Sunday, March 20, 2011

Induction and Augmentation of Labour

I'd love it if you could let me know if you found this helpful or not, and let me know if you want me to write more about anything mentioned here. Thanks!
First of all, we should discuss the reasons for which induction should not be done in and of themselves. In these cases, the risks of induction outweigh the benefits.
  • Doctor, midwife, or family’s schedule, ie. Relative is leaving town and wants to see the baby before they leave or Mom’s preferred doctor is going on vacation.
  • Mom is uncomfortable or impatient
  • Gestational age 40-42 weeks
  • To pick (or avoid) a certain birth date
 Secondly, occasions where an induction MAY be called for, but there may also be other alternatives.
  • Low amniotic fluid. To help prevent this diagnosis, make sure to drink a lot of water, especially in the days before an ultrasound.
  • Baby’s size. With the exception of some women with diabetes or a true malformation of her pelvis, a woman’s body usually will not grow a baby that she is not capable of pushing out.
  • Gestational age 42+ weeks. You can do non-stress tests (NSTs) once or twice weekly to make sure Baby is doing well.
  • Maternal illness, such as diabetes, kidney disease or high blood pressure.
  • Prelabor Rupture of Membranes (PROM). The amniotic sac breaks open before labour starts. As with AROM (see below) care practitioners do not like to allow you to go more than 12 to 24 hours with the membranes ruptured without giving birth. However, studies do not show any increased risk of infection as long as labour starts within 72 hours of ROM. Meconium staining, maternal fever (a sign of infection), and increased number of vaginal exams all increase risk.
Thirdly, when an induction is probably necessary.
  • Uterine infection
  • Fetal illness
  • Severe maternal illness
  • Preeclampsia
RISKS OF INDUCTIONIncreased risk of premature baby even if your calculations say that your baby is term.
  • Placental abruption
  • Fetal distress
  • Uterine rupture
  • Increased risk of cesarean section. Having a cesarean after a long labour or failed induction is associated with increased risk of complications than a planned cesarean.
  • Increased use of interventions including pain medications and continuous fetal monitoring.
Yes. You'll need to have a c‑section (or, preferably, wait for labour to start on its own!) rather than an induction whenever it would be unsafe to labor and deliver vaginally, including the following situations:
  • Tests indicate that your baby needs to be delivered immediately or can't tolerate contractions.
  • You have a placenta previa or a vasa previa (when blood vessels from the umbilical cord are embedded in the amniotic membranes and at risk for rupture during labor); or the cord is lying in front of your baby's head and could be compressed as his head enters the birth canal or prolapse through your cervix when your water breaks.
  • Your baby is in a breech or transverse position, meaning that he's not coming head first. (Breech babies can be birthed vaginally but should NOT be induced.)
  • You've had more than one c‑section. (Some practitioners believe that women with even one previous c‑section shouldn't be induced.This doesn't mean that you cannot birth vaginally though!)
  • You had a previous c‑section with a "classical" (vertical) uterine incision or other uterine surgery, such as a myomectomy (surgery to remove fibroids).
  • You're having twins and the first baby is breech, or you're having triplets or more. (As with a single breech, twins and triplets can be birthed vaginally, but should not be induced.)
  • You have an active genital herpes infection.
HOW - MEDICAL METHODSArtificial Rupture of Membranes (AROM or amniotomy)
  • Using an amniohook (looks like a crochet hook with a sharp point on the end), your doctor or midwife hooks the amniotic membranes and creates a tear, releasing the amniotic fluid. You may continue to leak fluid throughout your labour.
  • The procedure should not be any more painful than a regular vaginal exam.
  • If you have not been contracting, you may start having contractions or feel like your baby has dropped further in your pelvis.
  • If you have been contracting, this is called augmentation. You will likely feel the contractions increase in intensity and frequency.
  • You might not be allowed to take baths due to the risk of infection (studies do not show any increased risk, but some care providers do not allow it anyways) so you lose that pain management technique. Taking a shower should be okay, but does not provide as much relaxation (and thus pain relief) as a bath does.
  • Your temperature and blood pressure will have to be monitored for signs of infection, possibly as often as every 10 minutes.
  • There is no going back after AROM. The baby must be born. If the baby is not born after 12 to 24 hours, your doctor will probably pressure you to have more interventions or have a cesarean section.
  • Risks include:
    • fetal distress
    • failure of labour to start
    • augmentation of induction with Pitocin if labour does not start on its own
    • increased risk of infection if baby is not born within 72 hours
    • increase in fetal malposition
    • increase risk of cesarean section
    • increased pain and so increased risk of pain medications like epidurals being requested. Many women choose to just go ahead and get an epidural before AROM because the pain is so intense afterwards. This risk is lessened if AROM occurs shortly before the birth of the baby.
    • risk of catching the umbilical cord in the amniohook, causing it to bleed and putting the baby in extreme danger.
  • Synthetic form of Oxytocin, the hormone your body produces to start and maintain contractions.
