Not Just Another Induction Post

You might remember me posting on my Banned From Baby Showers Facebook page about a mom who had been declared "high risk" due to "maternal age."  She is 35 years old.  Her OB had also told her that her amniotic fluids levels were low.  At about 37 or 38 weeks, she recommended induction.  My student declined induction and I'd just like to take a moment to relay to you what the "Treatment Declination" form said:

Our records indicate that you have declined medical induction.

The medical induction was indicated for the following reasons:
1.  Maternal age
2.  High risk pregnancy

You have also been informed of the risk of declining said treatment/procedure, including fetal death, worsening maternal condition, irreversible neurologic (brain) fetal damage resulting in cerebral palsy, mental retardation, developmental delay and motor skills delay.  You are also aware increased cesarean section risks and increased risk of poor fetal or maternal outcome.

By signing below you have indicated that you completely understand the risk of delaying or declining the above procedure and willingly have decided to do so.

From the beginning of classes, I had told her she had some other (great) options in the Ft. Worth area.  Thanks to several of your comments on the Facebook page, she realized that she likely was not really high risk, and decided to go ahead and switch care providers.  It was  39.3 weeks when she transferred to the UNT Midwives.  Her charts had lots of doomsday stuff in it and the midwives recommended that she visit with their perinatologist. He commended her for declining the induction and told her there was absolutely nothing wrong with her, her baby, or her pregnancy!   She had a fabulous unmedicated birth 4 days later!

I've had some overseas births (France and Switzerland) in the last couple of months who were really pushed into using pitocin too.  One of them ended up not having it, but the other one did.  The nurses were very aggressive in wanting to keep upping the dosage and the mom was barely on top of things as it was.  She was dilating very quickly, but for some reason, the nurse wanted her baby to just fall out, I guess.  It made for a very difficult labor for her.  Afterwards, she hemorrhaged and battled dizziness for hours.  The very quick labor really took a toll on her.  Had they not pushed pitocin on her the way they did, she could have enjoyed her labor instead of gripping the rails, so to speak.

In 8 1/2 years of teaching, I've never had a baby die until recently.  The mom was pressured into induction (those declination forms are really scaring) and had a uterine rupture due to "misuse of pitocin."  The OB was extremely negligent and went in with a vacuum to try to get the baby out.  The mom was only 9 centimeters.  After 3 hours from the beginning of the rupture, they went to a code-red emergency c-section.  The baby was flown to an out-of-state hospital where he received "head cooling" for the brain damage and hematoma from the vacuum attempts.  The baby had such severe brain damage, after many tests, the parents were told the baby would not survive.  He lived 18 days.  They buried their sweet baby on November 1.  To make matters worse, this mom had to go back in for surgery because they left 4 centimeters of placenta and membrane inside the uterus.  She is understandably completely devastated.  I sincerely hope she knows this is not her fault.  This is the fault of her OB who pressured her into the induction and then went about it negligently.  My heart goes out to her and her family.  I am so very sorry they are living this tragedy. 

As an Educator, I have gone through many emotions this weekend as I learned what happened to this couple and their baby.  Women are being scared into induction -- being told it is the safe thing to do.  Declining the induction is the unsafe route.  Are these parents being told about the risks of the induction themselves?  Never!

Did you know that a woman who is VBACing has the same risk of rupture as a woman who is being induced with pitocin, having never had a c-section?  The women who are asking for VBACs are being told it's too dangerous -- they might rupture and kill their babies.  But we NEVER hear of women being told about the risk of rupture when they are induced with pitocin.  Never.  Both carry a risk of less than 1%.  Did you notice in the Treatment Declination form that it said that by declining induction, you were risking a cesarean section?  I love that.  When a woman is induced, she is twice as likely to have a cesarean than if she starts labor on her own.  
Shame on these doctors for leading women to believe that induction is harmless.  As birth advocates, we must stand up and be loud about the risks of induction!  Risks to moms and risks to babies.  These babies deserve their time to grow inside the uterus and not be forced out.  They will let us know when they are ready to be born. 

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MY List of Things You Can Do to Avoid a C-Section

I've seen a couple of lists lately about the top 5 things a woman can do to avoid a c-section. While I think these lists are good, they differ from my personal list. I thought I'd take the time to write out my list. I guess I'll keep it to a top 5 as well, so as to not overwhelm anyone.

