Induction Truths

LABOUR INDUCTION:

THE TRUTH ABOUT THE TIME LIMIT

By Jen McKinnon

Previously published in Birth Issues, Summer 2011

Brittany Sarah Photography

Brittany Sarah Photography

Every day I talk with women who are in the process of creating life. I talk with women about their bodily changes and the emotions that may be enhanced and tender. Being pregnant is an incredible experience and one we only have a few times in our life, at best.

What I wish we could spread to every newly pregnant woman is that her body is the protector, the incubator and the only place divinely prepared for this purpose. All of this happens automatically, with very little conscious intervention from the mother. While pregnant women are sitting in a movie theater there is brain development happening. While they are driving through city traffic a human being is taking form. All of this is a stunning event that goes fairly unnoticed. All a woman has to do is to stay healthy in body and mind.

However, while most women go through pregnancy trusting that their bodies can grow a baby doubts start to pierce them once they are close to term. Is my baby okay? Can my body sustain this life? Should I try to start labour? They seem to stop trusting their bodies. Why is that?

It is most likely due to a combination of factors. At the end of a pregnancy many women are subject to innocent comments by other people such as “Oh you are so big?” or “Oh you haven’t given birth yet?” and “You are ready to pop!” The repetition of these comments may start making a woman feel uneasy about their pregnancy. They may also encounter the fears of their friends as well as of their caregivers when they hear, “You are measuring too little or too large” and “You know your baby could die if you continue this pregnancy.” On top of that women may have more difficulties with sleeping and being, which makes them more sensitive and emotionally vulnerable. They may also have some natural fears about the unknown of birthing, which would make anyone more tired and vulnerable to negativity and fears surrounding them. The accumulation of these experiences can discourage an otherwise stable and happy woman. She will start doubting her ability to protect and nurture her child.

Please take courage in what your body has been naturally doing for almost a year, have faith and don’t rush it. I believe there is no time limit on a pregnancy. There is no standard limit to the amount of time a child may need to prepare for the journey into this world. However, my belief does not represent what many medical professionals believe. They believe in due dates, that a baby must be born by 40 weeks gestation or 280 days.

As your due date gets closer there may be pressure not only from your friends but also your doctor or midwife to start labour and to use a number of methods to force the body to go into labour. This is called inducing labour. It will involve a number of decisions that will affect you and your baby. The best outcomes in your birth experience will come when you educate yourself about the pros and cons before the need arises.

Brittany Sarah Photography

Brittany Sarah Photography

Most doctors are insistent on starting or inducing labour before 42 weeks, with most doctors inducing women at 40 weeks. However, the World Health Organization (WHO) warns caregivers to refrain from routine inductions before 41 weeks. “In uncomplicated pregnancies, it is recommended to induce labour after 41 completed weeks of gestation. Available evidence does not support the policy of induction of labour before 41 weeks in uncomplicated pregnancies. Every possible precaution should be taken to obtain a reliable estimate of gestational age prior to induction of labour. Failure to do so can increase the risk of such adverse consequences as iatrogenic respiratory distress syndrome.”1

As you may have read about how menstrual cycles and the calculation of gestational age can affect your actual due date, you now know that your due date can be grossly inaccurate. Although a common method of calculating a due date is a dating ultrasound, the Society of Gynecologists and Obstetricians of Canada (SOGC) has said that ultrasounds can be inaccurate by 5 days for 1st trimester dating ultrasounds.2 If your labour is induced at 40 weeks and your due date is inaccurate you run the risk of harming your baby because it is difficult to know 100% if a due date is accurate, and because so many people forget that the due date is not the expiry date (42 weeks in Canada). So try to remember that your due date is less about the actual D-Day and more about the progress of your pregnancy.

