Photo by Martin Dubé

Midwifery Today, Issue 143, Autumn 2022.
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I became a nurse midwife after working for 15 years as a nurse in a high-risk labor and delivery unit. I was a staff nurse, then charge nurse, helicopter transport nurse, nurse educator, and critical care OB-certified.

Over the years, I flew out to small hospitals in our region and brought back women with many high-risk conditions, from PROM to preterm labor, to preeclampsia, cardiac conditions, and diabetes. We cared for a young woman who fell off a balcony at 20 weeks and was in a body cast. We had a woman who had a dissecting aortic aneurysm. Women with triplets, quads, and quints, women with too much fluid, not enough fluid, and twin-to-twin transfusion. We had many women with other issues that are rarely seen. We had a team of perinatologists, along with several Ob/Gyn practices, and a very busy OB unit. It was a wonderful place to work and learn. I saw cases there that I had never seen in any of the other hospitals where I worked. These women often needed to have their babies born, due to deterioration of their condition. They were induced, if possible, but often needed cesareans.

Our hospital was one of the most advanced hospitals in the region and used the most advanced technology. That meant that we also cared for women with perfectly normal, healthy pregnancies and labors who were also the “beneficiaries” of all that technology. They had IVs with blood tubing, “just in case.” We started out using fetal monitors for only the sickest women and doing NSTs every day while they were in the hospital. Over time we acquired more and more monitors and eventually had one for every labor room and every delivery room, so we started using them on every laboring woman. Women were not allowed out of bed and could only have ice chips. Nearly every woman had an epidural, so they had no idea what their bodies were doing. Around that time, inductions started to be more the norm, instead of a needed intervention. The OB practices in town started sending women in for induction as early as 37 weeks, especially if they were multiparous and their cervixes were starting to open. They were sent in so they could be home for Christmas, or the doctor was going on vacation and wanted to deliver them before they left, or the women had families visiting and they had to leave soon and wanted to see the baby first. Often all the doctor had to do was ask if the woman was tired of being pregnant and offer induction. The women jumped at it. It sometimes took three days to even get a small contraction. These women had laminaria forced into the cervix at night and the Pitocin started the next morning, day after day, until the poor uterus complied. The nurses joked that a woman who came in with a normal labor must have slipped under the radar.

I worked as a nurse for 15 years and saw only a handful of normal, natural labors, usually with one of the two family practice doctors who had offices in one of the small towns outside of the city. They fascinated me. They were becoming very unusual.

I worked in four different practices as a midwife, the first three with OB doctors. The midwives had quite a bit of independence, but the doctors would send women in for induction from time to time. Usually for convenience or after a lot of complaints that we called, “end-of-pregnancy blues.” We always spent a lot of time explaining that their cervix was not even close to being ready, that it would probably take days and days, and she might end up going home without giving birth. We talked about how the baby might not do well if it was forced to be born early. We explained that rupturing her membranes is very risky if she is not in labor, that she could end up with an infection or a c-section.

The women who had been told that they were going to have their baby that night were usually angry at us. They told us that their cousin or sister or friend had an induction at 36 weeks so she could go on a cruise and everything was fine, or, she couldn’t stand the heat any longer, or her feet were so swollen she couldn’t walk, or her back was killing her, or her parents were there from out-of-state and had to leave in two days to go home and wanted to see the baby before they left. We were the bad guys and the doctors were the saviors.

I finally found a job that I stayed at for the rest of my career. I worked in a community clinic with family practice doctors. We attended births at the nearby hospital. Our clientele were women who were poor, often homeless, malnourished, had addiction disorders, were sex workers, or had partners who beat them up. Many were immigrants and refugees who did not speak English. We had interpreters for every language they spoke. Most of the women from other countries were adamant about waiting for natural labor to start and never even considered an induction.

Our induction rate was very low, as was our cesarean rate. We had a social worker who helped women get stable living conditions and a nutritionist who worked with them to find less expensive, nutritious food. We had a dentist who came once a month to address tooth issues. We had an OB group and a perinatologist we worked with for high-risk mothers. One of our doctors and the perinatologist were certified to treat addiction with methadone and buprenorphine.

Every woman I saw as a new patient, and at all of her other visits, was told that the date of delivery was an estimate and not etched in stone. We talked about how the last few weeks in the womb were very important for the baby’s brain and lungs and even if her sister’s baby came early and did fine, it was lucky and no guarantee that her baby would do well if we forced it to be born before it was ready.

We talked about activity, plenty of water, staying on their medication if they had addiction disorders, resting, and diet. I had them feel the baby’s position with me, especially having them tell how high in the pelvis it was if it would move from side to side. They learned that when the baby was getting ready to be born, the head would shift down and not be so easy to move. I had them spend a few minutes each day in a quiet, comfortable environment with their baby, feeling the movements and identifying the kicks and squirms. If they had no place like that, I got them some juice and let them lie down on the exam table and stay in the exam room for a few minutes. I wanted them involved with their own care.

I found that even on the hottest days, when their back hurt and their feet swelled, they were willing to take suggestions to alleviate their discomfort, instead of trying to talk me into an induction. The doctors were also on board with this and we worked as a team to lower the induction rate to the lowest possible. That also decreased the c-section rate and our epidural rate, as well.

In this way, the birthing moms were active participants in their care, came to the hospital in active labor, ate if they felt like it, drank fluids, walked, used the tub, had dark quiet rooms with only the people that they wanted there. They did not have fetal monitoring machines attached, and the heartbeat was auscultated while they were in any position they wanted to be in. Their births were powerful and happy events for them.

Induction still occurred, but only when it was warranted, based on the mother’s or the baby’s condition. The reality was that it was not warranted very often and was used judiciously. In my 20-year career, I personally did only one induction for convenience. The woman’s partner was in the Army and leaving for the Middle East to war. She was 39-1/2 weeks, dilated to 4 cm, and soft. The head was low. I told her that I would start Pitocin, but I would not break her water, even though she had a bulging bag. She agreed and went into labor almost immediately. When her water broke it was nice and clear, so we turned off the Pitocin so she could be off the monitor and walk around. She delivered in about two hours. She and her partner were happy, crying, and cuddling their baby. The baby was healthy and nursing well and they went home that night. At her six-week checkup, they were doing great. He had shipped out three days after she delivered. About three weeks later he was killed. That was the only convenience induction that I had felt was the right thing to do.

I was very happy that there is the technology to care for a high-risk mother and induce her when needed, but I am also very happy that inductions done for convenience, too early, and leading to problems are becoming a thing of the past. I think that there is a place for inductions, if they are done judiciously and for a very good reason. I also think that if mother and baby are healthy and doing well, inductions should be avoided.