Education for both husband and wife: Some women are able to advocate for themselves in labor, but most are not. Preparation on the front-end is huge. Dad needs to know what is going on and how he can help. He needs to know what's normal and what's not. He needs to know the questions to ask. Having a doula will help with a lot of this. The doula cannot speak for mom, but dad can. I love The Bradley Method for this reason. Both individuals take responsibility for their role in the birth.

Careful Choosing of a Care Provider: Also huge. All the education and preparation in the world won't matter a bit if you have chosen a care provider and/or hospital who is determined that you need to be rescued from your pregnancy, labor and/or birth. This is the step where, if you ignore the red flags popping up during the education/preparation phase, it will bite you in the end. If you are getting information and statistics about your doctor or hospital that make you second-guess their philosophies, don't ignore them. It's never too late to switch care providers. I've had people change in the middle of labor! Typically, care providers like to see you for the last month of your pregnancy. I changed care providers at 33 weeks with my third pregnancy. A bit nerve-racking, but worth it for a great outcome. You will only give birth to this baby one time. Don't take on the "maybe for the next baby" attitude. Do it this time! Do it for this baby! If you don't know where to start, ask your out-of-hospital educator or doula for referrals.

Keep Moving - Don't Lay Down and Take It: Remaining in a hospital bed is one of the worst things you can do. They can/will strap a monitor on you and "watch" you from the nurses station. Health care at its finest! Laying around for your labor leaves it all up to your baby to make its way out. Baby needs movement. He is moving around, changing position, trying to find the easiest, most comfortable way out. If mom is moving -- walking, sitting on birth ball, pelvic rocking, rotating hips, even standing -- she's using gravity and movement of the pelvis to help her baby descend and get into a good position. Mom will have less vaginal exams (which often lead to Failure to Progress diagnosis), less time on a monitor (which often leads to a false-positive signaling fetal distress), and usually a more comfortable and faster labor. What's good for mom is usually what's best for baby.

Drug-Free Birth: I'm not just talking epidurals here. I'm talking inductions as well. Pitocin is a drug. Prostaglandins (cervical ripeners) are drugs. Baby may react "fine" to induction drugs, and he may not. There's no way to know how your baby will react. So trust in your body to start labor on its own. Don't be induced. Stadol, Nubain, Demerol -- they are all drugs that go to the baby. There will be physical results to the baby when they are born if they received these drugs -- more sleepiness, "laziness" at the breast, depressed breathing. If mom had educated and prepared herself during the pregnancy, she probably skipped this step. It's a tough thing to hear a mom's birth story and realize that her c-section was a direct result of her own actions -- induction, pain-relieving drugs, trusting her doctor, and not educating themselves on the normal process and what to do and what not to do. A woman is 50% more likely to have a c-section if she is induced, and four times as likely to have a c-section if she has an epidural. These are numbers that we simply cannot ignore.

Remain Low-Risk: If you do not take care of yourself and become high-risk, you give up a lot of power. You need to physically prepare your body to give birth by regularly doing pregnancy exercises. You need to eat the required nutrition to grow a healthy baby. A well-balanced diet with plenty of protein will benefit both mom and baby. The old saying "eating for two" does not mean eating for two adults! Be wise and mindful in your life choices. Practice relaxation every day. This will help with all aspects of your life, even after the baby comes. Keep stress out of your life as much as possible. Choose pre-natal tests wisely. There are so many that are done these days. Find out why it's being done and what they expect to do with the results. You can opt NOT to do them. Some may unnecessarily put you in the high-risk category if you test positive.

Of course, I must mention that every now and then I do have couples that do everything right and still have a c-section. I recently had one of these and it broke my heart. This mom worked so hard. I truly do not know what she could have done differently. You can't feel bad about a c-section that comes out of a situation like that. I feel sad for her. She really wanted a natural, unmedicated birth, and was so prepared. ICAN will be an important part of her healing.

My c-section rate of people who take my class is 14%. Some of those were necessary and some were not. Most that were not necessary can be traced back to one of these steps. One other way that can often help prevent a c-section is not rushing off to the hospital the minute your water breaks or you realize you are in labor. The longer you are there, the more excited everyone is to intervene.

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Do Epidurals Affect the Baby?

In class last week, I had a couple express surprise when I said that all drugs get to the baby, including epidurals. They have friends that are doctors that have said otherwise. I have spent the week looking up several articles and resources, and, my friends, epidurals indeed adversely affect the baby. I do not want to make this an overwhelming post, so I will touch on the highlights of how the babies are affected.

First, it is important to note that the "older" studies with very significant data were largely done by pediatricians. The newer studies, found to not be nearly as complex, have been done by anesthesiologists. Obviously, there is a conflict of interest there!

