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Inducing Labor

Let me begin by assuring that there are some valid reasons for inducing an otherwise healthy pregnancy.

Life-threatening illnesses that will affect the health of mother or baby. These include preeclampsia, severe hypertension, cancer, diabetes, organ disease, or placental age or deterioration.

There are many more reasons women induce their labors to begin:

Suspected large baby. No technology exists to accurately predict the size or weight of an unborn baby. Measurements, ultrasounds, and assessments through other means can be off by several pounds, higher or lower. Even still, women commonly induce out of fear of having a big baby.

Being overdue. Early in pregnancy, women are assured that their due dates are mere estimates; by the end of pregnancy, that has changed, and going past one's due date has become undesirable. I don't think it's a stretch to assume that this is connected with the first. Merely being past the due date, however, is not a medical reason.

Being full-term. This is more common, as women take lightly the act of inducing labor and try to have their babies at an arbitrary time, so long as it's after 36 weeks (and often before 40).

Doctor scheduling. Your doctor has told you that he or she will be out of town at a certain time, and you want to ensure that you are in labor during a time he or she can attend you.

Family scheduling. Many women feel pressured to produce a baby when family will be around. "My mother will only be here for ten days!" "Grandpa will be in town on the 26th, and he'll want to see the baby!" Some women want to give birth so they can attend a family event or go on a scheduled trip.

Discomfort at the end of pregnancy. Your hips hurt. Your belly is huge. You can barely walk or stand up. Sleep is elusive. You're ready to be done. The baby, though, is not.

All of these are inducing for convenience.

Why it matters

Whether or not to induce your labor depends largely on what you want to experience in your labor and what you want to avoid.

As a result of induction you may have:

1. A vacuum or forceps-assisted birth;
2. A baby unable to tolerate contractions.
   

As a result of induction you are likely to have:

1. Increased fetal distress;
2. Pitocin administration, which will make labor contractions stronger and far more painful;
3. Epidural anesthesia to cope with the pain;
   
4. Rupture of your bag of waters, which puts a time limit on how long you will be allowed to labor and increases your baby's and your own chances of infection;
5. Problems with presentation and position of the baby in the womb;
   
6. Increased incidence and severity of jaundice in your baby.
   

As a result of induction you will have:

1. Doubled your chances of delivering by cesarean section;
   
2. A highly-medicalized and regulated birth where you have little or no decision-making power;
   
3. A premature baby. (By premature, I mean a baby born before it is ready; since we do not know when that date would have been, it is safe to assume that all babies born before that point are, to some extent, premature.)
   

The most important part of prenatal care

So, you're pregnant, for the first time -- congratulations!

You go to your prenatal appointments. You're gathering supplies and cute clothing for your little one. Maybe you're picking out the perfect crib, changing table, rocker with matching footstool. You're filled with tender visions of motherhood.

Maybe you can already feel the tiny being moving around inside your abdomen. It's magical.

Your doctor assures you that everything is normal. You continue along in your pregnancy.

As your birth looms closer, your excitement grows. So does the realization that this baby, which seems impossibly huge in late pregnancy, must come out of your body somehow.

You will probably begin to hope that your labor will begin early. This means that not only will the baby be smaller, but you'll spend less time feeling as large (and agile) as a barn. Inductions, stripping the membranes, anything you may be offered at your doctor's office to speed the onset of labor, sound sweet.

What will happen in your labor is an unimportant mystery -- after all, isn't that why you have a doctor? Whatever happens will be fine, because your doctor and nurses will make sure that you come home with a healthy baby, and that is the very most important thing.

..

Except it isn't.

..

You will find that how your baby comes into the world, and how you feel about it, matter tremendously. You might be asked to make decisions you don't understand. You will experience new sensations and emotions and not know if they are normal or aberrant. You might feel afraid, insecure, discouraged, or foolish.

