Tag Archives: Induction

Does your provider know the research?

This JUST happened and I could not go on without sharing this.  I’m almost speechless but I had to say something LOL… (But its NOT funny)

I often read little research blurbs and then see and hear what goes on during hospital birth and wonder to myself  “Has anybody around here picked up a scholarly journal since graduating from nursing/medical/midwifery school?”

I am by no means a research buff nor do I profess to be but there are some things that have been shown, and discussed, and proven over, and over, and over and to me its common knowledge. One of those things is the benefit of fetal growth through (and beyond) 39 weeks.  Research has shown, before then… all bets are off.  This common knowledge has instituted the 39 week hard stop policies that have been implemented across the country to stop providers from doing elective c/sections and elective inductions prior to a woman reaching her 39th week of pregnancy.  Where these policies have been enforced, they have seen c/section rates decrease, more successful inductions, and fewer NICU admissions. The March of Dimes has a national campaign around the issue.

With that in mind…. it is shameful for me to participate in an online CEU module put together by Medscape, a well respected online portal of information and educational opportunities and see THIS:

First there was the case study followed by this question:  “According to the ACOG recommendations, when is the earliest a fetus can be delivered with a low risk of respiratory and nonrespiratory morbidities?”

I answered the multiple choice question, clicked enter then saw this chart.

 Your Colleagues Responded:
At 34 to 36 weeks’ gestation  16%
At 37 weeks’ gestation  22%
At 38 weeks’ gestation  19%
At 39 weeks’ gestation Correct Answer  43%

*Blank Stare*     Only 43% of the individuals taking this test got that right? SERIOUSLY??!! And we wonder why things are moving at such a slow pace…. WOW!! There is work to be done. #FistUp

Did you know the answer to this questions? Does your doctor/midwife/nurse know the answer to this question?

 

Monday Musing… Don’t Change That Date!

Over the years I have heard a lot of pretty ridiculous things OB providers have told women. I have heard women verbally bullied and virtually forced into hospitalizations, procedures, inductions, tests, etc in the name of “safe obstetrics.”  The other day I was completely enraged because I was reminded, some doctors are taking the bull shit to a whole new level.  I’m convinced many of them REALLY believe women are stupid and incapable of making good decisions. 

I have a friend whose sister is pregnant.  During a recent conversation I asked about her sister.  I was especially concerned since the last time we spoke her sister was being referred to the MFM (Maternal Fetal Medicine high risk folks) because something on her early ultrasound was suspicious for downs syndrome. 

My Friend:  “Well… that  issue (The Downs Syndrome) has been resolved apparently because they have discharged her from the MFM BUT…. Now, the new thing is… her doctor is telling her he thinks she is going to have the baby early…. “

ME:  “HUH?? WHY??? What do you mean??? Shit… he is already setting her up mentally for an induction…  What’s her due date?” 

My Friend:  “Well it was March 8th but at her last appointment he felt like she might go in early. Told her she might be ready around February 28th”

ME:   *gasp* “Are you F-Bomb kidding me??!! That’s bull-shit. She had multiple ultrasounds with the MFM. If her due date needed to be changed they would have said something.  You don’t just all of a sudden change somebody’s due date at this stage. He is setting your sister up so he can schedule an induction. She will be 39 weeks then. That’s some straight bullshit. Tell your sister to call me.”

My Friend:  “Wow…. She has said she definitely doesn’t want to be induced”

Me:  Well he is playing games and setting her up for an induction. Putting bull shit in her head now makes it easier for him later. Tell your sister to call me…

I was pissed!!!  The bottom line is this:  The earlier the ultrasound, the more accurate the estimated “due date” (EDD) Each time you get another ultrasound it is possible that they will give you a new “due date.”   Regardless of the so-called new due date your original due date DOES.   NOT.   CHANGE. 

Ultrasounds and their ability to predict due dates are affected by a number of things including but not limited to:  the skill of the person doing the ultrasound, what they measure to obtain the date, the approximate gestational age of your growing baby, and the percentile growth or size of your infant.

Most women these days get at least two ultrasounds.  The first ultrasound, usually called your “dating ultrasound” is done as early as possible.  If it’s done during the first 12 weeks of pregnancy, it is the best predictor, after the date of your last menstrual period (LMP), of your EDD.  It is pretty accurate to a few days.  If the difference between your LMP due date and your first trimester ultrasound due date is more than a week, your provider will assign the ultrasound due date. If the difference is less than a week, they should go with your LMP date but many don’t. IMO its because they are more comfortable with technology than they are believing a woman knows her cycle but that’s a post for another day.