There are a couple of problems that researchers have run into with these studies. The first is that so many women that have epidurals also have other "pain relieving" drugs in their bodies that also influence and affect the babies. This makes it difficult to assess the effects of just the epidural. In addition, epidurals have different drugs in them. Different anesthesiologists and/or hospitals will often use different drugs in their epidurals.

So many of the effects on the baby have to do with the effects on the mother from the epidural. I am not focusing on the effects for the mother in this post, however, but some of these effects on the mother is what creates a problem for the baby from the epidural. For example, maternal fever is very common and can cause complications for the babies. So is a drop in maternal blood pressure. This is why a woman will receive IV fluids before the epidural is administered -- it is a preventative measure.

Effects of the Epidural on the Baby
Epidurals can change the Fetal Heart Rate (FHR), indicating that the baby is lacking blood and oxygen. This will often occur in the first 30 minutes after an epidural is placed. Opiate drugs, common in spinals and epidurals, are the likely culprit. These changes in FHR will often resolve themselves if the mom is allowed to move a bit or change position. If the baby's heart rate does not bounce back, the woman may have a cesarean section.

The supine position (lying on your back), also contributes to changes in fetal heart rate. A woman with an epidural is mostly in this position, which can deprive the baby of oxygen, affecting the baby's brain. In my case, this is why I nearly had a c-section. I had the epidural, pitocin, etc., etc., and my baby's heart rate would not come up after contractions. Moving from side to side after each contraction is what helped his heart rate. Had I remained on my back, his heart rate would not have come back up, and I would have had surgery. Had my sister-in-law, a doula, not been there, I would have had a c-section. The nurses or doctors certainly weren't telling me what to do. They would have been happy to perform surgery, I have no doubt.

Babies that are born to mothers who developed a fever from the epidural in labor are more likely to have a low Apgar score -- poor muscle tone, require resuscitation (11.5% versus 3%), or have seizures in the newborn period. One of the most common problems from the maternal fever is that the doctors do not know if the fever was from an infection involving the uterus or from the epidural. They will typically do a sepsis, or evaluation, of the baby. This involves prolonged separation from the mother, invasive tests, and almost always, antibiotics until the test results are available. In a study of first-time mothers, 34% of epidural babies were given a sepsis evaluation, but only 9.8% of nonepidural babies underwent the evaluation.

It is important to note that a newborn's ability to process and get rid of drugs is much less than an adult's. It must also be considered that the drugs are often stored in the newborn's tissues such as the brain and liver where they are more slowly released. Epidural babies are more likely to have jaundice. The reasons are not entirely clear on this, but it is suspected that it is related to an increase in assisted delivery (forceps or vacuum extraction) or to the increase use of pitocin with epidurals.

Neurobehavioral Effects
Epidural babies have been found to have a depressed NBAS (Neonatal Behavioral Assessment Score, devised by pediatricians) Score at five days old, with difficulty "controlling their state." Babies that received pitocin as well as the epidural had even more depressed NBAS scores, as well as higher rates of jaundice. At one month of age, epidural mothers found their babies "less adaptable, more intense, and more bothersome in their behavior."

Other differences between epidural babies and unmedicated babies include: less alertness and ability to orient themselves. The epidural mothers typically spent less time with their babies while in the hospital, finding the more drugs they received, the less time they were with their baby.

In another study, researchers found that at three days old, epidural babies cried more easily and more often and aspects of this continued for the entire six weeks of the study. In the conclusion of this particular study, researchers expressed concern about "the importance of first encounters with a disorganized baby in shaping maternal expectations and interactive styles."

Finally, the effects of an epidural on breastfeeding must be addressed. The first hour is a critical time to establish breastfeeding and if a baby has poor muscle tone or sucking reflex, or mom is hemorrhaging (more likely with an epidural), breastfeeding may be put off until well past that hour. As I write this, I have mixed feelings. It is crucial that mothers understand the effects of their actions in choosing an epidural, but if something happens and for whatever reason you cannot breastfeed immediately, do not give up since you missed out on that first hour. Babies and moms can figure this out! With that being said, I will continue on the effects of the epidural on breastfeeding.

Oxytocin is a breastfeeding hormone. If a mom has been induced with pitocin, administered an epidural, had an instrumental delivery, etc., this hormone was not allowed to be present in its natural form. There were just too many disruptions. This can adversely affect how well breastfeeding gets started. If mom is tired, baby is still feeling the effects of the drugs and not sucking well, the nurses, and even the pediatrician, may be pushing formula on this baby. And then starts the vicious cycle of nipple confusion. The baby doesn't have to work to get milk from the bottle, and when he is put to the breast, gets frustrated. Mom gets frustrated and resorts to those stupid formula samples she's been receiving on her doorstep for months!