On the contrary, you have the opportunity to experience your birth as a wonderful and normal passage. You can feel comfortable, even in the midst of unfamiliar sensations. You can be confident in your knowledge that you are where you should be, that what you are experiencing is normal and good, and what to expect to come shortly. You can bring your baby into the world, fearless and radiant, with no sense of unease to cloud your joy.

..

Does it depend on whether or not you had an epidural?

Not at all.

All this hinges on your education. Do not miss the opportunity to learn about childbirth. You need to know what will happen, to become very knowledgeable about what is normal and what is outside the range of normal.

Whether or not you choose pain medication does not ultimately matter. You will do what you feel comfortable with, and education may or may not change your course of action in that respect.

But if you arrive at the hospital in labor, are examined and found to be 3 centimeters dilated, and the care practitioner offers to break your waters, what will you choose? There are consequences to early rupture of the waters, not all of which may be disclosed to you in that moment.

If you are told that you need to be induced because of a large baby, what will you say? Do you know how the measurements were made and how accurate they may be? Why does the doctor want to induce for a large baby anyway? Is induction safe?

If the baby's heart rate drops to 100 bpm for a moment, is there something seriously wrong? What will the medical staff do? What does it mean?

Are you prepared to make these decisions?

Do not miss your classes. If you find you still have questions, find out. There are plenty of resources, and for most things, there is reliable, studied information available. Read about birth until you are weary of reading because you know the subject so well.

Prepare yourself.

What happens in your birth, and how you feel about it, matters tremendously.

"I have a doctor; why would I need a doula?"

The roles of doctors and doulas are in different spheres.

Your obstetrician is there to monitor your health and your baby, look for signs of presenting problems or issues, and handle all medical aspects of your care.

When you are in labor, you will typically see your doctor briefly during labor and then when you are pushing out your baby. The doctor is present for a very small percentage of the time you will spend giving birth to your baby.

You will see more of your nurse or nurses (depending on when you are at the hospital, and for how long,, taking shift changes into account). The nurse will come in to check on you, maybe check dilation through a vaginal exam, ask you to rate your pain on a scale of 1-10, take blood pressure, take a lot of notes, and then leave to do it again for however many women are laboring on the same floor as you.

Some nurses are better than others at attending women in labor and giving them help and personalized care. Many have a practical, businesslike approach to caring for laboring women. Some are downright harsh to their patients. Most are too busy.

The hole left between medical visits is what's filled by a doula. Doulas are not medically trained and will not perform vaginal exams to check dilation or blood pressure measurements, but they will remain with you at all times.

Doulas give constant emotional support. They can explain to you what is happening, help you maintain your focus and keep you grounded. They can help with positioning and comfort. They know your intentions and help to communicate them to staff and gently remind you of your goals if needed. They are there to help you have a safe and satisfying birth experience.

This is not the role of the doctor or the nurse. The nurse's priority is the hospital protocol and communicating with the physician. The doctor's priority is the health of the baby and the mother. The doula's concern is your happiness, comfort, and helping you have the birth you want.

No matter what kind of birth you desire, you can benefit from having a doula present. We do not replace the nurse or your partner; we are simply an extra pair of hands and a caring heart to help and encourage you through this amazing rite of passage.

Who is going to give birth to your baby?

What kind of birth experience do you imagine having?

Do you picture your baby coming into the world without your experiencing any sensation of his or her passing through your body?

Will you have a cesarean? Are you expecting twins and therefore (as is standard in many places) have your c-section date scheduled, even if you are newly pregnant?

Do you want to know what birth feels like, even if it is painful and lasts for several hours with increasing intensity?

Are you undecided?

Perhaps you have heard from other women that no one receives a medal for having an unmedicated birth, and you are determined not to exhibit any unnecessary heroics. Maybe you are so scared of birth, having heard too many times that it is the most painful sensation women have ever felt, and you want to avoid the pain. After all, we have medications that make it a pain-free experience, so what excuse do you have to refuse them?

