Sunday, November 22, 2009

What an induction looks like

Want an induction? Ask yourself if you want this:

Monday 9 p.m.: Arrive at hospital. Change into hospital gown, get in bed, be connected to contraction and fetal heart rate monitors (external belts). Cervix hard, thick, and high. Receive one dose of Cytotec (medication to soften the cervix, an off-label use of this medication which has serious risks).

Monday night: Sleep, intermittently interrupted by the nurse to adjust monitors, take temperature and other vitals, etc. Another dose of Cytotec around 3 a.m.

Tuesday 7 a.m.: Checked by incoming shift. Little change. Place another dose of Cytotec.

Tuesday during the day: Some contractions. Skip a dose of Cytotec to be able to go off the monitors, shower, eat, and walk the halls for an hour or so.

Tuesday 7 p.m.: Checked by incoming shift. 1-2 centimeters. Agree to Foley bulb catheter to expand cervix. Two hours later, Foley bulb falls out. Now 3 cms. and ready to start Pitocin. No more eating, drinking, or going off the monitor (so no walking around, limited movement).

Tuesday night: Sleep, with intermittent contractions, as Pitocin is ramped up.

Wednesday 7 a.m.: Checked by incoming shift. 4 centimeters. Doctor breaks bag of water (=AROM, Artificial Rupture of Membranes). Intense, strong contractions immediately ensue. Intrauterine pressure catheter (IUPC) placed to monitor contraction strength. Hour-and-a-half wait for anesthesiologist, who is in back assisting at a c-section. Receive epidural. Labor slows down again, Pitocin is ramped up.

Wednesday during the day: Some wearing off of the epidural effects. Cannot get up or move around to help with pain because even somewhat ineffective epidural doesn't allow for enough control of legs. Still not allowed to eat or drink. Constant itching from epidural. Nurse comes in frequently to adjust baby heart rate monitor. Nurse checks cervix and says 5-6 cms.; doctor comes in later and says only 4. Now attached to 7 different wires: oxygen saturation monitor, blood pressure cuff (worn continuously, going off every 30 minutes), external fetal monitor, IUPC, epidural catheter, bladder catheter (can't get up to pee), and IV line.

Wednesday 7 p.m.: Checked again, 7 cms. Anesthesiologist has come in twice to try to fix epidural and comes in a third time for one last try. Re-upping medication helps slightly; sleep intermittently for 20-30 minutes and then epidural stops working well again. Still itching - nurse says she can offer Stadol for the itching, but that will cause a lot of sleepiness/loopiness and "out of it" feeling; decline the Stadol.

Thursday 12 a.m.: Checked again - completely dilated to 10 cms. Begin pushing. Back begins spasming, possibly from being in bed so long, makes it difficult to continue pushing but do so anyway. Push for 2 hours. Baby's heart rate begins to drop and doctors suggest a vacuum extraction. Also give oxygen - now connected to 8 different things.

Thursday at 2 a.m.: Vacuum extraction successful; baby is born crying and vigorous but immediately taken over to the warmer because of the heart decels and use of the vacuum. Doctor repairs perineal tears while peds team checks over baby. Finally get to hold baby after 45 minutes, but baby is not interested in nursing yet. Nurses impatient to take baby to nursery for first bath; give baby to nurses, be unhooked one by one from all wires and medical team leaves. Wait in empty room until it's time to be transferred to the postpartum floor.


I have attended many inductions, and this is based on a composite of multiple inductions I have witnessed. I think it accurately represents the experience of many women who are induced without any cervical readiness for labor (and even some who are induced with greater readiness).

It's not a very nice story. Do I write it to "scare" people? "ZOMG, if you get induced you will be in labor forever and in pain and your baby will need to be pulled out." That's not what I'm aiming for; there are inductions that go smoothly and quickly (although more often when the body is ready and willing).

Instead, I write it to inform. There was an online workshop offered this summer for doulas called "Do You Dread Inductions?" because the answer is YES! We only wonder why our clients don't dread them more, and the best answer I can come up with is that people don't understand what they're consenting to. I think the impression many women of an induction is that it's similar to regular labor, but you just get to pick your day. Let me be one of many doulas who can tell you: this is not the case!