There is a great need to ensure the last days and weeks of pregnancy are intact because the last weeks before birth are vital for growing infants. So much happens in these last moments. Every day inside the womb increases a baby’s chance to breathe on their own because the lungs are the last organs to mature. During this time babies are practicing the muscles to breathe while still safely inside their mother’s body. Practice really does make perfect because a baby able to breathe on its own is able to forgo the experience of a NICU stay and the use of a respirator. This is why the SOGC encourages caregivers to only start medical induction methods at 41 weeks, to minimize the risks of prematurity of the newborn.3

Because of the discrepancies between the practices of different doctors, take the time to ask your doctor or midwife what their standard practice is for pregnancies that go past 40 weeks. Their preferences may not correspond to evidence-based practice. Knowing this information will help you advocate for yourself. This is especially important when being approached with the prospect of an induction. According to the Public Health Agency of Canada, “Almost two-thirds (65.0%) of women who delivered by cesarean after attempting a vaginal delivery had medication or other techniques to start their labour.”4 You may feel a need to change caregivers if you feel they may cause you undo stress during a sensitive time in your pregnancy.

There are a number of other reasons why your caregivers may encourage you to accept an induction. Your caregiver may tell you that your baby is too small, too big, or not growing at the normal rate. You may be told that your placenta is getting old and may stop working. You may hear about “low umbilical cord arterial blood PH,” which may indicate that gas exchanges are not optimum (e.g. problems with baby’s oxygenation and getting rid of CO2). Your bag of water may have ruptured naturally and be told to augment labour because contractions haven’t started yet. You may have twins or a baby in breech presentation. You have diabetes and are told that you may have a macrosomic ‘big’ baby. You may have unusually high blood pressure or excessive water retention, which may endanger yourself and your baby.

Any diagnosis must be considered carefully. Make sure you have all the information and all the time you need to make an informed decision that you are comfortable with. Ultrasound technology (e.g. Biophysical profiles) is a complex technology and the interpretation of its results depends on the skill set of the ultrasound technician and caregivers. They rely on a sophisticated set of mathematical equations, software programs and medical knowledge when they come up with their interpretation of the ultrasound results. In any case ultrasounds are like weather forecasts—fraught with confusion but highly depended upon. Because they can be easily misinterpreted ultrasound technology is one diagnostic tool amongst many.

Encourage your caregiver to give you a number of reasons for his or her diagnosis. Checking the amniotic fluid volume, regular non-stress testing, and fetal kick/movement counts can offer a more accurate picture, which may give women extra time and allow them to go into labour naturally. For more information about best evidence on inductions and the associated risks go to the Childbirth Connection website pages on inductions. They have the latest 2011 research findings.6

If you want to be able to advocate for yourself and make an informed decision about the timing of the onset of labour, it is especially important to know what causes labour to start on its own.

First and foremost before going into labour your cervix needs to be favourable. It needs to be soft and stretchy, just like your mouth would be when it is relaxed. Usually the mucous plug has already dropped and the cervix has started to shorten. If it has started dilating and thinning then it is absolutely favourable for labour! Second, you need to have uterine contractions. These contractions push your baby down onto your cervix, dilating and thinning it further, and bring your baby through your pelvis and out.

If the cervix is not stretchy or soft and a woman has contractions her labour may be put into jeopardy. Contractions are useless if the cervix is not favourable because it will not dilate. Imagine your baby throwing himself into a door that never opens! This will exhaust your baby and perhaps cause distress and an emergency cesarean. Non-progressive contractions can also exhaust a woman, which may lead her to ask for pain medications and a number of interventions.

So how does the cervix-uterus-duo start dancing? For your cervix to soften and become stretchy you need hormones called prostaglandins. For contractions to occur a woman needs a certain amount of a hormone called oxytocin. A baby who is ready to be born sends a signal to his or her mother’s body, which creates a chain reaction—producing a steady flow of prostaglandin and oxytocin into the bloodstream—initiating early labour.

So inducing labour means that we, as well as caregivers, attempt to raise the levels of prostaglandins and oxytocin in the body so that we can go into labour before the baby is ready. Inducing labour has many faces and can happen in different ways. Here is a list of the most common forms of induction:

Movement: Walking, stairs, and the motions of daily life encourages baby to be in a good position. Gravity and motion can rock your baby into the birth canal, which initiates your body into labour. Don’t sit and wait, get moving!

Sex: Lovemaking is one of the ways you might be able to start things off without the use of drugs or of caregivers. What brought the baby in will be bring the baby out! Indeed during intercourse prostaglandins and oxytocin are naturally produced in the body. Some women are particularly sensitive to prostaglandins present in semen, which helps dilate their cervix. Nipple and clitoral stimulation, pleasure and orgasm augment the amount of oxytocin present in a woman’s body. So you and your partner can naturally produce a release of these hormones without a hospital visit. So spend some quality time together!

