MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

The Mini-Midwife

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During my bouts of pre-labor contractions with number 3, one of my favorite positions was to kneel in front of the couch and lean forward so my upper body rested on the seat cushions.

One such time, Felicity, my 16-month-old daughter, decided to investigate. She came up behind me and started rubbing my lower back. Then she patted my butt, lifted up the skirt of my dress, and peered underneath.

“Baby?”

I think she may grow up to be a midwife.

Felicity

The Miso Tablet

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Not too long ago at a birthday party I talked to a mom of a brand-new little baby boy. Her fourth baby. She was telling me about her birth; that she was five days past her due date and the doctor decided she “had to” induce. So, this sweet lady went in and was given a magical little “miso pill,” as she called it. “It’s a tiny little white pill they stick next to your cervix to start labor. My baby was born at noon. They had to do that to get my third baby out too.”

I stood there talking to her, trying to act normal and fervently hoping my look of horror didn’t show. That little “miso” pill, as she called it, is none other than Misoprostol, the generic name for Cytotec, a drug used off-label that has caused the damage and death of myriads of laboring women and their babies. Of course, I wasn’t horrified at the mom. There is no way she could know that the doctor she trusted was essentially performing an experiment on her to start labor. I was shocked that the doctor (who also happened to be my childhood doctor, which made it even more disturbing) would knowingly put this mother at risk without giving her any information on the drug she administered.

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Miso was first used as an induction drug in the mid-1990s. FDA approved as an ulcer drug, this pill has never been tested or approved for use on pregnant women. In fact, in 2000, the manufacturing company sent out a letter to all obgyns and midwives, warning against the use of miso because it causes uterine rupture (the uterus detaches and breaks open) and can harm or kill both mother and baby. And yet, eleven years and many deaths and lawsuits later, doctors still use it.

Essentially, the pill is dangerous because it’s unstoppable. With other induction drugs, like Pitocin, Prepidil, or Cervidil, the source of the drugs can be removed or slowed if a woman’s uterus shows signs of hyperstimulation or the baby goes into distress. Those drugs aren’t foolproof, but they don’t have as many cases of infant or maternal mortality due to uterine rupture as does misoprostol. A “miso” tablet, once absorbed into the body, cannot be stopped. It is an all or nothing deal. Therefore, even if the contractions strain the uterus to the point of rupture, there is no way to reverse or slow down those contractions.

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Talking to that mother got me thinking… if you know something about a drug a woman is given for childbirth, what do you say? Should you just stay silent, even though you know it causes death, disability, or infertility? Is it even ethical to stay silent? Do you tell her that the drug is that dangerous? Do you tell her to research it, knowing that she probably won’t? What on earth do you do in a situation like that?

In my mind, it would be different if the information was well known and in the news, such as the dangers of smoking cigarettes or binge drinking or a mainly fast food diet. Then I wouldn’t say anything because I know she made a conscious, informed choice. But medical interventions or prescriptions are an entirely different ballgame. We tend to trust our doctors and what they give us, believing that they have done the research and will give us the most beneficial treatment. This is not always the case. Most women don’t even know the potential side effects of labor drugs until it is too late and they’ve experienced the damage.

Women like the one from the party are the reason I started this site. Every woman deserves the right to make an informed choice about what is done to her body, especially during one of the most normal and natural processes she experiences: bringing forth life.

Induction: a step by step guide

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This post has been inspired by conversations I’ve had with women about their experiences of induction. Induction of labour is increasingly common, yet women often seem to be very mis-informed about what it involves, or what was done to them during induction and why. For example, one woman was told by her obstetrician that induction involved him using a pessary to ‘gently nudge her into labour.’ Women need to be given adequate information in order to make birth choices. Practitioners need to give adequate information in order to meet legal requirements. I have written about the risks of induction in a previous post so will not repeat myself here. Instead, this post aims to provide some basic information about the process of induction – what is done and why. I would really appreciate input from readers about their experiences of induction – what was done, how it felt etc. I am hoping this post will be a resource for women who are considering induction, or are unsure about what happened during their induction.

Induction is…

In my old 1997 version of the ‘Midwives’ Dictionary‘ induction is ‘causing [labour] to occur’ ie. someone causes a labour to occur rather than allowing the baby/body to initiate labour. The dictionary goes on to say ‘this may be carried out when the life or health of the mother or fetus is in danger if the pregnancy continues.’ Of course this statement is open to interpretation and many inductions are not ‘medically indicated’ (link). However, I am not entering this debate here… I’m trying to stick to the process.

There are a few things you need to be clear about before choosing to be induced:

  • That the risks involved continuing the pregnancy are greater than the risks involved in induction (risk is a very personal concept – see a quick word about risk).
  • You are committed to getting this baby out. Once you start you cannot back out, and a c-section is recommended for a ‘failed induction’.
  • You are not having a physiological birth. You have intervened and this intervention creates risks that require further monitoring and intervention. There is no ‘natural’ induced birth – vaginal birth maybe, empowering perhaps, but not physiological.

There are 3 steps to the induction process. You may skip some of the steps along the way, but you should be prepared to buy into the whole package when you embark on induction.

Note: If your waters have broken naturally the term ‘augmentation‘ rather than induction is used to describe getting labour started. This is because it is assumed that your body has started the labour process itself. You can read more about this situation here.