Epidural mothers are less likely to breastfeed exclusively compared to nonepidural mothers. Epidural mothers are more likely to report having "not enough milk."

It is unfortunate that doctors are leading people to believe that the epidural is safe for moms and babies and there are no risks. There are risks, not just to our health, but to how we parent our babies. The more attached you are, the better you will appreciate your baby. You will trust your body to breastfeed and your baby will be eager to nurse.

I'd like to end with a quote by musician, Ani DiFranco, talking about her unmedicated birth: "I'm really happy in the end that I felt every last bit of the pain, and was as present as I could be. Whenever you go through something terrifying and come out the other side, you grow and have more self-respect in terms of your own strengths. I wanted that more than I wanted whatever sort of numbing the hospital would have offered."

What's good for mom is good for baby. Just say NO to the epidural! You are strong and powerful. You can do this, just like millions of women before you have done this. Giving birth is giving life. You and your baby deserve the very best start down this new road. Surround yourself with positive people who believe in you and your abilities.

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Benefits & Stimulants of Oxytocin

This month I had the opportunity to attend the International Childbirth Educators Association (ICEA) Conference in Oklahoma City. I actually had to take a test for another certification (I passed!). The conference ran for three days and there are lots of things I'd like to share with you here.

In honor of all the women that I have due right now and in the next few weeks, I decided the first thing I wanted to write about is oxytocin - its benefits and how to make it flow!

Let's review for a moment: We hear so much about pitocin, but rarely oxytocin. Pitocin is the synthetic form of oxytocin. Oxytocin is what causes the uterus to contract. Released are also endorphins that help mom to cope -- even feel good. In other words, when oxytocin is released naturally, it crosses a blood-brain barrier to release those endorphins. When labor is started artificially with pitocin, or "pit", the uterus contracts without all these extra benefits I'm about to share.

Benefits of Oxytocin that you may not be aware of:
Mom experiences lower blood pressure and fewer stress hormones.
Her pain threshold increases.
Her sleepiness, even laziness, increases, causing relaxation.
Her muscle tension will decrease.
She will feel more calm and even more curious.
She will become more trusting and possible more daring.
She is more open to touch and be touched.
Oxytocin facilitates learning.

Wow! Who knew! Oxytocin levels are at their highest in a woman right after she gives birth. If you have given birth without medication, think back to how you felt right afterwards.

And did you know that women being together will also produce high levels of oxytocin. In comes the doula. Why is it that women are more able to relax and have fewer interventions and medications with another woman by her side in labor? We often assume that it is because she is more sympathetic or has been through this experience before. While these are often true, it's more than that. Think of when you have a girls night out. Oxytocin is flowing! Men will often report that their wives are in the mood for sex they come home from a girls night out. Oxytocin is often called "the love hormone" and makes us feel good!

So how do we get it flowing? There are many different ways. I always talk about nipple stimulation and sex as the number one way. This weekend, another educator reported that some serious kissing can often get oxytocin flowing more than nipple stimulation. If you have read anything by Ina Mae Gaskin, she'll probably say the same thing. Following is a list of several contributing factors to the natural production of oxytocin:

Ways to get oxytocin stimulated:
Warmth
Sex
Stroking
Descent of the fetus
Good food
Doulas/Companions
Low light
Mediation
Visualization
Positive thought
Movement
Suckling
Pleasant smells

Adrenalin is the opposite of oxytocin. If a woman in labor, or one who is trying to start labor, is under too much stress (ie. the threat of induction!), the production of oxytocin is squelched. Too much stress can actually stop labor. We've heard of the "fight or flight" response. It applies to labor as well. You can sometimes tell if a woman is under too much stress by looking at her eyes. Her pupils will likely be dilated instead of her cervix. Her digestion will slow, while her heart rate and blood pressure will increase. When this occurs, not enough blood will get to her vital organs and muscles, including the uterus.

The mind is a powerful, powerful thing. I was talking with one of my moms-to-be this week who was due about a week-and-a-half ago. I found out she was still working because she feels great. Better than sitting around waiting for baby to get here, right?! Wrong! I told her, no matter how the baby comes out, she will be a mother by the weekend. Her brain knows, when she's still working, that she has someplace to be tomorrow. Her focus needs to be on getting oxytocin to flow.

