Valerie Gommon Midwife’s Blog

Archive for the ‘Induction’ Category

There is an excellent article in The Guardian discussing the pros and cons of going overdue http://www.guardian.co.uk/lifeandstyle/2010/oct/01/pregnant-for-10-months

Although many women are very “fed up” by the end of pregnancy it is worth thinking about the risks and benefits of accepting a hospital induction.  It is also worth noting that different doctors and different hospitals set wide ranging dates for induction so there is clearly room for discussion with your midwife or doctor about if and when you should be induced.

Remember no one can force you to be induced!

The most important thing to remember is that you should monitor your baby’s movements – although the movements will change towards the end of the pregnancy as the baby runs out of room s/he should still move in his/her usual pattern.  Another important thing to monitor is that your bump continues to grow and is not getting smaller.  If you are at all concerned speak to your midwife or local maternity unit.

The first thing I should say is that Induction of labour is not an easy option and should, in my opinion, be avoided if at all possible.

There are many debates about when women should be induced – the NICE (National Institute of Health and Clinical Excellence) suggest that women should be OFFERED induction at between 41 and 42 weeks of pregnancy www.nice.org.uk/nicemedia/pdf/CG70quickrefguide.pdf

Of course there may be medical reasons for an induction, and these should carefully be discussed with your midwife and doctor, however there are also risks associated with induction, for example you are more likely to have a longer, more painful labour after an induction and you are more likely to need some help for example a ventouse or forceps delivery or a caesarean section.

If it is agreed that an induction is preferable, I would urge you to try “alternative” methods or induction before resorting to a surgical induction https://midwifevalerie.wordpress.com/2008/12/09/alternatives-t…ital-induction/

Although methods of induction vary slightly from area to area, the principles of a “surgical” induction will involve you going into the hospital where you will first be checked over (blood pressure, urinalysis, abdominal palpation), your baby’s heartbeat will then be monitored for a period of time to ensure that the baby is well and that it is safe to proceed with an induction.

You will then be assessed internally to ascertain the best and safest method to induce you.  If it is your first baby and you are not yet in labour it is likely that the doctor will prescribe a drug called “Prostin” which is inserted into your vagina to soften your cervix with the aim of starting labour.  (Prostin is an artificial preparation of the hormone prostaglandin which is naturally present and involved in the labour process.)

Your baby may well be monitored for a period after the insertion of prostin – we want to ensure that s/he suffers no adverse reaction to the drug, – the monitoring is performed by placing two elastic belts around your abdomen to hold a “transducer” (a plastic probe) onto your tummy to obtain a print-out of the baby’s heart pattern (this is just a glorified version of the sonicaid that the midwife uses antenatally to listen to your baby).

Once the midwife is reassured she will be happy for you to get up and perhaps go for a walk or go to the hospital restaurant – it is a good idea to eat as you will need lots of energy when you are in labour!  Some hospitals will also allow you to go home and wait for labour.

Prostin does not always work first time, indeed often women need two, three or sometimes more doses and these are usually repeated at 6 hourly intervals.

An alternative to prostin is to break your waters – this can only be done if your cervix has already started to open – this is more likely if this is not your first baby, or if you have had prostin which has started the process but not put you into labour.

Breaking the waters is not particularly painful, although it can be very uncomfortable.   The midwife or doctor will need to do an internal examination and will attempt to “pop” the bag of waters that your baby is inside.  We use a plastic hook and literally try to burst the balloon of water!

Very often after the waters have broken labour will naturally start within a couple of hours, so again we wait … you can go off for another walk (are you getting a sense of the timescale here … an induction can go on for several days, so don’t expect things to happen in a hurry!).

If at this point the woman still is not in labour we usually suggest giving her a drip with a drug called synotocinon which usually starts uterine contractions.  These contractions are frequently more painful than a natural labour and because we are giving a drug we will also need to continuously monitor the baby’s heartbeat meaning that you are somewhat constrained in your movements (you can still stand by the bed or sit in a chair though).

In a few cases despite all our best efforts none of this will work and we proceed to a caesarean section.

Despite my doom and gloom, many women who are induced successfully labour and go on to have a normal birth, but to give yourself the best chance of a normal birth think carefully about whether an induction is right for you.  The decision as to whether you are induced or not should be made by YOU, in consultation with your doctor and midwife, remember it is your body and your baby, you have the right not to be induced.  A normal pregnancy is defined as between 37 and 42 weeks – so you are not even overdue until you get passed 42 weeks!