Quite honestly, as a doula, an educator, a woman, and a mother, I don't care what women visualize for their births. What they want does not matter nearly as much as their approach to it.

If a woman is educated about birth, she will know what the benefits and consequences of her decisions are. She will know that:

• There may be unexpected hazards with low-risk, uncomplicated births, but cesareans are always riskier. The recovery after a cesarean is much longer, too, and it will change your body forever.

• Epidurals are relatively safe, but the anesthetic and narcotics used DO pass to and affect the baby.

• Epidurals don't have the same effect on every woman. Sometimes the chemicals have a partial or even NO effect on the physical sensations of labor. If you are one of those women, what will your next course of action be?

• Often, when a medically-trained person claims that a medical procedure has no risk, the meaning is that there are risks but they can be medically treated. An example of this is the use of narcotics as painkillers during labor. The narcotics may cause respiratory problems in the baby, and there is a pharmacological treatment for respiratory distress that usually takes effect swiftly. While that does not truly equal NO RISK, it does for medical purposes.

• Women cannot depend upon the medical personnel to support them during labor. They may have a nurse who completely supports her goals, but that nurse may be attending twenty other women in labor that day, and her good intentions do not count as 'support'. Women need to go into the hospital with their own team.

• Doctors and nurses do not necessarily know more about birth than women do. They know how to treat complications. As a whole, they rarely see the birth process untouched by medical procedure.

I am certain this sounds very anti-hospital, but I assure you I am not. I wish to challenge the notions many women harbor that they do not need to think about their own births, that they can simply give the experience over to the medical staff AND have the births they want. You are not guaranteed anything by going into the hospital to have your baby. The medical personnel will operate by their own protocols, and those may or may not agree with what you have envisioned for yourself. In the absence of an emergency, it is up to YOU.

I want to rally women into education. If you are choosing to have an epidural because you are scared of the pain, then research how women have coped with it and what they have said about their labor experiences. Epidurals may have no effect on you. Have a backup plan. Know how to cope with difficulty, just in case you cannot have the pain meds or they do not work for you. If you have had a cesarean but want to have a VBAC for your subsequent birth(s), you need as much support, knowledge, and strength as you can muster. Go to it.

Find the location and the care providers, the doulas, and every community resource you can, to have the birth you want. Do everything you can.

No one else is going to give birth to this baby. You need to be the woman you envision, not one making choices out of ignorance or even operating on the advice of a few friends or your sisters. Be strong and take the responsibility that is yours.

We are no longer in the age of absolute trust in our doctors. The choices are largely yours. The path you take is one you alone determine. Learn all you can, from all sources. If something sounds too good to be true, do more research to find the truth, because what you have heard is probably misleading. People and doctors pass along bald lies about birth. Find out what they are.

Drop your laziness and apathy. You are becoming a mother, and any bit of knowledge and toughness with benefit you in this capacity. It will help you in labor. It will serve you when you are in the trenches of parenthood. You will not be handed the tools you require; you must seek them out.

Nobody cares about your birth as much as you do. Take up your burden of authority and find out what you will do with it. Bear it well. Educate yourself.

SOOO Big

"We just had our first granddaughter! She was born six weeks early, which is really a blessing for her mom, since the baby already weighed 5 pounds."

"The Porters have just added a small blessing to their family -- actually, a rather large blessing, at 8 pounds 12 ounces."

I don't know where we have learned our fear of delivering a large baby. Sometimes babies can get rather big, and sometimes size is a consideration in determining how a baby is born, vaginally or by cesarean section. But our collective fears are exaggerated. Macrosomia (large baby) is frequently misdiagnosed; ultrasounds are notoriously unreliable for determining a baby's weight before birth.

