Induction, part 3: Luck

I am a great believer in luck, and I find the harder I work, the more I have of it.
     -- Thomas Jefferson

I started to write this post about two months ago. I had collated a ton of information on questions to ask when you're headed into an induction. Then my computer crashed, and I lost all of it, and I haven't had the motivation to write it again.

Until a few weeks ago, when I got a text from my good friend "N." After months of preparing for a med-free childbirth, she was facing a medically-necessary induction, and was wondering if I had any tips? Gee, it would've been nice to be able to point her to that blog post...

As it turns out, N didn't need it: She made it through her induction epidural-free and birthed her baby girl vaginally. But with induction rates soaring, there are still a lot of women out there who do need this information.

I see a lot of commonalities between N's labor/birth and mine with Littles. We both got lucky, for sure. One of the things that really struck me about Littles' birth was how little control I had over the process. It was up to my body to do its thing, or not do its thing. Thankfully -- luckily -- it did.

But I don't think my successful induction, or N's, was due to pure luck. We both worked hard to be that lucky. There is nothing a woman can do to guarantee a successful induction, but there are certainly some things she can do to up her chances of it.

Namely, ensuring that she has answers to a couple of key questions.

Do I have the support that I'll need?
A successful induction starts long before the induction. In retrospect, three keys to my induction were in place many weeks before I found out I would be induced:

1. I educated myself -- and perhaps more importantly, my husband -- on birth and birth options via childbirth preparation classes.
2. I talked over my birth plan with my OB, and ensured that she was on the same page.
3. I hired a doula.

Many people say that these things aren't important, and for some labors, that's true: I probably could have gotten through my two-hour labor with Q without any of that in place. But inductions can be challenging -- Littles' certainly was! And so having that support in place can make a huge difference in the outcome.

In fact, if you have that kind of support lined up already, you could probably skip the rest of this post. You won't have to ask a whole lot of questions before/during your induction, because the people around you will automatically shepherd you in the right direction. Indeed, my friend N had great support as well: She birthed at the awesome hospital where I originally planned to have Noob, she took Bradley classes with her fabulous husband, she hired M (who attended my last two births) as her doula. So when she texted me to ask for advice heading into her induction, I gave her a few quick pointers, but trusted that I didn't need to say a whole lot. She already knew most of what I'm about to write, and I was confident that her husband or OB or doula or L&D nurse would help with the rest.

What are the risks of an induction?
Even the most necessary of inductions carries some risk. This goes back to my key #1 above: If you've taken a good childbirth prep class, you're probably well aware of these risks. If you haven't, ask your OB. If your OB tells you that there are no risks... do some research on your own. M (my doula) has a great blog post that will get you started.

Why am I being induced?
Hopefully, you don't even need to ask this question, because you and your provider are communicating well and you fully understand the reasons behind his/her recommending induction. But if you're unsure, well, you'll want to clarify whether you're being induced for urgent medical reasons or just because your provider is going on vacation.

Can we wait to induce for another day? Two days? Three days? Longer?
Every day your baby stays inside is another day for him/her to develop, and another day for your body to prepare for labor. (Or even go into labor on its own!) Even so, sometimes, babies reach the point where they are safer out than in and really need to be induced ASAP. But it's worth clarifying whether this is the case with your baby or if you could wait another couple of days (or weeks?) to induce.

What is my Bishop score?
Your Bishop score takes into account the dilation, effacement, consistency, and position of your cervix, along with your fetal station.

The higher your Bishop score, the higher your chance of a successful induction. Bishop scores of 9 or higher are associated with the greatest chance of induction succeeding.

Your Bishop score should be weighed against the answers to the previous two questions. If you have a low Bishop score but you're being induced for solid and urgent medical reasons, you should start with cervical ripening and hope for the best. But if you have a low Bishop score and you're considering an elective induction... well, you might want to give some serious thought as to whether that is the right course of action.

If I need cervical ripening, will you use Cytotec?
If you need to be induced despite a low Bishop score (5 or lower), your provider should recommend cervical ripening first, before starting Pitocin. There are a variety of methods for achieving cervical ripening, including a foley catheter, Cervidil (prostaglandin E2 gel), and Cytotec (misoprostol).