Acupuncture: A study done through the University of Vienna, Austria concluded that acupuncture done on healthy women at full term resulted in an earlier delivery date.7 There are many great acupuncturists in Alberta that are qualified and trained to naturally induce labour through this method.

Chiropractic: Your body goes into labour when your baby is in a good position within the pelvis and when your body is releasing the right hormones. Getting your pelvis adjusted can help you go into labour.

Stimulation of bowels, enema or castor oil: You can start your labour by stimulating your bowels to empty. This causes mild cramping of the uterus, which can put a woman into labour. However, do not attempt this if your cervix is not favourable. Remember the image of your baby pounding into a door that never opens! If you are considering using castor oil, make sure that you know that your cervix has started to change. It may take 4-6 hours before you notice any contractions. Make sure you do not become dehydrated. Drink lots as you may have diarrhea.

Membrane Sweeping or Stretch-and-sweep: This is done by a physician or midwife during a vaginal exam and ranges from slightly uncomfortable to very painful depending on the woman. By ‘sweeping’ their fingers inside the opening of the cervix the physician or midwife will attempt to separate the cervix from the membranes. This releases hormones that can sometimes start labour. The risks are infection, bleeding, accidental rupture of the membranes and of course the discomfort of the procedure.8

Herbal and homeopathic remedies, blue and black cohosh, evening primrose oil: They can help with starting uterine contractions. May cause nausea and high blood pressure. Again make sure you remember to only use these if your cervix is favourable. Consult with an herbalist, homeopath, naturopath, or your midwife about the dosages and how to obtain them.

Protaglandin gel, or Cervidil: This is the synthetic form of natural protaglandin. It is produced in a gel format and placed by your caregiver at the hospital on and around the cervix to ripen it. Fetal heart and uterine contractions may be monitored. Depending on how favourable your cervix is already, you may need several applications before it starts making the cervix stretchy. Usually you can expect one application every 12 hours. It may work overnight or take 3-5 days for any stretching to occur. You can go home in between each application of the gel.

Synthetic Oxytocin, or Pitocin or Syntocinon: This is the synthetic form of oxytocin. It is produced in a liquid format. This is used to artificially stimulate uterine contractions. However there are many risks associated to its use. “There is a higher risk of using pain medication such as epidurals when being administered Pitocin. Pitocin causes stronger and more erratic contractions. There is a higher chance of fetal distress because of the contractions pushing on baby. [It] is administered through an IV, which limits your mobility. Forcing the uterus to work so hard can lead to a tired uterus, which can be blamed for postpartum hemorrhaging and in rare cases even uterine rupture. Pitocin dramatically increases your likelihood of a cesarean section. All women, especially women who are choosing a VBAC should weigh the risks of medical induction very carefully.”9

Artificial Rupture of the Membranes or breaking the bag of water: A cervical hook is inserted into the opening of the cervix and used to puncture the membranes. The procedure does not hurt as there are no nerve endings in the membrane. Breaking the bag of water is usually initiated only if the cervix is favourable and has started to stretch. The risks are increased risk of prolapsed umbilical cord, higher risk of cesarean section, fetal distress and possibly infection.10 The chances of infection increase as time elapses and with each vaginal exam performed. Now that the bag of water is broken the sterile environment where you baby is living is broken too. This causes an increased risk of infection so caregivers will want you to give birth within 24 hours of this procedure.11 Because contractions may take hours before starting, keep in mind that you may need to advocate for yourself to reduce further management of your labour.

Be Calm: Your emotions and your state of mind have a giant impact on when you have your baby and how you feel about your labour experience. Stress makes you produce excessive amounts of adrenaline, which block oxytocin receptors – thus preventing you from going into labour. Let your fears and frustrations go. Go to the spa instead of watching baby birth dramas. Stay away from arguments or fights. Surround yourself with people that are positive and make you feel happy and confident. Stop working and pamper yourself. Be physically active but emotionally calm. Find ways to relax not only your body but your mind.

