|June 4, 1999|
Volume 1, Issue 23
|Midwifery Today E-News|
“Induction of Labor”
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In This Week's Issue:
1) Quote of the Week
1) Quote of the Week:
""The ultimate measure of a person is not where they stand in moments of comfort and convenience, but where they stand in times of challenge and controversy."
- Dr. Martin Luther King Jr.
2) The Art of Midwifery
Spleen 6 is an accupressure point
used to stimulate contractions. It is located about four finger breadths above
the inner ankle on the shin bone.
- Sharon Glass, Midwifery Today Issue 24, Winter 1992
In preparation for labor, have the mother begin eating extra servings of complex carbohydrates daily. This will build up her glycogen reserves for the work ahead and enhance the probability of the spontaneous onset of labor.
- Anne Frye, Understanding Diagnostic Tests in the Childbearing Year
Understanding Diagnostic Tests in the Childbearing Year, 6th edition, by Anne Frye is available from Midwifery Today
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3) News Flashes
Routine cesarean section for breech presentation has been recommended over the last forty years. As a consequence, the rate of vaginal breech delivery has decreased sharply. In the United States, the rate of cesarean section for breech presentation rose from just 10 percent to nearly 80 percent in 15 years (1970-1985). On closer examination, however, it is clear that the association between breech presentation and perinatal mortality is due principally to the confounding variables of prematurity and congenital malformation. Traumatic injury and complications giving rise to birth asphyxia in a vaginal breech delivery are uncommon. The recommendations for routine cesarean section have therefore been made on the basis of imperfect data. The issue of vaginal delivery compared with abdominal delivery of the term breech pregnancy is currently being addressed in a a worldwide multicenter randomized controlled trial ("The Term Breech Trial").
- MIDIRS 9:1, March 1999
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4) Assessing Fetal Well Being
This may well be the midwife's most difficult job: walking the fine line of supporting a woman who is post dates within the political climate. In my community, there is no easy interaction with the medical community so I must use my hands and doppler, rather than a sonogram to ascertain the baby's well being. Beginning at 41 weeks, I feel for amniotic fluid amounts every three days. Postmature babies often have almost no fluid. Using the doppler, I listen for fetal heart tones for five to 15 minutes. My apprentice writes down the numbers while I do 5-second counts aloud. A flat baseline can be a sign the baby is not doing well, so I look for some variety in the 5-second counts. After wiggling the baby's head suprapubically, I watch for a rise. If there isn't much variability, the baby may be sleeping, so I wait awhile, then listen and wiggle again. A reactive pattern shows an elevation of 15 beats per one-minute count lasting 15-30 seconds. There should be two or more occurrences in 10 minutes. If there isn't appropriate reactivity, the mom should be checked by an obstetrician. If everything is fine and the cervix feels totally compliant, stretchy, yielding and will admit a finger, perhaps induction is in order, unless there is a family history of late babies.
- Alison Osborn,
5) Misoprostol Caution
The opinion of the best perinatal scientists is that misoprostol (cytotec) induction is still experimental and should only be done in a controlled research setting with the usual protection of research subjects including fully informed consent. This is because to date our scientific data are inadequate to tell us whether or not misoprostol induction is safe.
How to hold back the rapid spread of misoprostol induction, which heralds the return of all the convenience of daylight obstetrics? That the drug is not approved by the FDA for this purpose, not approved for this use by the drug manufacturer, not endorsed for this use by the American College of Obstetricians and Gynecologists or midwifery organizations and not recommended for routine use by scientists (who tell us we do not know if it is safe) has had no apparent effect on the enthusiasm with which clinicians, both doctors and midwives, are starting to use it.... Midwives need to make every effort to achieve evidence based practice, particularly when using drugs and invasive technologies, and the clear lack of data on serious risks of misoprostol induction should be sufficient to deter all midwives from this procedure, whether in hospital or out of hospital.