Cytotec is a favorite villain of the natural birth community, primarily for these three reasons:

1. Cytotec is not FDA-approved for labor induction. Induction is an "off-label" usage.
2. There have been reports of uterine rupture after using Cytotec to induce labor.
3. As a result of #1 and #2, Searle (the former manufacturer of Cytotec) sent a letter to doctors warning them not to use Cytotec to induce labor.

While all of these criticisms are true, they do not give the full story:

• Regarding Cytotec's "off-label" usage, doctors prescribe drugs off-label all the time. It is not necessarily dangerous or sinister. Case in point: I've mentioned previously that I took progesterone supplements (specifically Prometrium) during the first trimester with both Noob and Q. Prometrium is FDA-approved for hormone replacement therapy in menopausal women; pregnancy is listed as a contraindication. Yet it's commonly prescribed "off-label" for pregnant women with low progesterone, and I credit it with saving both Noob's and Q's lives.
• Regarding the reports of uterine rupture, they occurred primarily in women attempting VBAC (vaginal birth after cesarean). Certainly, Cytotec should never be used in women with a history of uterine surgery. But for women without such a history, the risk of uterine rupture with Cytotec is similar to what it is during a spontaneous labor.
• Regarding Searle's letter, it was primarily a "cover your ass" move, to absolve the company of any responsibility for adverse outcomes resulting from off-label use of the drug. Again, it does not mean that this off-label use is dangerous or sinister.
• Cytotec has been shown to be more effective than other methods of cervical ripening. Women induced with Cytotec are less likely to need other interventions, such as Pitocin or a c-section. See, for example, this study and this study.

All that said, when I was facing induction, I specifically talked to Dr. S and Dr. K about avoiding Cytotec. There are two things that I don't like about Cytotec:

1. It is a pill that you take either orally or vaginally. If it does cause uterine hyperstimulation, which is a known risk, you cannot remove it (like you can with Cervidil) or turn it off (like you can with Pitocin). You just have to wait for the dose to dissipate and hope your uterus doesn't rupture in the meantime.
2. A Cytotec pill contains 100 micrograms of misoprostol. The recommended dose is 25 micrograms. This means that the pill must be cut into quarters before administration to the patient. Since the medication may not be dispersed evenly across the pill, a quarter of a pill could contain 25 micrograms of misoprostol... or 0 micrograms... or 100 micrograms. You just don't know.

Bottom line, there are benefits and risks to Cytotec. Informed consent is key. Ask your provider if s/he plans to use Cytotec, and if s/he does, have a conversation about those benefits and risks so you can decide if Cytotec is right for you.

How do you see my induction unfolding, as far as which induction mechanisms at what time?
Most providers will have women who need cervical ripening (Cervidil, Cytotec, foley catheter, etc.) come in the night before the actual induction to get started with that. For example, my Monday induction started with Cervidil on Sunday night.

If your cervix is already ripe, your provider will likely have you come in on the morning of your induction to get started with Pitocin, amniotomy (breaking your bag of waters), etc.

You should talk over the "schedule" with your provider, as well as discuss which induction mechanisms s/he plans to use and why. For example, if your provider plans to induce you via amniotomy, you might want to talk about whether that will put you "on the clock" (many providers want women to deliver within a certain time frame after their bag of waters is broken, usually about 24 hours), when and why s/he might decide that you need Pitocin to move things along, the risk of infection, etc.

Will I be able to eat/drink freely during my induction?
I already wrote a whole post on eating and drinking during labor, but it is even more relevant to an induced labor because inductions can take a long time. And unlike a spontaneous labor, where you can labor at home (and therefore eat and drink freely) for much of your labor, an induced labor typically takes place entirely in the hospital. I've had friends who have had 2- and 3-day inductions where they were allowed nothing but ice chips. That seems borderline cruel to me!

As I pointed out in the other post, there is really no good reason for hospitals to restrict food during any labor, induced labors included. With Littles, my hospital brought me breakfast on the morning of my induction, after the Cervidil was removed but before starting Pitocin. If your hospital isn't as progressive, consider sneaking some snacks to keep your energy levels up.

