Induction, part 2: A change in mindset

I headed in to my 41-week appointment with Littles prepared to set an induction date. I wasn't prepared for how upset that would make me.

The appointment was with Dr. S. He and I had never really "clicked," and our relationship certainly didn't improve as my pregnancy progressed. By this point, I had the on-call schedule memorized and was actively hoping not to go into labor on the days he was on-call.

He did all the usual appointment stuff, as well as a cervix check to assess my "progress," and a non-stress test (NST) and biophysical profile (BPP) -- two common forms of monitoring for overdue women. Then, at the end, he announced that the baby needed to be born by 42 weeks, so I needed to get an induction date set. He also said that I had an "unfavorable cervix," so I would need to come in the night before (i.e. no later than 41 weeks 6 days) for cervical ripening prior to Pitocin.

I left the appointment in tears. Dr. S had not seemed real open to questions. For example, when I asked him whether I'd get Cervidil or Cytotec for cervical ripening, he stared at me in surprise for a moment before answering -- like he wasn't used to answering questions like that.

But I had lots more questions running through my head: Would I need continuous fetal monitoring? Would that mean I'd be stuck in bed? Since I had to come in the night before, would I get breakfast in the morning, or would I be expected to labor the entire time with no food at all? And perhaps the most important questions: Could I do this without an epidural, as I had planned all along? Did I have a decent chance of delivering vaginally, or would I likely end up with a c-section?

I pretty much cried for three days straight. My husband was upset at seeing me so upset. He encouraged me to call and schedule another appointment, with Dr. K, who would be the OB on call during my induction. (That was one benefit to being induced: I was able to choose to deliver with Dr. K, rather than Dr. S, or one of the other four doctors in the practice, none of whom I'd met before.)

They squeezed me into Dr. K's schedule on Friday morning, 41 weeks 3 days. Dr. K ran me through the same tests that Dr. S had done earlier in the week, but she seemed much more relaxed, and it made me more relaxed. Rather than rushing through the ultrasound for the BPP, as Dr. S had done, Dr. K took her time to explain what she was looking at and why it was important. Later, I asked her the Cervidil vs. Cytotec question again, and she took it completely in stride, spending a few minutes explaining what she planned to do and why. I was able to open up and get all my other questions answered to my satisfaction.

My induction date didn't change as a result of that appointment. My mindset, however, changed drastically: I felt 100% comfortable with what was happening. I still wasn't thrilled about it, but I had come to terms with it, and became determined to make the best of it.

I hope every woman facing induction can have a similarly productive conversation with her provider -- especially if she wants a pain med free birth. If you're one of those women, and you're wondering how to kick off that conversation, stay tuned for my next post...

Dating the pregnancy

"Dating" a pregnancy is the process of calculating the estimated date of delivery (EDD). Typically, the EDD is set at 40 weeks after the mother's last menstrual period (LMP). This assumes that all women have a standard 28-day cycle with ovulation on day 14.

In many cases, this assumption isn't valid, and then, the EDD should be determined by other means. Doctors like to use early ultrasounds to date pregnancies, since embryos grow at a very well-defined rate during the first few weeks of pregnancy.

In addition, women can "chart" their cycles and identify their personal ovulation date with a great degree of accuracy. I'm not going to get into a whole explanation of charting here, but if you're interested in learning more, I highly recommend the Fertility Friend site or the book Taking Charge of Your Fertility.

With Littles -- October 2007
My own cycles have always been on the long side, suggesting that I likely ovulate later than day 14. I explained this to the nurse at my first appointment after getting pregnant with Littles. I was not charting, but based on this and some other signs, I suspected that my actual EDD was about six days later than my EDD per LMP.

The nurse got me set up with an ultrasound, at what was 8 weeks 4 days per LMP, but 7 weeks 5 days per my suspicion. Littles measured 8 weeks 0 days -- so, closer to what I suspected based on my cycle history.

But Dr. K said that since Littles measured within a week of my EDD per LMP, she would not adjust my EDD. At the time, I thought this was great! Six fewer days of the miserable first trimester to put up with!