Now that you know what the different methods of starting labour are, you may have noticed that they are all associated with words of caution. They have side-effects and may lead to further interventions. Induced labours can be very powerful. Some women find that the pace of induced labours is too fast and they have a hard time relaxing and catching their breath. This can cause maternal exhaustion and may increase the need for pain medication and interventions. There is also an increased risk with fetal distress as contractions can become hypertonic (too powerful) and interrupt the blood flow to fetus, which would lead to a cesarean section.

Spontaneous labour contractions build slowly and gradually increase in intensity. This allows you to get used to the rhythm and to produce hormones that enable you to cope. Imagine it as a marathon run. An induced labour is more like a 100-metre race. You may be fine with the race, just make sure you know how to breathe and relax if you choose that route.

Remember that none of these methods guarantee a baby coming today. Many times the consequences far outweigh the chances of labour starting. All of these induction techniques may not be effective. Be prepared for the possibility of days of discomfort without labour starting and a cascading effect, which may lead to more interventions and perhaps a cesarean section.

There really is no sure way to predict the minute let alone the day that your baby will be born. Due dates are extremely arbitrary and notoriously inaccurate. Babies grow at different rates and are often absolutely healthy. Ultrasound technology is not an exact science and needs to be considered as only one component of a diagnosis. The only way to be sure that you are making the right choices is to know your body and to know your options. Weigh the need of making a decision right now against the consequences of each choice. More than anything trust yourself and your instincts. Your baby will let you know when it is time for him or her to be born. As obstetrician Michel Odent notes, “There are no natural methods of induction. If a method is effective, it means that it is not natural, because it has preceded the signals given by the baby. We understand today that the fetus participates in the initiation of labour by sending messages that mean: I am ready.”12

Jen McKinnon is married to Chuck and is the mother of four children. She homeschools her children in her Cochrane home where she can look at the mountains while her children learn about multiplication and the Amazon Rain Forest. She is now a doula where she can support and advocate for other women during childbirth.

Notes:
1. Cuervo LG. Induction of labour for improving birth outcomes for women at or beyond term: RHL practical aspects. The WHO Reproductive Health Library. Geneva, World Health Organization: 28 December 2006. See also http://apps.who.int/rhl/pregnancy_childbirth/complications/prolonged_pregnancy/lgcguide/en
2. Society of Obstetricians and Gynecologists, “SOGC Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks,” Journal of Obstetricians and Gynecologists of Canada 214 (2008): 802.
3. Society of Obstetricians and Gynecologists, “SOGC Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks,” Journal of Obstetricians and Gynecologists of Canada 214 (2008): 807.
4. Public health Agency of Canada, What Mothers Say: The Canadian Maternity Health Survey (Ottawa: 2009), p. 14.
5. It common to not have any contractions immediately after your membranes (bag of water) break spontaneously. Know that it can take between 2 – 24 hours for contractions to start. Doctor will usually put some pressure on you if your contractions have not started within 12 hours. Main reason used is that there is an increased risk of infections.
6. Childbirth Connection. http://www.childbirthconnection.org/article.asp?ck=10654 (accessed April 8th, 2011)
7. Rabl M, Ahner R, Bitschnau M, Zeisler H, Husslein P. “Acupuncture for cervical ripening and induction of labor at term–a randomized controlled trial.” Wiener Klinische Wochenschrift 113, no. 23-24 (2001): 942-946.
8. Association of Canadian Obstetricians and Gynecologists, ACOG Technical Bulletin, 1996.
9. Sarah Buckley, Gentle Birth, Gentle Mothering (Toronto, Celestial Arts: 2008), p. 73, 110-114.
10. Samuel Parry, and Jerome F. Strauss III, “Premature Rupture of the Fetal Membranes, Mechanisms of Disease,” New England Journal of Medicine 338, no. 10 (1998): 665.
11. Seneviratne HR, de Silva GD, de Silva MV, and Rudra T. “Obstetric performance, perinatal outcome and risk of infection to the newborn in spontaneous and artificial rupture of membranes during labour,” Ceylon Medical Journal 43, no. 1 (1998): 11-15.
12. Ways of the Wise Woman. Interview with Dr. Michel Odent. www.waysofthewisewoman.com/dr-michel-odent-notes-obgyn-studies.html (accessed April 11th, 2011).