Relax. Take some time for you. Gather your girlfriends for some plain ol' fun. Go see a movie. Take a warm bath. Close your eyes. Take some good deep breaths. Enjoy the end of your pregnancy. Burn a favorite candle. Get a pedicure or foot massage. Wrap yourself in a warm blanket and read a book. Nap. Make out with your hubby and have some great candlelit sex. Let the oxytocin flow. Don't fight it. I feel good just writing all this!

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9 Months of Preparing -- A Last Minute Change in Plans

I was joking in the last post about having another homebirth from this class, but low-and-behold, Rachel and Andrew decided in the middle of labor to have a homebirth. Let me back up a bit:

According to her LMP, Rachel's due date was Feb. 18. Her ultrasound said a week later. I always tell everyone, and you've heard it here before, to fight for the latest date possible because it literally buys you more time. The midwifery group she was to birth with at the hospital would not allow her to go more than 10 days. They wanted to induce her yesterday, a Friday, even though that was day 9, but more convenient for them. She refused, insisting that she was taking every day she had been told she had. Good thing she did...

She had been contracting all week long, thinking it was the "real thing", several times. I see this a lot, where the mom finds it hard to believe it when she is actually in real labor. They tend to become obsessed with not doing things that will possibly stop labor. And so it goes...

Their doula, Hannah, was nervous for them to be induced, so she went to their house Friday afternoon and worked with Rachel on several different positions to help bring the baby down into a more favorable position. She also applied several acupuncture and pressure points which really got things going, to the point that the contractions were consistent and not stopping. Really, if the nurses could/would do this at the hospital, there would be no "need" for pitocin!

About 5:00 in the afternoon, Rachel started mentioning the homebirth midwives and by 7:30, they were at their house. Her cervix was almost 100% effaced and she was dilated to a 4 or 5. They announced that a baby would likely be born that night, and they were correct! Eventually, there were 2 midwives, 3 apprentices, and their doula in their home. Rachel said that the more people that showed up, the more confident she felt. It is so important for a laboring woman to have other supportive women around her -- women who believe in her abilities to birth her baby.

Their baby girl was born in their bathroom at 11:47 p.m. Baby weighed 7 pounds, 10 ounces, and was 21 inches long. Baby did have to be resuscitated with oxygen and even CPR, but she is doing fine. According to Hannah, the midwives were incredibly calm and never appeared to not know what to do. The reason I include this in this story is simple: this would have happened no matter where their baby was born, including the hospital. But it would have been handled entirely different. The baby would have been rushed to the NICU, where she likely would be kept for many hours, maybe even days, for monitoring, meanwhile, racking up a huge bill. Breastfeeding and bonding would have been drastically affected. Rachel and Andrew knew the midwives knew what they were doing and had absolute confidence in them. In fact, when I talked to them this morning, this was a very minor part of their story. I got more of the details when I talked to Hannah, who found those moments a little more intense than the new parents. I thought that was interesting. Fear was not present at their birth. Baby has a strong suck and is breastfeeding well. Everyone is happy.

Rachel said this entire week she kept thinking, "As long as the baby is still inside me, I have choices." She is a true example of this statement I am always making. I am so proud of them for taking control of their birth experience and making it their own. She really listened to her body, not just in pregnancy, but in labor. She was not reckless in her decision making. She was educated and fought for the birth she wanted. In the end, she knew the hospital was not where she wanted to give birth. And she did something about it! This took a lot of courage -- hats off to Rachel and Andrew. You have set a wonderful example of being educated, prepared, and willing to do what it takes to have the birth you want.

There have now been 4 homebirths from this class -- unheard of! I like to think that I have instilled the safety of birth, and homebirth, in my couples. The fact that I have birthed with an epidural in my spine with a C-section-happy doctor, and then with a CNM in a hospital, followed by 2 homebirths, my experience with birth is vast. I believe home to be a better place to have a baby. I am truly happy these couples have all chosen homebirth -- even Nancy and Frank, who did not choose it, but it certainly chose them!

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What Would I Do?

I have been thinking about my last 2 posts about induction. I gave a lot of info, and I believe that everyone needs to make their own decision based on education and what is going on with her body.

I did not mention that seeing a chiropractor might really help get things aligned and ready for labor. Ideally, seeing a chiropractor is a good idea in the last trimester, but if you haven't done so, I would recommend it at this point.

But, it's still bothering me, I didn't really answer what I would do if I were in this situation. So, if it were me, and I had been doing the entire list of natural induction methods, and my induction date has arrived without a baby...