I came to regret it at the end of my pregnancy. My OBs would not let me go past 42 weeks gestation, because the risks to the baby increase past that point. Since my EDD had been set based on my LMP, this meant 42 weeks from my LMP.

I ended up having to be induced. Of course, if my suspected EDD was actually correct, I was really closer to 41 weeks at my induction date. We could have allowed Littles to keep baking for another six days before she got into the increased-risk territory.

As I've explained previously, I ended up having a very positive induction experience anyway. But I still felt a little deprived of the experience of spontaneous labor. I still believe that Littles would have come on her own had she had those extra days that she rightfully deserved.

With Noob -- June 2009
I started charting after my pregnancy with Littles, so when I got pregnant with Noob, I knew that I had ovulated nearly two full weeks later than "expected." This was another reason why I insisted on an early ultrasound (in addition to wanting some peace of mind after my previous miscarriage).

The ultrasound was at 8 weeks 2 days per LMP, but only 6 weeks 5 days per my chart. It came as no surprise to me that Noob measured 6 weeks 3 days. I didn't quibble over those two days, since I knew it gave him two more days to bake at the end!

As it turns out, he arrived two days "early" -- that is, precisely on his EDD per my chart. Of course, had we not accurately dated the pregnancy, he would have been considered 11 days "late." Many doctors would have induced him by that point... wrongly, because he was not at all overdue.

With Baby Q -- December 2011
I charted again, and so I know that I ovulated late again. But my midwife, C, does not routinely induce for being overdue. If I reach 42 weeks, as long as everything is fine with Q and me, we'll keep waiting. This is another reason why I didn't insist on an early ultrasound with this pregnancy: I'm less worried about accurately dating it, because I know there's no induction looming at the end.

(By the way, you might be curious as to why my OBs with Littles felt that it was too risky to continue past 42 weeks, but C is fine with it. I'll address that in another post, at some point.)

Also, unlike many doctors, C trusts my chart. When we went through the initial paperwork yesterday, she asked me not only what my LMP was (as all my previous providers have done), but also if I knew my ovulation date and my actual EDD -- both of which I do know, thanks to my chart. That's what we're using for dating purposes. Neither of my previous providers ever asked me about these two key pieces of data.

How I embarked on this journey: The long version

(The short version is here.)

My birth -- June 19something (Yeah right. Like I'd tell you the actual year :) When I asked my mom about my birth when I was growing up, she described it like this: She went into labor early in the morning, precisely two weeks after my due date. She labored by herself for a few hours and then woke up my dad to go to the hospital. She did not receive an epidural or other pain medication. I was born about twelve hours later, weighing in at 9 lbs 6 oz.

What I wrote above is pretty much how she said it. No long drawn-out horror stories of the aaaaaaaaaaaaaaaaaaaaagony of waiting two looooooooooooooooooooong weeks to go into labor, or of laboring without an epidural for the better part of a day, or of delivering a nine and a half pound baby.

So I grew up thinking that delivering 9+ pound babies two weeks late with no epidural was just "normal."

Littles' birth -- June 2007

Throughout my pregnancy with Littles, I saw an OB and planned to deliver out of a hospital, with minimal interventions, including no pain medication.

Again, I believed that delivering babies two weeks late was "normal," and so I was not at all surprised when I went overdue. As week 40 turned into week 41 and started approaching week 42, everyone seemed to assume that I must be miserable and just done being pregnant. I really wasn't. I was eager to meet Littles, but I also loved being pregnant.

Finally, my OB said that she needed to be out by 42 weeks. I went in to the hospital on Sunday night to get Cervidil, and then started Pitocin on Monday morning. Littles was born that night, weighing in at 9 lbs 7 oz. Aside from the Cervidil, Pitocin, and antibiotics due to being GBS positive, I had no other medications.