Some where between 18-22 weeks most women receive their second ultrasound, often called an anatomy scan.  As your baby grows and is somewhere on either side of “average” this anatomy scan may produce a different EDD, but it does NOT  really CHANGE your due date.  An ultrasound at this gestational age is not as accurate as the earlier ultrasound.   If you have a good ultrasound during the first twelve weeks of pregnancy, there should be no reason to change your due date.

After the first trimester, ultrasounds have a margin of error of up to 10 days.  After 26 weeks of pregnancy that margin of error increases to THREE  WEEKS!!! That’s up to 3 weeks wrong in either direction.  This means if you did not have an early ultrasound, and you don’t know your LMP, and you get an ultrasound that says you are 32 weeks… you could be anywhere between 29 and 35 weeks. That is the nature of the ultrasounds.

If you had your initial ultrasound during the first 12 weeks of pregnancy, or shortly thereafter, be VERY leery if your provider wants to change your date, especially to an earlier date.  Just because your baby may “measure big” does not mean that your baby is gestationally older. It just means you have a baby on the high side of average.  (Not that “measuring big” is all that accurate anyway but that’s also a post for another day)  If you are like my friend’s sister, and you had multiple ultrasounds, and all of a sudden your provider tells you they need to make your due date earlier… all I can say is RUN!!!  Or at a minimum get to asking some SERIOUS questions. Your birth experience and may depend on it.

Were you constantly confused because your due date kept changing? Were you induced because of a new due date that made you  “post dates?”  I would love to hear about it.

Pitocin is NOT Always Poison

As a rule, I am in favor of natural birth:  a birth that among other things, starts on its own, includes non-pharmacological forms of pain relief, avoids medical augmentation, and allows a woman to be free to eat, drink, walk, and move during labor.

While I am in favor of natural birth, I also understand that sometimes interventions are necessary, can be helpful and do save lives AND… if you chose a provider, and a plan for birth that employs medical management of labor, what may, under different circumstances, be something I would advise against, all of a sudden can become something I am completely in favor of.

As an example… I am not in favor of randomly using Pitocin.  I understand that in the wrong hands Pitocin can create a very difficult and even unsafe labor.  I understand that Pitocin is over used and its dangers are often understated.  In spite of that understanding, there are times when Pitocin can be the difference between a cesarean section and a vaginal delivery.

The Scenario:
You enter the hospital in spontaneous labor.  You opted for an epidural and your water bag was broken artificially.  You progress at a slow normal rate getting vaginal exams/cervical checks every 1-3 hours. First you are 3-4cm. Two hours later you are 4-5cm.  Six hours and a few vaginal exams later your cervix is “stuck” at 6-7 centimeters dilated.  For some reason, Pitocin was never started or the nurse who was giving your Pitocin did not know how to titrate the drug.

You are told:   “On average we expect you to dilate 1.2cm each hour and here you are 6 hours later and you have only dilated 2 centimeters.  Looking at the monitor you seem to be having adequate contractions and I just don’t think this baby is going to fit.  You have a fever and your baby’s heart rate is now higher than normal. At this point I recommend that you have a cesarean section,” and your cycle of primary to repeat c/section has begun.  I have seen this scenario twice recently.

Mother #1:
Pitocin had never been started on this mother and I tried to advocate for a trial of Pitocin. She was “stuck” at 7-8cm and I had learned in report that the MD had been saying all day… “I don’t think this baby is going to fit.”  While her contraction pattern may have been “adequate” for a mother who was walking during labor and using other techniques i.e. nipple stimulation to increase contractions and to move her baby to optimal birthing position, she had opted for an epidural.  She was having what we call a “coupling” pattern to her contractions. This pattern is often associated with a posterior presentation, a slower labor, and what we call a “dysfunctional pattern.”   Anecdotally, Pitocin can help create a more “effective” contraction pattern in order to help dilate the cervix. This mother’s pelvis felt more than adequate to birth her 6 pound baby. The FHR was fine and my exams showed small but definite progress in the 2 hours that I was her labor nurse.  I thought if only I could give her a little bit of Pitocin.  Unfortunately, the MD disagreed and instead opted for a primary c/section. I later discovered the MD was going out of town in the morning and I believe based on previous dealings with this MD that under a different travel schedule he would have managed this patient differently. (He gives Pitocin to EVERYBODY!!)

Mother #2:
This mother was also progressing at what would be considered a slow pace.  She also had an epidural and her water bag was broken.  She received Pitocin but the initial nurse increased the Pitocin minimally and the mother remained 6cm dilated. At shift change the new nurse was told the MD was considering a c/section. She immediately began to increase the Pitocin (SAFELY) keeping a watchful eye on her contraction pattern and baby’s heart rate.  In less than 2 hours, she was completely dilated and birthing her baby vaginally.

