OBGYN

The Truth About Induction

Photo @monetnicolebirths

Photo @monetnicolebirths

My friend, and former collaborative and consulting OB, Melissa Wolf is our resident OB today. She always reaches out to me when there is some horror story in the news that results in a lawsuit, because malpractice suits for maternity care providers are the real deal and they can ruin a careers worth full of work, dedication and passion.

She asks me, like our OB last week, what she can do to be a better doctor to her patients. Emotionally and energetically.

So, we've been talking a lot about birth trauma lately and both acknowledge what a tricky conversation this is...so, this week let's talk about induction.

People are extremely confused about the topic of induction. We are not sure where the confusion comes from, but I can lean to believe it is because a clear explanation needs to be given to women when induction is necessary and indicated.

For instance, many women who are induced for a medical reason maybe didn't receive a clear explanation as to why they were being induced or didn't understand the indication. Then, if they have an unwanted labor and birth experience, post-birth there can be a lot of feels.

Feels that need acknowledgement to move forward thoughtfully and holistically.

But today, we're educating because we can blaze through some of the confusion by giving you a clear, direct explanation. It is what we do best around here.

Today's post is real brass tacks. And now, we want to hear from you.

What was your experience like with induction? Did you feel supported in your quest to understand induction during your pregnancy, or not? Tell us your experience in the comments below.

Without further ado...thoughts from Melissa.

x,
R


Outside of western medicine, the concept of labor induction is shrouded in mystery. Myths abound as to why it’s recommended, how labor is started, and what effects induction has on the actual process of labor and childbirth. In the medical community; however, the process is fairly clear and the guidelines surrounding its use are well established.

Here’s the skinny: there are two categories of labor induction, elective and medical.

Elective induction means a woman has her labor started artificially because she requests to have this done. In elective cases, there is no medical reason for the induction; the patient simply wants to plan the birth of her child. Women commonly elect to have their labor started for logistical reasons such as child care arrangements, or for visiting family.

In order to have an elective induction, a patient must meet all of the following criteria:

  1. Be at least 39 weeks pregnant
  2. Have a “favorable” cervix, meaning a cervix that is soft and open, not firm and closed.
  3. Have a “proven pelvis” meaning she has delivered a baby of similar size through her vagina in the past.

A woman who meets the above criteria has no higher risk of cesarean section with induction than if she went into labor on her own.

Medical induction means a woman has her labor started artificially for a specific medical reason. These are advised by a health care professional because it is safer for the baby to be outside the womb, or, continuing to be pregnant is dangerous to the health of the mother.

Common reasons for medical induction are:

  1. The mother has diabetes of pregnancy or high blood pressure.
  2. The mother’s water breaks and true labor does not start on its own within 6 hours. If labor is not started, the baby can develop a serious infection requiring IV antibiotics in a hospital instead of snuggling up with mom, or, the mother may develop a serious uterus infection causing ineffective contractions and requiring cesarean delivery.
  3. The amniotic fluid is too low or the baby has stopped growing.
  4. The pregnancy is more than a week overdue.

If labor is not initiated in the above circumstances, the risk is fetal death which is obviously very serious and unwanted. Medical inductions can be started at any number of pregnancy weeks depending on the situation and do carry a higher chance of cesarean delivery.

Labor induction is typically done by giving oxytocin (the same substance a woman’s own body produces to start labor naturally) through an IV, or using a prostaglandin gel or tablet placed directly in the vagina next to the cervix. Some women are very sensitive to these medications and begin to contract painfully right away while other women need a much higher dose before they feel anything.

It is not possible to reliably start labor on your own at home by having sex, eating spicy food, walking, or driving on a bumpy road. If these strategies could routinely start labor, all women would be advised to avoid sex, walking, spicy foods, and bumpy roads throughout their pregnancies so as not to create premature births! Drinking Castor oil will give a woman diarrhea and sometimes contractions; however, it does not reliably create true labor either.

Labor inductions can be more painful and intense than natural labor and some women prefer to have an epidural for pain relief in these circumstances. Ultimately labor induction is something that each woman must individually discuss with her provider relative to her specific pregnancy.

Melissa Wolf is a witty, dry-sense-of-humored board-certified OBGYN and Holistic Health Coach who lives and works in Bozeman, Montana. She is also a professional speaker who entertains national audiences with presentations such as “Unwind Your Mind: Live Inspired,” “Boredom in the Bedroom: There Is No Female Viagra,” and “Menopause: Puberty in Reverse”. She spends time volunteering for Doctors Without Borders to expand her perspective and skills with global women's healthcare.  

How Can I Be Better With My Patients?

Photo by @monetnicolebirths

Photo by @monetnicolebirths

Behind the scenes, I have had a handful of OBGYN's approach me on how they can do better.

Better - to ensure their patients feel secure, safe, supported by their care. Better communicate with women when her birth might be the first time this doctor has met a woman and her support team. To take care of a woman's heart better. The concerns all come straight from these providers hearts, because they're concerned about everything they're hearing and reading and seeing on the internet.

Being a maternity care provider is a political event, as much as a calling to provide excellent health care for many. Because the maternal health system in the U.S. has pulled us far apart - "us" the midwives from the doctors - is a fairly recent event. In fact, doctors started doing the majority of deliveries in the U.S after 1920.