I wouldn't say it was an easy birth. Mostly, it was just long. I was so tired by the end that I was falling asleep between contractions. But it was an absolutely amazing experience and I loved it. The next day, my nurse asked me if I'd do it without pain medications again, and I didn't even hesitate with my reply: "Absolutely."

I consider Littles' birth to be a very positive hospital birth experience. I'm not at all anti-hospital. I've learned over the years that having an experience like that, or like my mom's, may not be as automatic as it really should be, when you're birthing in a hospital -- but that doesn't mean it's impossible.

Noob's birth -- January 2010

We moved out of state when Littles was about a year old, so delivering future babies with my same OB was not an option. In a way, I was relieved, because although I had had a really positive experience, there were also some things I wanted to change, and our move gave me the opportunity to do that.

In particular, I felt that most midwifes would be more in line with my views on birth than most OBs. I considered out-of-hospital birth early in my pregnancy, but my husband wasn't comfortable with it. Instead, I found two midwives who delivered out of a hospital considered to be one of the most natural-birth friendly ones in my area.

I loved my midwives, but as the birth approached, I found myself turning back to the idea of out-of-hospital birth. My hospital was great, but it's still a hospital, and there were some things I really wanted that simply didn't work well with birthing in a hospital, such as allowing Littles (then age 2) to be an integral part of the birth.

I finally decided that my husband and I needed to meet with a homebirth midwife, "C." We did that just before New Years. I was 35 weeks pregnant. I fully expected my husband to walk away from that meeting saying, "I'm sorry, I'm still not comfortable with this idea." And then, I was fine sticking with our original plan of the hospital-based midwives.

To my complete and utter surprise, C was able to address most of his concerns. We decided to make the switch. Noob was born almost exactly four weeks later, two days before his due date, at home, weighing in at 8 lbs 11 oz. His birth was quick, easy, comfortable, peaceful. Incredible.

Hospital vs. home
When I switched to homebirth, obviously I knew that it would be very different from hospital birth. Still, I was surprised by some of the more subtle differences that came out, even in just the four weeks that I was under C's care. I quickly learned that homebirth is not just like hospital birth except you stay at home at the end. It is a completely different approach to pregnancy, birth, and the immediate postpartum period.

Take Group B Strep (GBS), for example. GBS is a bacteria that colonizes the vaginal tract in approximately 25% of women at any given point in time. It's harmless to the woman, but if she gives birth while colonized by GBS, her baby is at a higher risk of becoming infected with GBS. GBS infection in a newborn can be very serious, even fatal.

When I was pregnant with Littles, my OB followed standard American protocol for minimizing the risk of GBS-infected newborns: I was tested for GBS at 36 weeks. When I tested positive, I received IV antibiotics during labor, cutting Littles' risk of GBS infection. Of course, antibiotics carry risks as well, such as possible allergic reactions and an increased risk of acquiring other bacterial infections (since antibiotics kill off not only "bad" bacteria like GBS but also the "good" bacteria that naturally keep "bad" bacteria at bay).

With Noob, I switched away from my hospital-based midwives right at 36 weeks, but it appeared that they follow the same protocol: Test at 36 weeks, IV antibiotics during labor for women who test positive.

My homebirth midwife takes a different approach. She is not licensed to give IV antibiotics to GBS+ moms during labor. Some might point to that as an example of how homebirth is less safe than hospital birth... but that's not the full story.

Rather than simply treating GBS colonization when it's detected, my midwife tries to prevent it in the first place. She recommends taking probiotics and certain vitamins that have an antibacterial effect, starting a few weeks before the test. (With Noob, I was lucky that my doula had proactively passed along a similar GBS-fighting regimen to me when I was still under the care of the hospital-based midwives. So I had been following it even prior to my switch to homebirth.)

I ended up testing negative. So the lack of IV antibiotics was a non-issue, and I didn't have to worry about any negative side-effects of the antibiotics, either.

The difference between preventing and treating GBS is not something that I can quickly explain to the average person who looks at me in horror saying, "Giving birth at home? Are you insane? That's so unsafe!" But they're the kinds of things I want to document in this blog.