Pitocin may have worked for mother #1 and definitely worked for mother #2.  However, while Pitocin is not always poison, sharing this information was not meant to give you the impression that Pitocin is always the missing ingredient or that Pitocin will be the answer to your delivery question. What I do want you to know is when used appropriately and at the right time, Pitocin can be the difference between a vaginal birth and a cesarean section.  Can Pitocin change your outcome?? YES Will Pitocin always be the answer? NO… it won’t be. Ask questions. Know your options and get informed BEFORE you go to the hospital in labor. By the time you sign your admission consents, it may be too late.

In Birth and Love
Nicole ~ On Twitter @SistaMidwife

Skip this Routine…

REPOST: From June 2009 Your Birth Right Blog…

It never ceases to amaze me the information that women are given and the procedures they undergo prenatally and during labor all in the name of “routine.” One of those things that always annoy me is the frequency of unnecessary vaginal exams/cervical checks.

While I personally don’t do frequent/multiple vaginal exams on a woman in labor, I do understand why some nurses, doctors, and midwives feel the need to do them. I don’t agree with their rationale but I understand it because I used to be a “frequent checker.”  What I have NEVER understood is the routine checking of a woman’s cervix prenatally when she has yet to have ONE contraction or any sign of labor.  Many providers do routine cervical exams on every pregnant patient  starting as early as 37 weeks.  Some wait until the 38th week and by the 39th week women are walking around wondering “Why haven’t I dilated past 1cm. I’ve been 1cm for 2 weeks now?”   These are often women who have had a FEW contractions that they might call “crampy” or “slightly uncomfortable” and otherwise have no signs of any sort of labor.  This sets up a cycle of fear of the inability of her body to have her baby. It is so important for a woman to have unwavering faith in her body and her baby.  The moment this faith is shaken, the cascade of fear can take over.

Let’s take for example the following…  The other day I received an email from a pregnant woman I have been doing some private consulting with.  When she emailed, she was 39 weeks pregnant.  She said…

“From my last week’s weekly OB appt {which means she was 38 weeks at the appointment}, my cervix is/ was still posterior and the station was high (-3).  I’m hoping to be somewhat dilated soon and am trying to get my cervix to be anterior. I’ve been swimming, walking, climbing stairs sideways and doing the head down with butt in the air wiggle wiggle exercise. Do you have any recommendations on how I can get my cervix to be anterior? I am going to have an unmedicated vaginal birth, so any advice you can give me will be totally appreciated.”

I took a deep breath before responding and then I said to her ….

“First I want to answer your question and I hope this does not sound too blunt…. you CAN’T get your cervix to be anterior.  When your body is in active labor it will naturally move anterior.

Now I have a question for you… Why did you have a cervical check last week?  Was it because you wanted one or because they said you needed one? The reason for my question is this…

Remember when we spoke, we talked about the importance of continuing to have full faith in your body and removing any outside forces that undermine your faith.  Well… unnecessary vaginal exams when you are not in labor and before your due date is one of the early/many ways that women begin to lose faith. When your body is ready to go into labor you will dilate and your cervix will move anterior. If it is not ready it won’t. If you are not in labor and contracting regularly with strong contractions you should not expect cervical change.  The question I always ask is this…. ‘Will the information gained from THIS vaginal exam change what we are going to do today?’ In your present situation, unless you are considering being induced a vaginal exam is irrelevant. What do I mean irrelevant…it does not change what we are going to do TODAY and things can literally change overnight.   Because of this, I encourage you to avoid all vaginal exams until you think you are in labor and are having a labor check or you are preparing for an induction.  I encourage you to let go of your current cervical change expectations and focus on getting your mind ready for labor and motherhood.  You can go from closed to delivered overnight.  It will happen. Don’t start to doubt and don’t start to worry.  Your body and your baby know the perfect time to move to birth. “

She responded, thankful for my reminder that her body knows best. She also let me know this…

“As for checking the cervix, I had no idea…the dr. just did the examination and said it was routine, so I didn’t question her until the whole posterior/anterior subject came along…”

Yep….  You read it right and it happens all the time … “I had no idea … the dr. just did the examination and said it was routine…” When did it become routine to violate a woman’s body without her permission? Why is it routine to check the cervix of a woman who has not passed her due date and has no signs of labor? Why do we continue to make women feel inadequate and incapable of having their babies? ROUTINE does not mean REQUIRED.  ROUTINE does not mean RIGHT.  Routine is a regular habit one that is done habitually. It does NOT mean something that has to be done.

Don’t let the Routine get in the way of RIGHT.  Your baby and your body know when the time right. Have faith.

In Birth and Love
Nicole