To be perfectly honest, if everything was fine with the baby, fluid levels, blood pressure, etc., and the only reason for induction is because my 10 days is up, I would seek out an out-of-hospital midwife (most likely a CPM or LM), and see if they would attend my birth, either at home or at a birthing center. They will give you a few more days of pregnancy, for sure! Most midwives like to be able to see their clients for at least a month, but a lot will still take you on. In fact, some midwives will discount the price since your prenatal care is finished. It doesn't hurt to ask. You will only give birth to this baby one time -- there are no second chances.

OK, but insurance is what keeps most women where they are, at the hospital. Depending on whether my cervix was softening, I would possibly need to make a choice between a prostaglandin gel or pitocin. If I chose to have a prostaglandin applied on or near the cervix, depending on the type used, I would ask for the smallest amount possible, and then use my own natural techniques with it, such as nipple stimulation or pressure points. Same thing, if I end up "choosing" pitocin, I would start out really mild, the smallest they would allow, and combine it with natural methods. I would really want my birth attendant to agree to stop the induction drugs if my body starts labor with the push.

I would not allow anyone to break my water. I would likely end up on pitocin if labor didn't start right away. I really don't like that time clock. They would be less likely to let go of the pitocin if my body started contractions because of the fear of the time. Labor does not like to be rushed. Adrenalin is the opposite hormone running through the body as oxytocin! It's hard to perform under pressure.

I have loads of stories that illustrate these different things I have talked about, but I am holding back! I will be addressing the dreaded "big baby" in the next post.

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But the Natural Methods of Induction Didn't Work...

I hope that no one ever has to refer to this post, but it's there just in case...

As I mentioned before, there are a number of ways of medically inducing labor. If I wrote about all of them, we'd be here all night, so I've chosen, what I believe to be the top three methods used to induce labor.

First of all, fight to get your full 42 weeks out of your care provider. I mentioned that in the last post, so I'm not going to dwell on that again.

If I were in the 41st week, I would do the following:
1) Sex and nipple stimulation 3 times a day.
2) Have my spouse, friend, mother, doula (if available for such) "massage" pressure points.
3) Strip the membranes.
4) Use a breast pump several times a day to release oxytocin to stimulate the uterus to contract. 5) Drink castor oil.
6) Argue that if the baby is doing fine, fluid levels are good, mom is doing well, what's the harm in continuing on with the pregnancy?

Some of those, as said before, I am NOT a fan of, but they beat the alternatives which we are about to discuss. If your doctor is suggesting a different form of induction than what I am going to talk about, feel free to leave a message and we'll talk about it.

Three most common forms of induction are:
1) Prostaglandins to ripen the cervix.
2) Pitocin through an IV drip.
3) Breaking the bag of waters.

If you have read my post about vaginal exams, you know how I feel about them and their "usefulness." Chances are, however, if you are approaching 42 weeks, you have probably had one. If the cervix is still thick, not softening or thinning, they will likely want to start you with a prostaglandin gel to try to soften the cervix. If they went straight to pitocin, with the cervix not "ripening," it would not be effective. The cervix is about 2-4 inches thick, so when they give you "effacement" numbers, in a percentage form, this is what it is referring to. For example, you may be told you are about 50% effaced and dilated to a 1. A lot of women only hear the number of centimeters they are dilated to and don't know what the effacement number really means. Effacement is huge! You cannot dilate with a thick, hard cervix. So, prostaglandins are often used to encourage the cervix to soften and thin out. Yes, this can cause contractions. There are many kinds of drugs used by doctors and some are more controversial than others. You might recognize some of the names: Cervidil, Cytotec, and Prepidil. These drugs are very powerful and can cause dangerously strong contractions for the mother and the baby. They are given in different forms, generally applied to or near the cervix and can be taken out or wiped away if need be. And remember, any time you have a drug in your system, you are required (necessarily so) to be on a fetal monitor because of the possible danger to the baby.

It's worth repeating -- your body produces prostaglandins and it is also found in semen. I'm thinking, no matter how uncomfortable sex might be at this point, it sure beats the alternative!

Pitocin: Where to start... Pitocin is the synthetic form of oxytocin. When oxytocin is released in a woman's body, it causes the uterus to contract. One of the most fascinating things about this is that when it happens naturally, the woman's body produces endorphins that cross the blood-brain barrier so she is able to deal with the intensity of the contractions. Often pitocin is given with prostaglandins or administered shortly thereafter. When pitocin is given, it is forcing the uterus to contract with no relief for mom provided by her body. So, relief usually comes in the form of an epidural. The uterus can function for a period with an epidural in place, but after a time, it gets sluggish, to the point where it has to be stimulated to keep contracting, which means more pitocin. It's a vicious cycle and often the baby is the one who suffers the most. His heart rate is all over the place, the doctor cries fetal distress, a c-section is performed, and isn't it wonderful, they saved the baby!