More information can be found in “Induction – do I really need it?” available from www.aims.org.uk or as always I am very happy to speak to you info@3shiresmidwife.co.uk

What is the definition of Natural Childbirth?  A hospital might say that a woman whose labour was induced and who had an epidural was a normal birth; others might say that induction, augmentation, analgesia, episiotomies etc do not constitute a normal birth!

A more radical definition of a natural birth might be a labour that starts spontaneously between 37 and 42 weeks gestation, and progresses to a vaginal birth without any intervention or pharmacological drugs.

Natural childbirth has been given a bad press – women choosing natural childbirth have been described as “hippy types” and indeed there has been an item in the press this week about a midwife who suggested that women would do better to avoid epidurals that has caused considerable outrage!

Pregnancy and childbirth are normal life events, not medical condition; a woman’s body is perfectly designed to give birth.

Of course some pregnancies and labours will need medical help – but the vast majority of women will go through their pregnancy and birth without problems and this process works best when interference is kept to a minimum.

For example anything we do to interfere with this natural processes has consequences – if mother and baby are well I am suggesting that we (the medical profession) should not interfere!

One example of this is the huge number of women whose labours are induced – why?  In some areas women are induced at 41 weeks (interestingly in France a normal pregnancy is defined as 41 weeks!).

Induction is not an easy option.  It is usually quite a lengthy process which makes the mother tired.  It is also usually more painful and the mother is therefore more likely to need pain relief, possibly an epidural … the mother is then less mobile … making it harder for the baby to find a way through the pelvis and consequently she is more likely to need the help of a ventouse or forceps, or even a caesarean section.

We all know that although caesareans are very safe in this country, it is still far safer for both mother and baby if the baby is born vaginally.  A caesarean section is major abdominal surgery which will take weeks and months to fully recover from – and the mother will have a demanding baby to care for too!  Babies born by caesarean also have many more problems, and are far more likely to need to receive Special Care.  There are also implications for future pregnancies – so, although fantastic if needed, caesarean sections are far from ideal.  The World Health Organisation recommends a 5 – 10% caesarean section rate, but our rate is approaching 30%, and I believe 90% at The Portland private maternity hospital!

This interference in birth has been called a “cascade of intervention”, because we do a) we have to do b) and because we do c) d) is also necessary this is also described as “iatrogenic” or hospital induced.  Whatever we do has consequences, for example a woman with an epidural will need more careful monitoring, she will need an IV drip and also a catheter – so you can see this spiral effect, because we do this, we have to do that and so on …

I believe there are several factors that lead to this escalation of intervention in childbirth:

Our cultural conditioning, fear, poor health habits and medical intervention in normal birth (perhaps because of fear of litigation) that make birth difficult often requiring more intervention, including surgery.

With good preparation, much intervention can be avoided – women who have a midwife they know and trust are less likely to need analgesia.  With good preparation they should be in optimal health for the birth – complementary therapies they may have experienced acupuncture, homoepathy, osteopathy or any number of helpful treatments during their pregnancy which will help align their body and prepare them for birth.  They may also have practised relaxation or hypnosis techniques all of which can be hugely beneficial.  There is also much a woman can do to help herself: mobilization, relaxation, support, the use of water …

The satisfaction that a woman feels when she has successfully given birth is amazing – it is empowering and is a fantastic start to the parenting journey, and of course breastfeeding is so much easier when you haven’t got a caesarean section wound on your abdomen.

If things didn’t work out this way for you, remember that you did the very best you could at the time.  Some labours do need help and some mothers and babies wouldn’t survive without the help of our medical colleagues.  If this has raised questions or distress for you I am more than happy to speak to you please do feel free to email me info@3shiresmidwife.co.uk

A difficult or traumatic birth experience has long-lasting implications for both the mother and sometimes her child.  We don’t have many babies in our lifetime and it is important to get things as right as we possibly can!

Despite Government policy to increase the number of births taking place at home or birthing centres, figures produced by the Office for National Statistics (ONS) show that the number of births taking place at home fell from one in three in 1955, to just one in 40 by 2006.  This is partly because the shortage of midwives often means that women are not offered a home birth, or have it cancelled at the last minute and are forced to go into hospital.  Only this week I have heard that homebirths have been cancelled in some areas.