When you start regular labor at term, it's because a complex set of signals and changes in your body say "This baby is ready; let's get it out." (One way to measure whether the body has begun preparing for labor is a Bishop's score.) When inducing labor, medical staff try to replace those natural signals and changes with manufactured ones: promoting cervical softening and dilation using prostaglandin gels or misoprostol (Cytotec), inducing contractions with artificial oxytocin (Pitocin).

As this cervical ripening and early dilation is generally the longest part of labor anyway, and is much less efficiently done by medications than by normal physiological processes, all of this takes a long time. Often by the time a woman in spontaneous labor would be showing up at the hospital (4-5 cms) you have already been in the hospital 12-24 hours, and still have a ways to go. You're also likely to experience a more intense, painful labor because induced contractions are different from natural contractions, so you're more likely to need pain medications.

In addition, when you induce without your body being ready (aka a low Bishop's score) you increase your chances of a c-section, and even if you avoid a c-section you increase your chances of a long, drawn-out experience that may not be what you are prepared for. Don't be electively induced, and understand the legitimate reasons for induction vs. the convenient excuses.

If you need an induction for medical reasons and your body is not ready, be prepared! Eat and drink as much as possible while you are still "allowed" to. Advise family and friends that it will be a long wait and make sure everyone gets a lot of rest whenever possible. Don't accept phone calls from people asking "Is that baby OUT yet??" As long as baby is doing OK, don't be afraid to ask for assists like telemetry (wireless) monitoring so you can move around more freely, and breaks to go off the monitor while nothing is actively being done. Get out of bed as much as possible whenever you can, because it can be hard to avoid an epidural and that will restrict your movement later on. Delay breaking the water as long as possible, because it starts the clock ticking for delivery. Use different positions for pushing - even if you have an epidural, it's possible to move around in the bed, and it helps counteract the position problems that can arise from a long stay in bed.

If you have to be induced, be informed. But if you don't HAVE to be induced - don't take the decision lightly. Wait for your baby and your body to tell you it's time.


Anthro Doula said...

Great post. :)
I'm going to re-blog and link to this post!

Dou-la-la said...

MON DIEU. Have you really attended labors that last for four days?? I mean, I undestand that it's a composite, but DAMN.

"I think the impression many women of an induction is that it's similar to regular labor, but you just get to pick your day." I think you're absolutely right, and frankly, FAR TOO MANY doctors are complicit in that very impression.

I'm spreading this like Frankie spread the news.

Dou-la-la said...

P.S. Honestly, though, I am AMAZED that any labor, inducted or otherwise, that took this long could possibly avoid a c-section. how often does that happen?

Hmm. Total speculation here, but I wonder if in some cases they might be MORE willing to give an induction extra time because they want to save face themselves . . . and not admit that the elective induction was a failure for which they bear responsibility because THEY jumped the gun. (Does that make sense? It's late . . .)

Rebecca said...

Anthro Doula - thank you! And thanks for the link :-)

Dou-la-la: Short answer, yes, although if you add this together it spans 4 days but actually takes 2.5 (about 60 hours start to finish). Still, not a walk in the park for anyone!

About the willingness of providers to tolerate that long a labor - excellent question, and maybe even one I should address in another post. Some providers will say "As long as your baby's looking good and you're making some kind of progress, even slowly, we'll just keep going." Some will count progress as not just dilation but effacement, descent, and contraction pattern, so as long as they're seeing progress on some fronts they'll continue. (Obviously this is helpful to apply to ALL labors, but is especially important for inductions as they can go so very slowly.)

Other providers will call an induction "failed" after a certain amount of time with no/very slow progress and go back to the OR. That's one of the reasons I suggest resisting AROM as long as possible. If your water's not broken, when things stall out the possibility exists to just turn off the Pit, let everyone rest for 12 hours, and then try again. Of course, at some point a woman may start asking for a c-section just because she's so exhausted and feels like it's not going anywhere, and at that point it's pretty easy for the provider to agree. (Would that then be classified as a maternal request c-section??)