  • When your body produces Oxytocin, it also produces endorphins to allow you to manage the pain (pressure) of the contractions. When given Pitocin, however, your body does not know what is coming and so you do not get the benefits of the endorphins.
  • Your body's natural production of oxytocin will slow down when you are given pitocin, so once pitocin is started, it can be dangerous to stop it or "turn it down".
  • Pitocin dosage is regulated with a medication pump. It is started slowly but the nurses may increase the dosage every time they come into the room (even if contractions are regular and strong) in an attempt to force the labour to progress more quickly.
  • You will have a continuous IV drip and continuous electronic fetal monitoring.
  • Also used to augment "non-progressive" labour.
  • Risks include:
    • fetal distress
    • possible increased intensity of the contractions and so increased risk of pain medications like epidurals being requested. As with AROM, it is pretty much a given that for most women they will end up getting some form of pain medication if they get Pitocin.
    • increased risk of cesarean section
    • uterine rupture in VBAC cases
  • Gel applied to cervix to help ripen it. May stimulate contractions to start labour. Doctors may insert up to three applications of gel to try to start labour.
  • If it doesn’t work, there is probably no harm done. You can just go home and try again later or wait for labour to start on its own.
  • Risks include:
    • fetal distress
    • possible increased intensity of the contractions and so increased risk of pain medications like epidurals being requested. However, this is much less intense then those caused by Pitocin or AROM.
    • uterine rupture in VBAC cases
Foley catheter
  • A device is inserted in between the amniotic sac and the bottom of the uterus. It is filled with a saline fluid in order to force the cervix open. It eventually falls out as the cervix dilates. You have to be dilated a little bit already in order for it to be inserted.
Stripping, or sweeping, the membranes
  • Done during a vaginal exam towards the end of the pregnancy. The woman may or may not be informed about it ahead of time.
  • The midwife or doctor places a finger inside the opening of the cervix and separates the amniotic membrane from the uterus.
  • You may be very uncomfortable during the procedure. Spotting or bleeding afterwards is common, as is feeling achy or having irregular contractions.
  • There is a risk that the amniotic sac may be ruptured during this procedure (either accidentally or on purpose.)
(Anna's note: Even so-called "natural" methods of induction are still interrupting the natural process and should be taken seriously.)

  • Labor Inducing Eggplant Parmesan
One of the methods of self‑inducing labor that's been sweeping the internet in recent years is the myth that eggplant will start labor. This maternity myth started when a news story began circulating about a restaurant in Georgia named Scalini's. Apparently the mothers of over 300 babies have gone into labor in the past 23 years, within 48 hours of eating the eggplant parmegiana. The funny part is, it may just be that the dish causes the women to go into labor, but it's not the eggplant. The herbs Oregano and Basil have properties that may cause contractions, though it is not yet known how or in what quantities. This is why, in aromatherapy circles, these herbs and essential oils are to be avoided whenever possible during pregnancy.
  • Sex to Induce Labor
Semen contains prostaglandins. Prostaglandins cause the cervix to "ripen", or soften and prepare to open. While it is debatable whether there are enough prostaglandins in semen to have any real effect, it is not a terrible way to keep hope alive and while away the last weeks of your pregnancy. Another great side effect is the fact that orgasms produce oxytocin, the hormone that causes contractions. So, between the two, there is a pretty good case for the cure for pregnancy. (In otherwords, what got you in this condition, may help to get you out of it!)
  • Evening Primrose Oil and Red Raspberry Leaf Tea
Neither will actually induce labor. While some lay midwives will argue that statement about the Evening Primrose, which is the reason it is not recommended until 36 weeks or "full term", almost all sources with experience agree that it does nothing that the body was not ready to do on its own. I will repeat this at the end of this section, to make sure you understand this, as there is a lot of confusion and misconception surrounding these two substances.
Evening primrose oil is an excellent source of prostaglandins, which we already determined readies your cervix for labor. It can be taken orally as soon as 34 weeks, and can be applied directly to the cervix at full term (36 weeks). The general recommendation is two 500mg capsules per day until week 38, at which time you increase to 3‑4 per day. The entire capsule can be inserted vaginally (inserted just before bed, it will dissolve before the first time you wake to use the bathroom), or you can use the oil on your fingers for your perineal massage, then also rub on your cervix (assuming you can reach it). Applying directly to the cervix is optimal, but the beneficial ingredients are absorbed through the external skin or the stomach also.
Red raspberry leaf tea is a uterine tonic used by Native Americans for thousands of years. It tones your uterus by helping to "focus" your Braxton Hicks contractions. Think of its job as helping your uterus do more effective exercising while you are pregnant. It does not "cause" contractions and can be safely used throughout pregnancy. It is contraindicated for those having complications "just in case", however, by most doctors who do not understand its use. Many women safely use it from the moment they learn they are pregnant at six weeks until months after delivery. (It helps to tone the uterus after delivery as well, shrinking it back to size more quickly and reducing bleeding.)
Again, neither of these actually causes labor to start!