The issue here is consumer protection and quality assurance in maternity care. We need a system of rational pharmaceutical management which guarantees adequate evaluation of every use of a drug prior to its use for that purpose and drug protocols developed by an officially recognized group of scientists, clinicians (including midwives), policy makers and consumers and based on the best scientific evidence. Present consumer protection systems in some countries, for example in Scandinavia, include mandatory prior evaluation and officially endorsed consensus protocols, and there is no evidence that progress in maternity care is held back.
- Marsden Wagner, MD, "Misoprostol (Cytotec) for Labor Induction: A Cautionary Tale," Midwifery Today Issue No. 49, Spring 1999
Learn more from these Midwifery Today issues:
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6) Question of the Week:
I would like feedback on the question, is breastfeeding a feminist issue? Lots of feminist tracts ignore it. When I asked some of my students, many saw it as limiting in the old feminist tradition--tied to breastfeeding, tied to the home. Others saw it as empowering and an integral part of motherhood, something men can't do, etc. By promoting breastfeeding are we working in the best interests of women?
I'd love some debate.
- Dawn Robinson-Walsh
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If you would like to submit a Question of the Week, please write to the above address.
7) Question of the Week Responses
Q: How and why do you induce labor?
If and when the intrauterine environment becomes more hazardous for the baby than the outside, or to relieve maternal suffering--which on occasions can only be subjectively described by the mother.
- Phil Watters,
I feel odd responding to this question because I don't induce labor. I am a direct-entry midwife in Kentucky. I have only been practicing independently for a year; however, I was trained by Mary Ann Watson, CPM, QE, a direct-entry midwife with over 18 years experience in homebirth. Her philosophy/protocols regarding induction questions are:
1. What if I never go into labor?
Women were designed to give birth. Gestation for each mother with each baby will occur at its own pace, just as labor progresses at its own pace. Just because the baby inside feels large enough to survive, it may need more time inside to develop a crucial system. No woman has ever been pregnant forever. Mary Ann continues weekly prenatal visits until the birth. As long as no complications arise, she does not risk out or induce women just because they are overdue.
2. What if my baby is too big?
Normal, healthy women do not grow babies they cannot birth. The species would have destroyed itself if this were true. Induction may also contribute to malpresentation. If the baby is allowed time to find a good birthing position, it will adapt to the pelvic inlet. Arbitrary induction may cause labor to begin before the baby is in a good position.
3. Should VBACs be induced?
Mary Ann's practice prior to coming to Kentucky was primarily VBAC births. She has an excellent record of successful VBAC births. Her VBAC moms are not induced and do not have a greater complication or transport rate than her other clients.
4. What if the placenta stops functioning?
Normal, healthy placentas do not just stop functioning 14 days past the due date. I myself have had one client go either 3 or 5 weeks overdue (she was unsure of her dates). Mary Ann has had clients confirmed at 30 days or more overdue. Those babies were fine, and those placentas were healthy.
Some women do try to induce themselves with herbal preparations, castor oil, or some other home preparation. She firmly discourages this, for all the reasons above. Many of these induction attempts are not successful. One mother who was successful in inducing labor later regretted it. She had three productive, relatively short labors. This fourth, induced labor was long, slowly productive, and exhausting. She now discourages other women from trying to induce labor.
Our philosophy that birth is a natural process and our desire to allow it to progress with no intervention that is not absolutely necessary begins with good prenatal care and with accepting that labor will begin when it is time.
- Candy Hall, midwife
The OB/GYNs at a small community hospital
in Georgetown, Kentucky use Foley catheter cervical ripening. I am an RN with
almost 10 years labor and delivery experience and mostly have seen the use of
Cervidil and Pitocin.