If you really have the threat of pitocin as an induction method, ask for the lowest dosage to see if it stimulates labor. If it seems to establish labor, they may stop the pitocin and let the mom labor on her own. This is the best case scenario, but if you don't speak up, they will not make this this option available to you. Just for the record, I've had several people over the years be induced with pitocin and not have an epidural. It can be done, so if this becomes your reality, don't resign yourself to the epidural. Yes, it will be hard, but try, for yourself, and especially for your baby.

Breaking water: I do not like this option at all, and yet, I recently heard that in labors that are planning to be unmedicated, this is the preferred method of induction, at least at one of the local hospitals in the DFW area. Here's the problem: the time clock. You now have to give birth within a certain time frame, usually 24 hours. If you don't, you are most likely looking at a c-section. Find out your hospital's policy. I've seen women be in active hard labor, but the 24 hour mark came and went and a c-section was performed. That is totally unforgivable! There is also loads of information out there that suggests that 72 hours is completely acceptable.

Breaking water may or may not start labor. I've had women in class whose water was broken for many hours (at home) before they started labor, let alone had their baby! There are some dos and don'ts when your water breaks, but it's not necessarily pertinent to this post. Here are some things to consider if you are contemplating this method of induction:
1) How often do they want to do vaginal exams? (The more you have, the more likely infection becomes with water broken.)
2) Can you walk around? Many hospitals do not want you to walk around if your water is broken because of the "risk" of a prolapsed cord. FYI -- the risk is .3%. The risk of not walking, using gravity, to help your baby out, is much greater, especially with that time clock going!
3) How long will they "let" you go before they want to start pitocin? Often, if you do not begin labor within a couple of hours of breaking water, they want to start pitocin. Find out! If this is the case, it would have been better to just have pitocin (that can be turned off) and not have a time clock added to the stress.

Ultimately, an induction can be stopped with the first 2 methods, but not with the 3rd. I recently had a student start labor by breaking water and her baby was born 6 hours later. But there was no way to know that going in. It's just a gamble and you don't know if you are going to win.

One more thing: You can always refuse. You do not have to consent to anything. If everything is fine with mom and baby and the only reason you are being forced to induce is because your "due date" has come and gone, it's obviously not about good medical care. It's now about a legal system, not a healthy baby. If there is a medical reason to induce, you need to decide which method is the best for you. Like I said earlier, there are other methods that I did not address here. If you'd like more info about a certain induction technique, let me know. I truly hope that no one who reads this ever has to make these decisions. It is a tough call.  I do feel obligated to mention that if you refuse consent and sign an AMA (Against Medical Advice), your insurance will potentially deny your claim.  Lovely, huh?

The mind is a powerful tool though. My friend, Alisa, has been 2 weeks "overdue" with all 4 of her babies. Some of that is likely her ovulation is different than the standard woman -- if you knew her you'd understand! -- but some of it is the letting go. Letting go of the pregnancy, tension, and apprehensions you might have about labor. Sometimes it's about relaxing, resting, nourishing your body, and being ready to welcome this little one into your arms.

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Natural Induction of Labor

As a general rule, I try not to post things that I talk about in class. Otherwise, why take my class, right? But repeatedly, the topic of induction gets brought up as a mom approaches or passes that magical 40 week mark. I have determined that when couples are in my class, they are thinking, "That won't happen to me. I'll be early." By the time they are due, often 2 months later, they need a refresher. This is worth repeating, as the induction rate is about 90%.

I know you are sick of hearing me say to trust your body to start labor on its own. But, TRUST YOUR BODY TO START LABOR ON ITS OWN. Now that that is out of the way, what if you really are trusting your body, but you have a threat of induction from your doctor or midwife? As I've said before, your baby has no idea that you have a calendar with his or her "due date" circled in red pen. That same date is also circled on your chart at your doctor or midwife's office. If you have been given a handful of dates, always go with the latest date to buy you more time. You might have to push for it, but it's worth it.

Make sure you are clear about the policy your doctor, midwife, or hospital have on induction. How long will they let you go? It used to be 2 weeks, standard. Lately, I've been hearing 10 days. It keeps getting shorter and shorter. Push for the 2 weeks. Evidence is on your side. Really, the time where there is an increase of stillborn births is closer to 43 weeks, so 42 has been considered safe for years. We have become dangerously comfortable with inductions though.