What sort of fetal monitoring will I need?
Most hospitals require continuous electronic fetal monitoring (EFM) for women being induced. This is for good reason: One of the big risks of induction is that it can be too effective, causing uterine hyperstimulation, potentially leading to fetal distress, uterine rupture, etc. EFM can help detect this situation before it becomes an emergency.

Normally, EFM requires two large belts to be strapped to your abdomen (one to monitor the baby's heart rate, another to monitor your contractions) and hooked up to a machine:

Obviously, this greatly limits your freedom of movement... but you can still move around while on EFM. I certainly wasn't walking the hospital halls during my induction, but I was able to sit on the edge of the bed, sit on a birthing ball, sit in a chair, stand up, squat, etc. Good thing, because lying in bed was absolutely excruciating for me. If I hadn't been allowed to move into other positions, I don't think I would have lasted more than an hour or two without an epidural. And if I had gotten an epidural, then I wouldn't have been able to move into other positions. My body was already at a disadvantage, trying to birth a nine and a half pound baby who was not necessarily ready to come out, without the benefit of all the spontaneous-labor hormones that would have prepared my body to help her come out. Being stuck in bed would have put my body at even more of a disadvantage.

Despite all this, many doctors require women to stay in bed while on EFM. As far as I can tell, there is no good reason for this. The only problem that moving around caused me was that the belts would slip and lose Littles' heartbeat. This meant that a nurse had to come in every few minutes to readjust the belt and pick up her heartbeat again -- inconvenient for her, I'm sure, but, well, it was her job. My job was to get my baby out. We both did our jobs, and I absolutely believe that contributed to the positive end result.

So, if you'll be on EFM during your induction, don't let them stick you in bed! Talk to your OB about moving around within the limits of the EFM machine. Also, ask if your hospital has wireless telemetry units. These allow for fetal monitoring while giving you complete freedom of movement. You can even go in the tub with one on! But not all hospitals have them, and those that do sometimes don't have enough for every laboring woman -- so it's good to know ahead of time whether it's an option for you, and to express your interest in using one if possible.

I wanted to birth without pain medication. Now that I'm being induced, is this still possible?
This isn't a question for your provider, but for yourself. And the answer is an unequivocal YES. You have to believe that you can do it... because you can.

Back when I was pregnant with Littles, I heard very few stories of pain-med-free inductions. Even my doula admitted (after the fact) that I was her first client to make it through an induction without an epidural. Now I hear those types of stories all the time. Women are doing it. You can do it.

I've done everything "right." Does that mean I'm going to have a wonderful, easy vaginal birth?
Unfortunately, no :( It might not be any of those things. That's labor for ya. Jefferson said that the harder he worked, the luckier he was -- not that he was lucky all the time.

But for me, this goes back to my birth mindset. I had a sense of peace when I showed up at the hospital for my induction. Induction wasn't what I had hoped for, but I knew that it was the safest, most informed decision under the circumstances. I knew that I had asked all the right questions. I knew I had a great support team surrounding me. And so that sense of peace came from knowing that I was headed for the best possible outcome. Again, not necessarily the outcome I had hoped for (that is pure luck)... but the best possible outcome regardless.

It's my hope that every woman headed into an induction -- or into spontaneous labor, or into a scheduled c-section, for that matter -- has that sense of peace, and achieves her best possible outcome as well.

Induction

Littles was born via induction, due to being two weeks late.

Labor induction is the subject of much debate, for a variety of reasons. For one, it's on the rise: Approximately 1 in 4 labors in the USA now start via induction, and it appears that much of the increase is due to elective (rather than medically-indicated) inductions. "Early term" elective inductions (at 37 or 38 weeks gestation) are associated with a significantly higher rate of NICU stays and other complications, compared to inductions at 39 weeks or later. Pitocin, a drug used in many of those inductions, has the reputation of stimulating contractions that are far stronger than contractions experienced during a spontaneous labor, dramatically increasing the likelihood that the mother will need an epidural. And since by definition, induction is designed to make a body give birth before it's ready, it has the reputation of greatly increasing the risk of ending up with a c-section.

These reputations are so pervasive that I've heard women say things like, "I knew the Pitocin-induced contractions would be awful, so I refused to let them start Pitocin until I had my epidural." Or, "My OB is talking induction, but I'm thinking it would be better to just accept the inevitable, and have a scheduled c-section. Better than an emergency one after a failed induction."