Since 2006 there has been an increase in home births however, despite the rise, only 2.5 per cent of births in 2006 were at home, compared with 30 per cent in the Netherlands.

As a midwife I know that not all women and offered the option of home birth, and there certainly is a shortage of antenatal appointment time to facilitate adequate discussion to enable couples to make an informed choice about where to have their baby.  Indeed in recent years the NICE Antenatal Care Guidelines have recommended a reduction in the number of antenatal visits for low risk women. http://www.nice.org.uk/nicemedia/pdf/CG62FullGuidelineCorrectedJune2008.pdf

With the many benefits to being at home:

* Shorter labours

* Increased likelihood of normal birth

* Less likelihood of needing forceps/ventouse/caesarean

* Less need for pain relief

* More likely to breastfeed

* More likely to be happy with experience

* Less likely to experience postnatal depression

it is hard to understand why more babies are not being born at home.

A common concern from my clients is “what if something goes wrong” – my answer is that things rarely go wrong in a hurry during a labour – midwives are trained to monitor the progress of labour and if things are not progressing normally then it is perfectly possible to calmly transfer to hospital, no drama.  There is no evidence that it is safer for women with low risk pregnancies to give birth in hospital.

Women giving birth at home are more likely to have one-to-one care from a midwife they know and who has contributed to their antenatal care.  This can help labour develop normally, reducing the risk of “failure to progress”, fetal distress and the associated medical interventions.

I often find that during the course of a pregnancy the couple gradually learn more and recognise the benefits of remaining at home.  Another thing I often say is that they can decide where to give birth in labour.  They can start out at home, if things progress well and they feel comfortable they can decide to stay at home, but if at any time they feel they would prefer to transfer to hospital then that is fine.  I believe the best place to give birth is where the mother feels safest and most relaxed and for many women that is at home, after all hospital is not a relaxing, intimate place.

I would encourage you to learn all you can about birth, ask your midwife, attend good birth preparation classes, have a look at www.homebirth.org.uk and consider having your baby at home.  If your local hospital says that homebirths are cancelled, as difficult as it is I would urge you to tell them that you are having a planned home birth and ask them to send you a midwife.  Unless women (and midwives) get political nothing will improve.

I confess that I’ve been quiet – I’ve actually been away!  As I have no babies currently due (in my Independent Midwifery Practice www.3shiresmidwife.co.uk) we took advantage and went up to the wilds of Cumbria for a week and had a great time staying at Dent railway station www.dentstation.co.uk – my husband is a train spotter!  So lots of walking, snow, eating and drinking for a week – fantastic.

Whilst away I saw a couple of interesting items in The Daily Telegraph.  One article discussed that scientists have found that young women are sensitive to babies physical appearance whereas post-menopausal women and men were less able to distinguish between babies.  The researchers believe that the difference could be a hormonal one and plan further research in relation to postnatal depression. www.telegraph.co.uk/scienceandtechnology/science/sciencenews/4306406/Women-can-distinguish-cute-babies.html

In the same newspaper there is an item discussing that early terminations of pregnancy (up to 9 weeks gestation) are to be provided in some GP surgeries www.telegraph.co.uk/health/healthnews/4306534/Abortions-in-GP-surgeries-to-be-extended..html

On a happier note, today I have been to a first birthday party – the baby was born at home a year ago.  Her mother had previously had a caesarean with her first baby but really wanted a natural birth second time around.  She laboured in a birthpool and had a relatively short and easy labour and birth second time around – wonderful!  It was lovely to visit and catch up with the family.

VBAC or vaginal birth after previous caesarean section has previously been controversial, but with better surgical procedures even doctors are keen that the majority of women attempt a vaginal birth next time as this is a safer option for both mother and baby.  Obviously it is important to review what happened during the last labour, and for some women a repeat caesarean may be the best option, but for many a vaginal birth will be possible.  Doctors and many midwives will recommend that a woman planning a VBAC give birth in hospital and that she be closely monitored, for example by having continuous external monitoring of the baby’s heart, and by having intravenous access in case of  uterine scar rupture which is a rare but very serious possibility.  Scar rupture rates are quoted at between 1:200 and 1:2000 depending upon which research you read, there is an excellent booklet discussing the subject “Birth after Caesarean” published by AIMS www.aims.org.uk/pubs3.htm However there are some who believe that by labouring at home, in a calm and relaxed environment, with no monitors or drips, will give the woman the best chance of giving birth normally.  Indeed some hospitals are now comfortable with “allowing” VBAC clients into the birthing pool for labour.  Most midwives and doctors agree that women attempting a VBAC should not have their labour “interfered” with; it can be dangerous to induce or augment a labour when a woman has a scar on her uterus.  If you are considering a VBAC I recommend that you discuss the matter carefully with your midwife or doctor and give yourself the very best chance of having a normal birth next time – many, many women are now achieving VBACs, and indeed I know of several women who achieved vaginal births after several previous caesareans so it is possible!