Step 1: Preparing the Cervix

During pregnancy the cervix is closed, firm and tucked into the back of your vagina. This means that you can have contractions without the cervix opening. In order for the cervix to respond to contractions it needs to make a number of complex physiological changes (Coad 2011). Relaxin and oestrogen initiate these structural changes, and prostaglandin, leucocytes, macrophages, hyaluronic acid and glycoaminoglycans are all involved in softening the cervix ready for labour. You don’t need to remember all of this scientific stuff (I never can). All you need to know is that it is a complex process, and prostaglandins are only one piece of the puzzle.

When you are being induced your cervix will be assessed by vaginal examination. If your cervix has already changed and is soft and open enough to get an amnihook in you can skip straight to step 2.  If your cervix is still firm and closed, attempts will be made to change it so that step 2 is possible. This is usually done by putting artificial prostaglandins (prostin E2 or cervidil) on the cervix in the form of a gel, pessary or sticky tape.  Artificial prostaglandins can cause hyperstimulation of the uterus resulting in fetal distress, therefore your baby’s heart rate will be monitored by a CTG after the prostaglandin is administered. You may also experience ‘prostin pains’ which are sharp strong pains sometimes accompanied by contractions. If there are concerns about giving you prostaglandin (eg. previous c-section) your obstetrician may suggest ways of trying to get your own cervix to release natural prostaglandin by ‘irritating it’ (this is the theory behind membrane sweeps). This is done by inserting a catheter into the cervix and filling it with water ie. you basically have a water balloon sitting in your cervix – very irritating.

Successfully completing step 1 may take a few attempts with re-insertion of prostaglandins. This can take hours or days because you must wait hours before re-assessment and re-insertion. You may respond to the prostaglandin by going into labour therefore skipping the following steps. However, you are still having an induced labour and will usually be treated as ‘high risk’.

Step 2: Breaking the Waters

I realise that this step is not always part of US inductions but I  have never experienced this approach, so will stick to what I know… Once your cervix has softened and is open enough to get an amnihook in, your waters will be broken. This is allows induced contractions to be more effective; the baby’s head to press harder on the cervix; and may trigger contractions avoiding step 3. I was also taught that it reduces the risk of an amniotic embolism (amniotic fluid getting into the blood system) but there is no good research supporting this. There are risks associated with artificially breaking the waters. Once your waters have been broken you can wait a few hours to see if labour starts, or go straight to step 3.

Step 3: Making Contractions

You now have a cervix ready to respond to contractions and no amniotic water in the way – next you need contractions. In a natural physiological labour oxytocin is released from the brain and enters the blood stream – it has two main functions:

  1. It works on the uterus to regulate contractions
  2. It works in the brain to contribute to the altered state of consciousness associated with labour and promotes bonding feelings and behaviour

In an induced labour, artificial oxytocin (pitocin/syntocinon) is given via a cannula directly into the blood stream. It is unable to cross the blood brain barrier therefore only works on the uterus to regulate contractions. I have written about the risks associated with artificial oxytocin here along with references. Basically, it can be pretty nasty stuff which is why your baby will be monitored closely using a CTG. Women usually describe artificially stimulated contractions as being different and more painful than natural contractions. Having supported women during inductions I am also convinced there is more pain associated with induced contractions. Obstetricians will argue that the physiology of a contraction remains the same whether it is initiated by natural or artificial oxytocin – which is true (see this post for an explanation of how contractions work). However, during an induced labour contraction pattern and intensity increases quickly compared to most natural labours. Women are not able to slowly build up their natural endorphins and oxytocin to reduce their perception of pain. In addition the circumstances and environment that often surrounds induction (intervention, equipment, etc.) can result in anxiety, increasing the perception of pain.

Once your baby is born you will need to continue using artificial oxytocin to deliver the placenta. A physiological placental birth is not safe because you are not producing your own natural oxytocin at the level required. Basically medicine has taken over and must finish the job.

In Summary

Inducing labour involves making your body/baby do something it is not yet ready to do. Before agreeing to be induced, be prepared for the entire package ie. all the steps. You may be lucky enough to skip one step, but once you start the induction process you are committed to doing whatever it takes to get the baby out… because by agreeing to induce you are saying that you or your baby are in danger if the pregnancy continues. An induced labour is not a physiological labour and you and your baby will be treated as ‘high risk’ – because you are.

More information / Resources

Parent Information Sheet (QCMB)

Home Births On the Rise

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The Feminist Breeder with her home-born babe

It’s official: more women are planning home births attended by midwives — 20% more — according to the Centers for Disease Control and Prevention. “One mother chose home birth because it was cheaper than going to a hospital. Another gave birth at home because she has multiple sclerosis and feared unnecessary medical intervention. And some choose home births after cesarean sections with their first babies,” reports the Associated Press. Physician groups are still opposed, but individual obstetricians are speaking out: “Dr. Joel Evans, the rare board-certified OB-GYN who supports home birth, said the medical establishment has become ‘resistant to change, resistant to dialogue, resistant to flexibility.’”

Update: Check out The Week’s five theories for the trend, including, “Women are taking charge!”

 

Best for Babes Foundation Features PUSHED

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It's You Babe!

What’s not to love about Best for Babes, fearlessly naming and shaming the “booby traps” that keep moms from breastfeeding (rather than shaming women!). “Women are being pressured to breastfeed but set up to fail” says the group. Check out their site, featuring celeb “champions for moms” like Laila Ali, Jenna Elfman, and Kelly Rutherford, and a new Q&A with yours truly about the booby trap of early elective birth.