Near your 40 week mark, your provider will likely want to do a non-stress test to monitor if you are having contractions and to monitor the movement and heartbeat of the baby. There is a wide variance of how long they will require you to do this -- anywhere from 20 minutes to 2 hours. An ultrasound will also likely be done to check the size of the baby and fluid levels. Remember, ultrasound can be off by 2 pounds either way as far as the size of the baby goes. (That is another topic for another day, but we'll get to it.) Just know that in the vast majority of women, despite what the doctor would like you to believe, it is OK to have a big baby.

When all of these things have taken place at once, it is referred to as a biophysical profile. This may be done a few times before you actually start labor.

Ways to start labor include:

1) Nipple stimulation -- It releases oxytocin, which is the natural form of pitocin. Studies have shown it to be just as effective in causing the uterus to contract as pitocin, with the advantages being that it is free and natural. Your body, and baby, will tolerate these natural contractions significantly better than artificially induced contractions. If nipple stimulation does not bring on contractions, your body is not ready. It is foolish to think that an induction is a good idea at this point. Your doctor does not know more about when your body is ready to give birth than you do.

2) Sex. Not just regular sex, but orgasmic sex. Orgasm causes the uterus to contract. When combined with nipple stimulation, this is very effective. Extra bonus -- prostaglandins, which help soften the cervix, are found in semen. So the more sex, the softer the cervix becomes. This is how 2 of my babies were "induced."

3) Breast pump. You might try this if you have a good pump on hand, like a Medella. Try it every hour or so for about 10 minutes. You don't need to crank it up either. If it's going to work, it'll work at a lower, less intense suction.

4) Castor Oil. Ina Mae Gaskin is a fan of using castor oil, but I would have to be really desperate to go this route, like 41.6 weeks. I did this with our first baby and it was like having the flu in early labor. Throwing up and diarrhea is not how I pictured this exciting time. The idea is that it stimulates the bowels, which stimulates the uterus.

5) Stripping Membranes. Again, not a fan. It's not a part of the natural process, yet if I were in the 41st week, I would probably think about it. A lot of midwives like doing this and will often suggest it, in my opinion, too early. Sometimes it's even done during a vaginal exam without the knowledge or consent of the mother-to-be. She might find herself bleeding a couple hours later and panic. Sometimes it works, and sometimes it doesn't, just like with anything else.

6) Acupuncture or Reflexology. It's no secret that pregnant women have pressure points throughout their body that can stimulate and cause contractions. That's why, when getting a massage or pedicure, you need to see someone who is trained to recognize these points and work around them. Your doula will likely be familiar with these pressure points and can work with you.

7) Walking. Normally I wouldn't list this as one of the methods of starting labor, but I feel that if I don't mention it, someone will think that I just didn't know about it! I laugh when I see women at the mall, obviously very pregnant, out for a power walk, trying to start labor. Walking will not start labor. It will help to keep it going and there are many benefits to walking in early labor but it will not start it. Don't tire yourself out with this method unless you feel up to it.

I do not believe in the artificial induction of labor unless there is a true medical reason to do so. We have gotten so far away from normality when it comes to labor starting on its own. Nurses are shocked when my students show up in labor to the hospital to give birth. I should mention that I have had a couple of students who went past 42 weeks, approaching 43 weeks, who never started labor on their own. Legally, their doctors wouldn't let them continue with the pregnancy and induced labor. It wouldn't be fair if I didn't mention that it does occur once in a blue moon (Dr. Bradley had 2 women remain pregnant for a year before giving birth!), but it is definitely an exception, not the rule.

There are medical ways of starting labor, but I'm not even going there. A woman is twice as likely to have a C-section when she is induced. Think about that for a moment. Why would that be? Simply because her uterus was forced to contract when it wasn't ready. But it's almost always too late to turn around. The parents are expecting a baby out of the ordeal, no matter how he or she gets here. The mother's bag of waters is likely broken. The doctor is just in too deep at that point and has to just get the baby out. Fetal distress in an induced labor is caused from one of two things: either the baby couldn't handle the pitocin contractions or he or she couldn't handle the drugs the mother had to take in order to deal with the pitocin contractions.

Pitocin is evil. Sex, combined with nipple stimulation, is the best way to go. Which would you rather choose?! It's a no-brainer. It's like I always say -- The same thing that got you into this will be the same thing that gets you out.

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