By pulling us apart in training, education, and practice settings, it's unfortunately caused a chasm between professions. However, today in 2016 - from where I stand - I keep hearing the call to come together and work together because everyone is over it. We are over the chasm of care.

Everyone I know wants to do better, even if they're providing excellent care. Why? Because, they hear you and they see you.

This OB approached me via Instagram stories, asking this very fundamental question after providing emergency obstetrical care to a woman who came into her care attempting a TOLAC (trial of labor after cesarean) at home that resulted in a fetal demise. The woman chose a home birth, because her hospital experience was a terrible experience. The OB asked me, "Any creative ideas on how I can debrief better with my patients after traumatic births!? I hate that this has to happen. 😔"

I told her to show up. This is the first step to care and follow up with a woman who has a traumatic delivery - be by her side more than your license or training tells you. It's more intuitive care than medical or midwifery care training teaches. 

Her message made my heart tug in many directions. As a result, she wrote this reflection.

We'd love to hear from you, now. What more you would have liked or loved to experience in your postpartum care? Alternatively, what was one thing you LOVED about your postpartum care? Tell us in the comments below. It will help us help the larger collective of providers who want to give you better care.

With big, big love,
The LMH Team


I’m writing this as a reflection – I’m writing about this because it seems like the right thing to do.

I became an OBGYN for many reasons – but the pivotal moment for me was watching a woman lose her baby after a breech delivery complicated by head entrapment in a small hospital in a developing country. I wrote my personal statement for medical school about how I wanted to learn the skills to be able to someday handle such a situation with not only knowledge about how to keep her safe but also the skills to navigate the sorrow that she had to experience when she found out that she lost her child.

Fast forward 4 years later, and I’m a newly graduated OBGYN, working in my dream job as a hospitalist – I am honing in my skills for obstetric emergencies. I’m helping to develop protocols for preventing obstetric hemorrhage, reviewing safety events, and training a fresh set of OBGYN residents.

I know in my heart what it means to be an OBGYN. My goals as an OBGYN were to walk with women in both joyous and tragic experiences that are all wrapped up in what God gave us as pregnancy. But I am also faced with many women in my community who have a misconception of why I go to work everyday.

So many of my patients have had a history of a traumatic birth, often related to their hospital experience, which they carry with them and unfortunately I become the new representative of that prior experience. How can I dig out from underneath that pile of misconceptions?

My family knows why I wake up at 5am and return home at 7pm, they saw the sacrifices I made when my daughter was a newborn and I was in training, only seeing her for 20 minutes per day – if that. My husband has seen me wipe tears away after crying on my way home thinking about a mother who lost her uterus to postpartum hemorrhage. He knows I wake up in the middle of the night recounting the events of a shoulder dystocia trying to make sure I did everything right.

How can I explain my motivations to my patients? Why is it even important to me to explain?

I work as an OBGYN hospitalist – meaning I don’t have an office, I don’t see patients in clinic or follow them throughout pregnancy. I am specialized to meet a woman, make a connection, and be with her throughout her hospital stay. I am like an emergency department physician – specifically trained in obstetric emergencies so that hopefully I’m the best person to care for you when pregnancy doesn’t go just right.

Where I live, this means that I often take care of women who don’t want to be taken care of by me. There is no other unit in the hospital where patients wish they could be doing the same thing but at home. No one chooses to have surgery at home, be evaluated for a heart attack at home, or recover from a major car accident at home. But because of how amazingly natural pregnancy and delivery can be, some women choose to stay in the comfort of their own home. I respect their decision – I can understand how sterile, isolating, and uncomfortable the hospital can be. I sometimes feel that way in the hospital, and it’s become my second home.

This is not a reflection on if home births should happen or not; it is a reflection on how I can care for those women better who end up with me in the hospital when they don’t want to be there.

It was surreal to sit in a room with a father, a 10 year old daughter, and a newborn girl who hadn’t lived through delivery. I felt like I knew what to say, how to sit in silence with them. I didn’t feel bad tearing up when I looked into the father’s eyes telling him how sorry I was that this had happened to his family.

But sitting in the waiting room later on with the two midwives who had been caring for my patient, attempting a vaginal birth after cesarean at home, with subsequent rupture of her uterus at home an hour away from the hospital, is still a place I don’t want to be. I want to scream out loud “WE ARE SUPPOSED TO BE ON THE SAME TEAM!” or… “WHY DID YOU NOT CALL US FOR HELP?!”

I was trained by midwives. A midwife delivered my one and only child. I look to the midwives in our practice for advice, grounding, and new perspectives on how to take care of women. During residency, I often told patients that I was “minoring in midwifery” because of how much I admired the way a midwife can walk through pregnancy and delivery with all types of women. I jokingly call myself a “high risk midwife who also does surgery,” but this is actually what I aspire to be.

That said, how can we all get on the same team? In a time where maternal mortality is escalating, and depends on where you live and what color your skin is, how can we all come together with the same goals in mind – taking good care of women and the families they are making? How can I rebrand myself to help my patients see how badly I want to help them? How can I show that my 4 years of medical school, 1 year of graduate school, 4 years of residency, and $291,000 of student loan debt is all worth it to be able to help save a life?

I know I can. I know I will.