? Does her heartbeat stay strong and happy when you have contractions?
There was a time when moms were induced because “my doctor says he’s getting big”. Although we know most babies gain about an ounce a day during the last few weeks – our guesses on how big the baby is are just that – guesses. Rebecca Dekker at Evidence Based Birth, notes:
Although big babies are only born to 1 out of 10 women, the 2013 Listening to Mothers Survey found that 2 out of 3 American women had an ultrasound at the end of pregnancy to determine the baby’s size, and 1 out of 3 were told that their babies were too big. In the end, the average birth weight of these suspected “big babies” was only 7 lbs 13 oz (Declercq, Sakala et al. 2013).
Most often, it’s not the size of the baby that makes labor and birth difficult – it’s the position the baby is in. So if you’ve been eating healthy, and exercising regularly, and using good body mechanics, you may want to think twice about just saying yes to a “big baby” induction.
Your cervix is telling you something.
Is your body ready for induction? Progress towards and in labor comes in many ways – not just dilation. As you get ready for labor, your cervix actually starts developing oxytocin receptors. If those oxytocin receptors aren’t ready, willing and able, no amount of Pitocin will put you into labor.
It’s interesting the way this plays out. What an induction is basically trying to do is speed up the last weeks of pregnancy. If you’ve known someone who said, “Oh, they induced me and I had my baby five hours later” – her body and her baby were probably going to go into labor very soon anyway.
But I’ve known moms who were pretty disappointed when they were sent home after a couple days of induction – and they were still pregnant. That’s a cervix that’s just not ready yet! (They came back a day or two later and had a baby – and not all of them needed to be induced the second time.) Physicians use the Bishop Score to figure out how ready you and your baby are. Here’s how it’s scored.
|Dilation||Closed||1-2 cm||3-4 cm||>5 cm|
|Baby’s Station||-3||-2||-1||+1, +2|
The components of the Bishop Score are exactly what your doctor, midwife or nurse are checking when they do a vaginal exam. This is information that will help you know where you are in the process. (My own personal philosophy of birth included “If you put your hand up my vagina, you are going to tell me what you discovered there.”)
If you are induced and your Bishop Score is low, it’s likely that the doctor or midwife will choose to use a prostaglandin method to get your cervix ready for Pitocin. This is usually done in one of three ways: a foley catheter bulb inserted into your cervix and slowly inflated with water, cervidil, or misoprostol. All three of these methods rely on prostaglandins – inflammatory hormones that help your cervis go from “firm” to “soft” (see that Bishop Scale above!). Once your cervix begins to soften and shorten, and maybe even to dilate a bit, an IV drip with Pitocin is likely to give you contractions that will bring your baby into your arms. (By the way – one other method that can be used to “get labor going” is having your bag of waters broken by the practitioner. You’ve got to have a cervix that’s ready for an amnihook for this to work!)
Each one of these choices has pros and cons – ask your childbirth educator for more information, or talk to your doctor or midwife about what they plan to use. Also ask about how long they think your induction will take.
Inductions make the labor process more of a challenge.
The process of having a baby is called labor, not picnic. It’s hard work! One of the most challenging things about an induction is how often you need to be tethered to a fetal monitor during the process. You will be on the monitor before you get induced (so we can see how the baby reacts without any stress) and then for varying amounts of time at various intervals, depending on which method is used. Once you’re on a Pitocin drip, you will be continuously monitored.
The reason for what may seem like an excess of caution? Every mom/every uterus/every baby responds differently to an induction. Except for a foley bulb, the other methods can sometimes overstimulate the uterus – potentially dangerous for mother and baby. You can turn off a Pitocin drip, but you can’t erase the effects of misoprostol or cervidil immediately. So we use our little window into your baby’s world – the fetal monitor – to make sure your baby is happy and the contractions aren’t overwhelming your body.
Unless a telemetry unit is available, being on the monitor means being pretty stuck in one place – near the monitor. Tubs and showers? Not at this time.
Beyond the oh-so-present monitor, the sheer length of time it can take to “get things going” before you’re even in labor can be an unpleasant surprise. If you’re being monitored regularly at night, it’s hard to feel refreshed in the morning and ready for whatever the day will bring.
Unfortunately, inductions often lead to a domino effect when it comes to interventions.
“I was doing great – but then I got exhausted. I decided to get an epidural….and then my contractions petered out and we needed to crank up the Pitocin. The baby didn’t like those contractions….and all of a sudden I was looking at a cesarean.” And we know that this is one of the most frustrating things about inductions – a first time mom who is being induced has increased her chances of a cesarean. See the excellent article at Childbirth Connection for more info.
Know what you want, and what you need.
Certainly there are times when induction is medically necessary. If you have high blood pressure it may be necessary for your health – high blood pressure coupled with inflammation can lead to some pretty scary scenarios. (Our grandmothers called it “getting toxic” – these days we call it preeclampsia. You can get pretty sick, and it can be dangerous. Of course you’d want to have your baby before that happens!) If your placenta isn’t nourishing your baby properly, of course you’d want to be induced so the baby can keep on growing – on the outside instead of the inside. If your waters break and labor doesn’t start, the chance of infection would of course help you make a good decision for induction.
But your labor nurse and I agree: think it through. Pregnancy miseries – being just plain sick of being pregnant! – are not a good indication for induction of your labor.
It would be cheaper and better for your mental health to have a spa day and go out for breakfast, lunch and dinner. Then sleep through the night…..Could be your last chance for a long time!
Baby Steps is a blog written by Dawn Kersula, RN, a perinatal specialist at Brattleboro Memorial Hospital Birthing Center.