It is awful when you see your due date come and go and still there’s no sign of labour.  People phoning you up every day asking ‘have you had it yet?’  If you’ve passed your due date and looking for some ways to get labour going here’s some ways that you can try. Don’t worry as the tips won’t set off labour, unless your baby is ready to be born – but if you’ve had problems in your pregnancy such as bleeding, or the threat of premature labour then check with your midwife first. Before you try anything make sure that you recheck your dates. Get your midwife to look again at the date when your baby is due working from the last day of your period or from your scan. At the beginning of pregnancy the odd days difference here and there doesn’t seem very important but when you have a date to be induced it can make all the difference!

 

Remember these ideas are for LATE babies – a normal pregnancy is 37 – 42 weeks!

 

1. Nipple stimulation. The idea of this is that it can encourage your body to release the hormone oxytocin which can make your uterus contract and set off labour. The truth is you’d probably need several hours, several times a day but it’s worth a try! Some women tell me that they’ve used the shower attachment or a breast pump to stimulate their nipples – but go easy they’ve still got work to do after the baby’s born!

 

2. Fresh pineapple. I’m not aware of any research backing up this theory but lots of women swear that eating fresh pineapple gets them into labour.

 

3. Sex. Prostaglandin, contained in semen, is a natural source of the hormone used in hospital to induce women. After making love stay lying down for as long as you can which allows the semen to bathe the cervix, which can also help the cervix to soften and encourage labour to start.

 

4. Stretch and Sweep. Midwives are encouraged to offer women this procedure once they have gone over their due date. It involves an internal examination either at home or in the clinic, and the midwife gently inserts a gloved finger into the cervix, and sweeps it around between and the bag of membranes that holds your baby. It can be a little bit uncomfortable, but it many cases, can work.

 

5. Oral sex. There is some literature that suggests that the hormone prostaglandin in semen, works ten times more efficiently when absorbed through the stomach than through the vagina.

 

6. Reflexology. Consult a qualified reflexologist about this.  There is a pressure point on the foot that can stimulate contractions of the womb, giving nature a helping hand.

 

7. Walking. Going for a long walk can help to encourage the baby in the right direction and puts pressure onto the cervix which is all good stuff for getting labour going. Make sure that you’re with someone and obviously not miles out in the middle of nowhere – walking round the shopping centre is just as effective!

 

8. Curries. Now obviously there are cultural differences in our diets and if spicy food forms part of your staple diet then it’s not going to get you into labour. The idea is if you eat something that will result in a few extra trips to the loo, then this can irritate the uterus and kick start labour. Eating the contents of a fruit bowl, or a few slices of raw courgettes, can often have the same effect.

 

9. Orgasm. If sex doesn’t appeal to you or your partner, which isn’t uncommon towards the end of pregnancy, masturbation can induce labour. When aroused, your body releases the hormone oxytocin, which can cause your uterus to contract, leading to labour.

 

10. Primrose Oil. At 36 weeks of pregnancy take one capsule three times a day, and from week 37–40 one to two capsules per day. There are some suggestions that this can help to soften the cervix encouraging labour to start.

 

11. Acupuncture. Contact an acupuncturist as there are points similar to using reflexology.

 

12. Raspberry Leaf Tea. Can be taken after 36 weeks of pregnancy. The tea tastes awful, but it is more palatable in tablet form.

 

13. Avocado. Laxative effect.

 

14. Lobster. Apparently contains prostaglandin.

 

15. Castor oil and orange juice.  Ask your midwife.

 

16. Homoeopathy. Contact a practitioner for individual advice.

 

17. Clary sage and Jasmine essential oils. Both of these oils can act as a uterine stimulant, which is why they are usually listed as being contra-indicated during pregnancy.  Many women turn to essential oils for natural induction – you could try massaging them into your bump, putting them in a bath, or putting them on a hot towel on your bump.

 


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