Simply put, this wasn't my experience. I labored on Pitocin for nearly 12 hours with no epidural or other pain medications. I ended up delivering vaginally with no complications. Even now, having experienced two spontaneous labors, I still consider Littles' birth to be a wonderful experience -- very different from my other two births, to be sure, but amazing in its own way. I also didn't find Pitocin-induced contractions to be any different from the spontaneous contractions of Noob's and Q's births. The main challenge in Littles' birth was just that it took much longer -- roughly 11 hours of truly "active" labor, compared to about 4 hours with Noob and maybe 2 hours with Q. The individual contractions weren't any harder to deal with; there were just a lot more of them to deal with :)

Numerous studies back up my experience. For example, this study, this study, and this systemic review all found that inducing labor does not raise the risk of a c-section, and may actually result in lower c-section rates in certain populations, e.g. women at or beyond 41 weeks gestation. And in the seminal Dublin study on active management of labor, 25% of labors were induced (via amniotomy followed by oxytocin [Pitocin] if contractions didn't start on their own) and 55% of labors were augmented with oxytocin at some point, yet the c-section rate was only 5.2% and nearly half the women in the study did not receive any pain medication.

(As for the issues associated with "early term" elective inductions? Those are definitely real, and are the reason for a March of Dimes campaign against such inductions.)

Okay. Studies are great and all, but it really seems like most of the moms I know who went in for an induction walked out with a c-section. Especially the first-time moms. And when I hear their birth stories, I often find myself shaking my head at some of the unnecessary hoops they were forced to jump through. Like the women who were forced to stay in bed for the duration of their induction. Or who were only allowed ice chips for sustenance.

The natural-birth community loves to vilify Pitocin, but this gap between the studies and my reality makes me wonder whether the problem is not Pitocin per se, but how it's used, or abused, as the case may be. For example, in the aforementioned Dublin study, each laboring woman was assigned a personal nurse for support -- essentially a doula. The mere presence of a doula has been shown to lower epidural rates and c-section rates. Perhaps that helps account for some of the study's results despite the relatively high reliance on Pitocin.

If that's the case, it is good news, because it means that women can do something to improve their chances of a successful induction. In my next few posts, I'll talk about some of the things that I believe helped with making my own induction successful.

Eating and drinking during labor

As I've mentioned previously, I'm a former Ironman triathlete, and I draw a lot of parallels between my Ironman experience and my labor experiences.

Ironman is lengthy (I completed mine in just over 13 hours; participants have up to 17 hours to finish) and physically intense. This can lead to the dreaded "bonk," which is sudden and extreme fatigue that occurs after exercise depletes the body's glycogen stores. Obviously, fatigue is not a good thing in the middle of a long race, so Ironman participants and other endurance athletes eat/drink throughout the race to replenish those glycogen stores. Not a five-course meal or anything crazy like that, just light snacks (fruit, pretzels, energy gels, etc.) and plenty of liquids (water, electrolyte drinks e.g. Gatorade, etc.)

Labor also tends to be lengthy and physically intense, so it makes sense to me that laboring women should be fed and hydrated much like Ironman participants, with light snacks and plenty of liquids.

So why do many hospitals restrict laboring women to only clear liquids or, in some cases, only ice chips?

The roots of this restriction lie in a landmark 1946 paper by an OB named Curtis Lester Mendelson, entitled "The aspiration of stomach contents into the lungs during obstetric anesthesia." I can't find the full text online, but this recent paper has what appears to be a pretty decent summary:

Nitrous oxide and ether anaesthesia administered by face mask for operative delivery was complicated by aspiration in 66 women from 44 016 maternities (0.15%) between 1932 and 1945. The only two deaths were from airway obstruction by solid, undigested food in two of five women who aspirated [vomited and then inhaled] solid material. In those who aspirated liquid, a syndrome of dyspnoea, cyanosis and tachycardia was observed. Recovery after 24–36 h was universal—in an era that predated respiratory intensive therapy by decades.

Prevention of "Mendelson's syndrome" via NPO (from the Latin nil per os, or nothing by mouth) after midnight of the day of a planned surgery became a key component of anesthesiology. After all, if you have nothing in your stomach when you're anesthetized, you have nothing to aspirate, right?