Here are some common myths about birth weight:

• If the baby grows too much in the womb, the shoulders will become stuck during birth. This is called shoulder dystocia, and while it is a rare and very serious problem, its incidence is not connected absolutely with how much the baby weighs. "It has been established that 48 to 89% of SD occur in non-macrosomic fetuses" (Blickstein). Shoulder dystocia is unpredictable and while its likelihood increases with larger babies, it has also been reliably linked to maternal diabetes, labor induction, and the use of pain medication. Cesareans done for suspected macrosomia have resulted in dismal statistics: 100 unnecessary c-sections for one true case of macrosomia. Plus, since there is no assurance of shoulder dystocia occurring even with a large baby, performing a cesarean for the sole reason of avoiding dystocia is unsupported. Causal relationships have been established between shoulder dystocia and the following: increased maternal age, shortened first stage, prolonged second stage, maternal obesity, gestational diabetes, position of the baby during birth, labor induction, epidural use, and a long time period (8 years or more) since the previous birth.

• A larger baby will result in larger vaginal tears. Not necessarily. While there is a limit to how much tissues can stretch to allow the passage of a baby, the most important rule to avoid tearing is to slow down. Pushing too hard, too fast, and not allowing the tissues to stretch out, will almost certainly result in tears. While there is a place for episiotomies, they absolutely do not help women avoid larger tears; they create a weak spot where stress is centered and can cause more injury rather than preventing worse tearing. The best advice for avoiding tearing during birth is to take your time. My midwife told me that "Your body will not grow a baby you can't birth." I'm not certain that that is entirely and completely true, but I do believe that in the great majority of circumstances, a woman can give birth to the baby she is carrying, without it being "too big" for her. As stated on a childbirth website, "your body is designed to accomodate even a large baby."
  


• Babies gain a pound a week during the last weeks of pregnancy. I have heard this misconception many times, and I don't know where it came from. It is a lie. By the end of pregnancy babies can gain as much as one ounce per day - that equals 7 ounces per week, or less than one pound every 2 weeks. This myth leads to...

• Induction before 40 weeks will avoid the trouble of having to birth a large baby. Inducing labor carries with it so many risks that there is no evidence of improved outcomes for women thought to be carrying large babies. Inducing labor before your body is ready to give birth also increases your chances of having a cesarean.

• A large baby's head will get stuck in the mother's pelvis. True cephalopelvic disproportion (CPD) is very rare. The baby may be too large for vaginal birth in some cases, called absolute disproportion, but this is, again, extremely rare. More common causes of CPD are bad positioning of the baby, inflexible tissues of the cervix or vagina, and impatience. Another very rare cause is an abnormally-shaped pelvis (rickety or trefoil). Many women who deliver a baby by cesarean due to a diagnosed CPD will go on to vaginally birth an even larger baby, disproving the initial diagnosis.

• The average birth weight of babies has increased over time, and soon babies will become too large to birth vaginally. There has been an increase, especially noted around the turn of the century (1900, not 2000). The average birth weight suffered a giant drop leading up to around 1900, and then made steady improvements, up until the modern day, the past twenty years or so, when they seem to have levelled off. Accurate birth weight measurements were not in place until the mid-1900s. So while the first part of the statement may appear technically true, the second part is unfounded. The increase in birth weight can be attributed to better health care and prenatal care, better workforce environment, lower levels of hard physical activity, better nutrition, and education.

I am not pleased when people talk about their "giant 8-pound babies". To me, 12 pounds is large, and 8 is pretty darn close to average.

The current average birth weight for all babies is 7 1/2 pounds.

Some are larger, some are smaller. Either extreme may result from and/or cause complications. But by definition, most babies fall within the average, normal category for birth weight.

Both of the quotes above are things I have overheard in the past few months, and it made me want to jump out of my skin.

8 pounds is not huge. Anecdotally, I know many moms who say that their latest, 10-pound baby was their easiest delivery. It isn't all about weight.

Prematurity is not a good tradeoff for low birth weight.

The optimal goal is a good outcome for both mom and baby. Most of the myths I discussed are based on fact but are not exactly true. Each individual needs to research and weigh her own risks and circumstances. My intention is to clarify the truth and dispel the misleading beliefs where appropriate.