  • Castor Oil to Bring on Labor
First let me just say that I do not recommend this method. That is because I used it with my second child and it was just about the most horrible mistake I could have made (other than maybe getting another epidural, anyway).
The theory behind this induction method is that the castor oil causes diarrhea and the diarrheal cramps cause sympathetic cramping in your uterus, another smooth muscle. This is another of the methods that "won't work if you're not already ready anyway", as the sympathetic cramping will be ineffectual if all conditions are not already optimal for labor. In my case, my contractions began 10 minutes after my first dose of oil, hours before the diarrhea began. Therefore, it could not have been the castor oil that brought on labor in my case, and I caused myself all that trouble for nothing.
There has been much debate over whether taking castor oil to induce labor will cause the baby to have its first bowel movement in the womb before birth. This pre‑birth bowel movement, called meconium, can be dangerous, because if baby inhales some of it it can cause pneumonia in the lungs. Meconium is also a widely‑held signal that the baby is in some sort of distress. Most professionals with any experience with castor oil inductions agree that this is untrue. They have found that there is no increased occurrence of meconium in castor oil induced labors over spontaneous labors.
The real danger lies in the mother when using castor oil for labor induction. With the severity of the diarrhea, a laboring woman can quickly become dehydrated. Especially in a typically highly managed hospital birth where a woman is allowed few fluids. Dehydration makes one tired and less able to endure through physical activity. Plus, not only does this endanger breastfeeding (proper hydration is necessary to make adequate milk), but a dehydrated uterus is an aggravated uterus, and an aggravated uterus causes more pain for the mother. More pain makes a woman less able to handle natural child birth and puts her and the baby at increased risk for a snowball of interventions.
  • Nipple Stimulation to Self‑induce
This is a practice often recommended by midwives when a woman is long past due or when labor is stalled. Nipple stimulation causes the release of oxytocin, the same hormone that causes uterine contractions. Many women report, however, that the contractions produced from this method are much stronger and more painful than natural labor, but are not any more effective.
Please note: In order to use this method for induction, you must stimulate the nipples for long periods of time. The usual recommendation is 15 minutes of continual stimulation on each nipple each hour for several hours. So, the amount of stimulation you may experience during intimacy, while nursing an older child, or while pumping your breasts while pregnant will not cause you to go into labor. The general recommendation on these activities is to abstain from them when your condition warrants doctor recommended pelvic rest. Please check with your practitioner before trying this.
  • Acupressure/Acupuncture for Inducing or Augmenting Labour
There are two points on your body that will cause uterine contractions. They are always warned against during pregnancy, though they are widely believed to be another labour inducing method that will not work if you are not already ready to deliver. These points are about four finger‑widths above the inner ankle on your calf, and in the webbing between your thumb and forefinger. You will know when you've found the spot because it will be very sore. You rub your calf, or pinch the webbing on your hand, in a circular motion for 30‑60 second at a time, taking 1‑2 minute breaks in between.
  • Stripping Membranes
There is a procedure your doctor or midwife can perform called "stripping" or "sweeping" your membranes. The healthcare professional will insert their finger(s) into your cervix and sweep from side to side, pulling the membranes (bag of water) away from the mouth of the cervix and the lower uterus, and in the process stretching and irritating your cervix. Sometimes this will generate local production of prostaglandins and enough of the necessary hormones to start labor. Sometimes it takes 3 or 4 attempts to begin labor. Many women find this to be a very uncomfortable, if not painful, procedure. This is a medical intervention and should be taken as seriously as any medical induction method.
  • Herbs and Homeopathic Remedies
All substances that would fall in this category, such as Blue and Black Cohosh are general considered to be as unsafe as medical interventions, and if they are to be used must be used only under the recommendation and supervision of your doctor or midwife.
  • Have a good relationship with your doctor. Make your desires known and make sure they are compatible with how the doctor practices medicine. If you are hoping for an intervention-free birth then a doctor that specializes in high-risk pregnancies and has a 50% cesarean rate may not be the best doctor for you.
  • Same thing goes for where you deliver. You are more likely to get an intervention-free birth at home, a birthing centre, or at a hospital that does not specialize in high-risk cases (assuming, of course, that your pregnancy is not high-risk.)
  • Have a birth advocate. This can be your husband or boyfriend, sister, mom, doula, midwife, or just a close friend. They will stand up for your wishes during your labour when the situation might seem confusing or intimidating to you.
  • Avoid unnecessary ultrasounds.
  • Inform yourself about as much as possible.
  • Drink a lot of water.
  • If you are in close proximity to your birthing place, then do not go there until you are in steady, progressive labour. You will know this if you cannot continue to talk through the contractions. If you go in too early, they are more likely to label it as "non-progressive" labour and pressure you to start augmentation when really you maybe should just go home and relax and go back when labour is more established.
  • Charting your fertility cycles when trying to get pregnant will allow you to pinpoint more accurately when conception took place. This will give you a more accurate due date.
  • Due dates are not “Best before” or “Expiration” dates! View it as a guideline only.

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