Well, not exactly: Turns out that the emptying of solids and liquids from the stomach is not as straightforward as you might think. For example, multiple studies have shown that your stomach contents are smaller if you drink clear liquids 2-4 hours prior to a procedure, versus fasting for 4 hours. As a result, the American Society of Anesthesiologists no longer recommends NPO after midnight prior to surgical procedures. Instead, they recommend fasting from solids for 6 hours prior to the procedure, but continuing intake of clear liquids up to 2 hours prior.

Even if you didn't follow those fasting guidelines, read the quote above again: In Mendelson's original study, only 0.15% of women aspirated at all, and only two out of over forty four thousand women (0.004%) died as a result of aspiration. And this was 70-odd years ago, when (as noted in the quote) respiratory intensive therapy didn't exist, not to mention numerous advances in anesthesiology that we enjoy today. Today's risk is almost certainly lower.

Finally, this should be obvious, but laboring women are not surgery patients. (With the obvious exception of scheduled c-sections, which are rightly subjected to the same restrictions as any other planned surgical procedure.) Despite all the consternation about the USA's high c-section rate, the fact remains that 2 out of 3 pregnant women will deliver their babies vaginally. And approximately 95% of those who do deliver via c-section will do so under regional anesthesia (spinal or epidural), which carries a much lower risk of aspiration than general anesthesia, like that used in Mendelson's study.

In other words, the risk of a woman going into labor planning a vaginal delivery and ending up with a c-section under general anesthesia leading to death via aspiration are miniscule. (One study theorized that it might happen in approximately 7 in 10 million births.) The risk of that same woman having a fairly lengthy delivery and needing something besides ice chips to avoid the labor version of "bonking?" Much, much, much, much higher.

So why the continued insistence on restricting food and drink? Well, old habits die hard: Even for planned surgical procedures, many hospitals still do not adhere to the updated ASA guidelines. See, for example, this study, this study, this study...

Also, women in labor (regardless of pain medications used, or not used) often vomit, which can obviously be unpleasant with a full stomach. Still, this is purely a comfort issue, not a safety issue, so it hardly seems right to tell a woman who wants to eat that she can't. Some providers recommend not eating anything that you wouldn't want to vomit back up, which is excellent advice. But that determination should ultimately be left to the patient, not the hospital. It's also worth pointing out that studies (such as this one and this one) have shown that women who eat during labor are no more likely to vomit than women who don't.

Finally, to be fair, I should also point out that those studies don't show any significant benefit to eating/drinking during labor. In fact, the first one found that women who eat tend to have longer labors -- although presumably, they're more comfortable because they're not starving! There is no significant difference in intervention rates or adverse birth outcomes. Again, I think this backs up the idea that the laboring woman is best positioned to decide whether or not she wants to eat. Blanket hospital policies should be reserved for safety issues. This isn't one.

OK, I'll step off my soapbox now. Here are my own experiences with eating/drinking during labor.

With Littles
When I went over my birth plan with Dr. K, I specifically brought up eating/drinking during labor. She said she had no problem with it, but warned me that the nurses might not be as accommodating.

The topic came up again when I got scheduled for my induction. Inductions can take a long time and I wanted to make sure that I wouldn't starve during the process. Dr. K encouraged me to eat a good dinner before coming in to start Cervidil at night. She also told me that the hospital would bring me breakfast in the morning. I chose to skip the bacon and eggs, and just eat cereal.

Once active labor got underway, my nurse informed me that I couldn't eat or drink anymore. I knew I could either sneak some snacks (I had brought some from home) or get Dr. K to tell the nurse it was OK for me to eat, but I wasn't hungry by that point anyway, so I chose not to push it. Since I was allowed clear liquids, I drank a lot of cranberry juice to keep my energy levels up. It worked out fine.

With Noob
When I asked F about eating/drinking during labor, I got a similar response to what Dr. K had said: She had no issue with it, but the nurses might. I talked it over with M at one of our prenatal visits, and she confirmed that I'd have no problems sneaking in some light snacks, but: "You probably won't be able to eat Chick-fil-A while in transition." :) This became a running joke between us, but in all seriousness, it was one of the things that made me start leaning towards homebirth. Even a great hospital is still a hospital. You simply don't have the same freedoms that you do at home. And while I was pretty certain that I wouldn't want Chick-fil-A while in transition, it made me wonder what things I might actually want that wouldn't be possible in a hospital.