Supplies needed: 16 French/30cc balloon silicone Foley catheter, 500-1000cc bag of warmed normal saline, IV tubing, 30cc syringe and needle The doctors usually use a speculum to visualize the cervix better, then place catheter with ring forcep, inflate balloon, and connect IV and tubing to infuse 60cc of normal saline/hour. Unfortunately, they also insist on "low dose Pitocin" (20u Pit in 1L Lactated Ringers-running at 5.0 mu through the night). The study they showed us also suggested use of catheter without Pitocin. Usually in 5-12 hours the catheter falls out and the cervical exam is 3-5cm. Pitocin is then increased until contractions are "adequate." I haven't seen the occasional hyperstim the Cervidil caused or the lengthy labors of Pitocin alone. Rarely the catheter doesn't work and after 12 hours it's removed and Pitocin increased.
Inductions of labor and Pitocin augmentation are done on more than 50 percent of the labors at our hospital. Labor here is still done in bed without walking, water use, eating, and drinking any liquids. And one of the worst things is an almost 95 percent epidural rate!!
Why is labor induced here? Well, our doctors fret when labor doesn't begin by 41 weeks, convenience for mom or doc, anticipated large baby (larger than 9 lbs), "small pelvis," the rare attempted VBAC and truly any other reason the docs can dream up.
I was wondering if anyone else uses this, especially anyone in a homebirth practice (without the Pitocin)? It would seem to me that use of this ripening procedure may be of some use in homebirth when postdates is becoming a real problem and nothing else has worked--albeit rare.
- Debi Savage RN, BSN, IBCLC (aspiring CNM)
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I had the recent pleasure of working with a completely competent doula in a homebirth here in Mexico. This doula came all the way from New York to stay for over three weeks, to care for a dear friend of hers who was about to have her first birth. In my study, I have not seen many doulas in action except for a few videos. This is hard work ladies and I commend you for your skills, training, patience and grace. This doula taught me so many things, from acupressure points, her takes on good yoga positions for transition to innovative techniques for finding the perfect counter-pressure spot. She was innovative, creative and most of all respectful and conscious. It was a real pleasure to see good labor support.
- Evette Richards
In response to Kelli Lincoln's question about juggling motherhood and midwifery: I am the mother of nine children and also an aspiring midwife. I am involved in many ways with many moms and I think I have some sound ideas and maybe some answers to your questions about "juggling" many things. You can contact me at lXKIDKEL@AOL.COM--I'd love to correspond with anyone interested. My children are between the ages of 16 and 2. Five of them were homebirthed, all were nursed, attachment parented, homeschooled, the list goes on.
- Kelly Ordway, LXKidKel@aol.com
I, too, grapple with the same concerns as Kelli Lincoln does, and I would be interested in the replies to her question concerning attachment parenting and midwifery studies.
- Kathy Corzine
My experience is that there really are differences in anatomy, never mind differences in nutrition and parity, which affect my ability to help a woman deliver with an intact perineum. The way I learned what I do know is by going to Jamaica with Shari Daniels. The women there have strong perineums with tough skin. But they had no Lidocaine for repairs. So if a repair was required, believe me, it was far more painful for most women than giving birth! I even bent a needle once trying to get through the tough skin. The women's screams provided ample motivation to avoid the next tear. Shari taught head flexion and perineal support and patience, and pretty soon I could get almost all the babies out intact. I still do pretty well here (about 80 percent without stitches), but not as well as in Jamaica.
The other thing I do here is try to prepare women for controlled pushing at the end by describing the "ring of fire" and saying it is a good thing to have (because it means they haven't torn yet). I also say that in addition to their own body's natural anesthetics, I will apply some viscous Lidocaine that will not only dull the pain, but also provide a "slippery slope" for the baby to slide out more easily. I don't know that I believe my own rap, but I do know that it helps moms to be less afraid, to believe they can do it, and to cooperate at the critical time.
When I look back at the worst tears I have had, they seem to have been caused by one of two things: primips delivering in the squatting position and blasting the child out or women with hematocrits under 30. Is this anyone else's experience?
- Cynthia Flynn, CNM, PhD
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