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Induction in the radar these days

Induction seems to be on everyone’s radar these days. From hospitals proudly announcing they will not induce a mother for non-medical reasons before 39 weeks (no problem having an elective induction after 39 weeks, though!), to medical groups urging ever-earlier induction deadlines, pregnant women have a lot to consider.

For every woman who waxes poetic about her marvelous induction, there are three who had a more difficult birth experience than necessary because of induction. What makes for an “easy” induction? Physicians like to talk about a “favorable” cervix, meaning that the cervix is ready for labor. They have even developed a chart by which they can calculate the likelihood that induction of labor will be successful. This is called the Bishop’s Score: bishopsscore

As you can see, there are multiple factors that predict the ease of induction. Cervical position, whether the cervix is behind the baby’s head and difficult to reach (posterior), or smack-dab in front of the head and easy to reach (anterior) is assessed first. The consistency of the cervix is also important. An “unripe” cervix has the texture of the tip of your nose. A ripe cervix can feel as mushy as cooked oatmeal. Effacement refers to how much the cervix has thinned. An uneffaced cervix is can be as much as two inches long. The cervix must gradually thin to almost paper-thin. Dilation, of course, refers to the opening of the cervix itself, and station refers to how high or low the baby is in the pelvis. Any minus (-) designation indicates the baby is above the spines of the pelvis where it must engage, and any plus (+) designation indicates the baby is moving below the spines of the pelvis (a small projection on either side of the pelvis, close to your “sit bones”.

One would think that having a high Bishop’s score, meaning your cervix is soft, thinned out, dilated, and the baby is low in the pelvis, would set you up for an easy induction, right? What many women are unprepared for is the length of time it can take to actually get labor started, even when they are already significantly dilated. Consider an induction an acquaintance of mine, Brenda (not her real name), recently experienced. Brenda was having her fourth baby. She was already dilated to 4-5 centimeters, her cervix was fairly thinned out and soft, and the baby was engaged in the pelvis. Her doctor was doing out of town for a conference, so suggested Brenda be induced. “It will be a piece of cake,” Dr. Alberts said. “Your cervix is favorable, your last labor was only two hours long, and you get to give birth at the time and day of your choosing.” Brenda was all for it. She arrived at the labor ward as instructed at 7:00 a.m. on the designated day, about six days before her official due date. She chatted with the nurse as her IV was started, and smiled through the Pitocin-induced cramps she couldn’t even feel. Dr. Alberts broke her water shortly after Brenda was admitted, promising that “with your cervix already almost five centimeters, your labor should just take off!” But it didn’t. Hours dragged on; afternoon, evening, night. Brenda wasn’t allowed to eat anything because she was being induced, but she wasn’t in labor! She was hungry! She devoured ice chips, trying to quiet her hunger pains. She was uncomfortable; not in serious pain, but strapped to monitors and unable to reposition herself without the nurse having to adjust everything. She was tired of her labor room and tired of her bed, and just wanted to go home. Finally, about midnight, she felt the first contraction that hurt. Another one followed with only a 30-second break in between.

Brenda describes it as being similar to jumping onto a moving train and hanging on for dear life. The next several hours were miserable, and Brenda had more frequent contractions than customary for normal labor. The contractions, rather than gradually building and then receding, as in normal labor, peaked almost instantly, causing Brenda to tense all her muscles just trying to cope with the sudden onset of pain. Finally, she felt the urge to push and gratefully pushed her baby out. Would she do it again? Brenda responds, “I learned that just because my body appears to be ready doesn’t mean it is ready. There are factors that trigger labor that we don’t yet understand. I don’t know why it took so long, but my body clearly was not ready for labor.

If I have another baby, I will definitely wait for labor to start on its own–even if my doctor is out of town! Do you want to know the ironic thing? My labor had taken so long to get going, my doctor went home to sleep for a while. She only lived five minutes from the hospital, but when I finally dilated, I dilated so quickly she missed the birth!”

A while back, I took care of Annie (not her real name) during her labor. Annie was a first-timer. She was five days past her due date, and one of my colleagues decided to strip Annie’s membranes. Annie’s cervix was not favorable in the least. It was only one centimeter dilated, thick, and felt like the tip of your nose–pretty firm. It was very painful to strip the membranes, as, at one centimeter, the cervix is not open enough to admit the average person’s finger, so it must be manually forced open. The examiner then runs her finger around the inside of the cervix in a circular motion, peeling the membrane away from the inner part of the cervix. This is thought to release hormones that trigger labor. In Annie’s case, she began painful contractions immediately. Annie really wanted a natural birth, so she waited at home for 12 hours before coming to the hospital, expecting that she would be well dilated after that time. When she arrived, Annie’s cervix was only 2 centimeters dilated and still thick. She was in so much pain, however, that she begged to stay at the hospital and get help with coping. She still did not want medication, so we tried the shower, the jacuzzi, walking, massage, positioning, the birth ball. . .you name it, we tried it. Annie’s baby was “OP”, an acronym for occiput posterior, meaning the baby’s back is lying along the woman’s back, rather than toward her belly. This causes intense, often knife-like pain in the back during and between contractions. None of my tricks were working to turn the baby. Annie was not dilating, but was having 90-second long contractions every two to three minutes. She finally asked for an epidural, but the anethesiologist was unable to get the epidural to work, despite repeated tried. Annie felt every contraction. Finally, her cervix began to dilate a little, but it still felt very firm and almost lumpy in texture, not soft and stretchy as a “ripe” cervix feels. After nearly 24 hours of painful labor, Annie finally delivered a beautiful baby girl. By then she was so exhausted, she could barely hold her baby. I went home sad, wondering if Annie’s baby would have been in a better position if labor had not been forced to start, but instead begun as the baby moved into the optimal birth position. I couldn’t help wondering how Annie’s experience might have been if she had been allowed to begin labor on her own, rather than subjected to an aggressive stripping of the membranes with an unripe cervix. We’ll never know, but I do know some things:

If you are not in labor, your body is not ready for birth, whether or not you are past your “due date”.
There are unknown factors involved in the onset of labor. By forcing labor to start, is it possible we are not allowing critical processes to take place before labor begins? Perhaps in 100 years, OB providers will shake their heads at our ignorance in inducing labor and missing out on essential factors for health that would otherwise have occured.
What your cervix is doing is meaningless if you are not having regular, close contractions. If you are 7 centimeters dilated and are not having contractions, you are not in labor. If you are past your due date and have not started labor, it is because your body is waiting for important things to occur before labor begins.
Be smart and make your labor as easy on yourself as possible. Unless there is a medical reason for which it is safer to have the baby out than to continue the pregnancy, don’t agree to an induction, regardless of your cervical dilation.


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