In contrast, C, like most homebirth midwives, actively encourages eating during labor. I had some fruit for breakfast on the morning of Noob's birth, and then when C arrived, she had me eat a light snack (apples and peanut butter). I also drank water freely throughout. As it turns out, my labor wasn't long enough to need anything else. And anyway, it was a Sunday, so Chick-fil-A was closed :)

With Q
I ate a normal dinner the night that I went into labor. Since active labor ended up spanning a time (roughly 10 PM to 1 AM) when I don't usually eat anyway, and since it went so quickly, I didn't end up eating anything while laboring, or even immediately afterwards. I ate a normal breakfast the next morning -- my husband's homemade breakfast tacos, yum! Much better than hospital food, or Chick-fil-A!

And in case you're curious: I've had some mild nausea with all of my labors (much more with Littles than with the other two), but no vomiting.

My birth mindset

If it hasn't come through already in my posts to date, I'm really passionate about birth. I think it's just the coolest experience ever! That said, I'm not planning on becoming the next Michelle Duggar, so my personal birth experiences will be limited. But I love talking birth with other women who are passionate about it -- or, even better, with women who are interested but maybe not so passionate, and helping them understand that birth doesn't have to be what they see on "A Baby Story" or "16 and Pregnant."

Obviously, I started this blog to talk about homebirth specifically, which I particularly love discussing because it's so different from the "Baby Story" view of birth and because so few people have any direct experience with it. But I also have a lot of thoughts on birth in general. Since you've wandered onto this blog, I assume you have some sort of interest in birth :) So forgive me if I jump up on my soapbox every now and then, and talk about stuff that isn't specific to homebirth -- or even related to homebirth at all.

Starting... now :)

One of the places I love to hang out is The Bump's Natural Birth board, because it's full of women who are passionate about birth! A few weeks ago, a woman asked about the "mindset" going in to a planned natural birth. How do you truly commit to avoiding an epidural -- because from what I've seen, most women who go in saying "I'll try to avoid an epidural but I'll see what happens" end up getting one -- without feeling like a failure if you end up really needing one?

A lot of people liked my response, so here it is, slightly modified to make some pieces more clear.

About a year before I got pregnant with Littles, I did an Ironman triathlon. It's probably the experience in my life most analogous to labor, in a variety of ways. The morning of the race, my dad told me something along these lines: "You've done the hard part. All the training and preparation. Today is the easy part. All you have to do today is get out of the way, and let your body do what you've trained it to do."

That was precisely my mindset going into labor. I lined everything up... I did the classes, I did the exercises, I talked over my preferences with my doctor, I hired a doula. I did all that because I needed to know going in that I had done everything possible to achieve the birth I wanted. I didn't want to look back and think, "If only I had sprung for a doula..." That preparation meant that on the day of the birth, all that was left to do was get out of the way and let my body do what I had trained it to do.

As for changing my mind, well, I didn't line up at the Ironman start line thinking, "I'll try to finish, but we'll see." After nine long, hard months of training, there was no doubt in my mind that I was going to finish. But -- this is hard to explain -- ultimately, finishing wasn't the important thing. It was the journey to get there. On the bike, I watched a guy 10 feet in front of me fail to make a left turn and go crashing over a ledge. He probably didn't finish, but he also didn't "fail." Just getting to that start line took more guts, more hard work, than most people are willing to give. He might not have gotten a finisher's medal around his neck at the end, but he still got the really important things. The improved fitness level. The discipline it takes to train for an event like that. The knowledge that his body was capable of doing way more than he ever thought possible. Those things come from the journey, not from the race at the end.

Again, this was my mindset going into labor. There was no doubt in my mind that I would do it. But if the unexpected happened, I'd know that ultimately, avoiding an epidural wasn't the important thing. It was the journey -- preparing, learning about birth, learning about my options, and setting myself up to make the safest, most informed decisions for myself and my baby. In some labors, the safest, most informed decision is an epidural, or a c-section, and that's not a "failure." In fact, it's anything but.

So. That's my mindset.