Wednesday, March 6, 2013

Pregnant & Overdue! What Are The Options?

My entire pregnancy I swore up and down I would go early. I just knew it. Once I hit the "safe" zone of 38 weeks I waited everyday for my water to break, and alas, it did not.

I knew that it is safest to let the baby come naturally, and to go past the "due date." I was just sooo tired of being pregnant. My experience carrying and growing life wasn't always enjoyable. I was in and out of the hospital and doctor's office the first 20 weeks (including a visit family didn't know about, sorry!) because of hyperemesis, and at the end of my pregnancy had such painful braxton hicks and pubic pain I couldn't get pants on. I was ready to be done.

I knew my baby wasn't, however.

Baby Bree decided to stay in her uterine home for 42 weeks. That was my midwife's and my comfort zone. Neither of us wanted me to go to 43 weeks, so the Sunday I turned 42 weeks we started some natural induction techniques. I was planning a homebirth and did not want a medical induction unless I had one of those rare babies who just don't want to leave.

So, we tried pumping, herbs, stripping my membranes (which I was too nervous for, so nogo), and sex with the hubbs of course. They didn't work and I was disappointed.

But one thing we must realize, is non-medical induction does will not work unless the baby and the cervix are ready. Sometimes medical induction doesn't work either. EDDs (estimated due dates), are just that. Estimated.

In this link - the ACOG (which is the nation’s leading group of professionals providing health care for women) states “Waiting for the birth of a child is an exciting and anxious time. Most women give birth between 38 and 42 weeks of pregnancy. But very few babies are born on their due dates. It is normal to give birth as much as 3 weeks before or 2 weeks after your due date.”
“The average length of pregnancy is 280 days, or 40 weeks from the first day of a woman’s last menstrual period. Your due date is used as a guide for checking your pregnancy’s progress and the baby’s growth and age. Doctors often use more than one method to check the age of the fetus and set the due date. The size of the uterus may help assess the age of the fetus. Ultrasound also may be used to help confirm the age of a fetus.”
There is an intense amount of pressure put on women if they go over 40 weeks. But a due date is not an expiration date.
"The 40 week due date is based upon Naegele’s Rule. This theory was originated by Harmanni Boerhaave, a botanist who in 1744 came up with a method of calculating the EDD based upon evidence in the Bible that human gestation lasts approximately 10 lunar months. The formula was publicized around 1812 by German obstetrician Franz Naegele and since has become the accepted norm for calculating the due date. There is one glaring flaw in Naegele’s rule. Strictly speaking, a lunar (or synodic – from new moon to new moon) month is actually 29.53 days, which makes 10 lunar months roughly 295 days, a full 15 days longer than the 280 days gestation we’ve been lead to believe is average. In fact, if left alone, 50-80% of mothers will gestate beyond 40 weeks."
Going past 40 weeks is normal for most women! 
As for myself, while I did not want to personally go to 43 weeks, I've known women who have gone as far as 44 weeks, with very healthy babies and placentas. Sometimes EDDs can be wrong, and I would rather the baby be in longer to continue his/her perfection than come too early because of an induction on a mom whose EDD may not be right.

Induction also increases your chance of c-section, and more interventions and issues. Many articles and studies have proven this to be true.

Here are some things I have borrowed from my awesome support group's files :

Here is a collection of information about the BISHOP SCORE. Before considering *any* form of induction, including natural methods or a "sweep" (stretch and sweep or sweeping of membranes), please ask about your Bishop Score. Methods of induction of any sort can stress your body, and more importantly, your baby - if both of you are not ready. Please try to be educated on this aspect of late-pregnancy before you are pressured into anything.

This link is related to acupressure in pregnancy, but I find the information neatly presented and easy to understand with charts.

From PubMed: "A Bishop score of 5 or less was a predominant risk factor for a cesarean delivery in all 3 groups (adjusted OR 2.32; 95% CI 1.66-3.25). Other variables with significantly increased risk for cesarean delivery included maternal age of 30 years or older, body mass index of 31 or higher, use of epidural analgesia during the first stage of labor, and birth weight of 3,500 g or higher. In both induction groups, more newborns required neonatal care, more mothers needed a blood transfusion, and the maternal hospital stay was longer."

This source also includes information on "low fluids" and what questions you need to ask.

"Weighing the newborn after delivery is the only way to accurately diagnose macrosomia [big baby], because the prenatal diagnostic methods (assessment of maternal risk factors, clinical examination and ultrasonographic measurement of the fetus) remain imprecise." This means that there is NO WAY of knowing how much baby will weigh until he or she is weighed after birth!

"Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered." This means, c-section should not even come up for discussion, unless the is estimated to weigh more than eleven pounds and it is debatable whether a c-section for a baby estimated over eleven is even beneficial.

"Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes." Inducing is not safer for mom or baby. 

"Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes." A baby estimated to be ELEVEN pounds or less and mom is no diabetic, should be attempted vaginally. 

"With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery." It is safe to have a trial of labor and if it doesn't work THEN take action. 

"Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery." You can still VBAC with a "big baby"!

Here are some links on what it means to have low fluids. Some links even help you weigh the risks and benefits to inducing or sectioning for low fluids.

Risks and Benefits of a Sweeping/Stripping Membranes

The Benefit: 
It might start labor.

The Risks:
Increased rate of infection (especially concerning if you are GBS positive!)

Increased rate of Premature Rupture of Membranes (PROM- which leads to the possibility of inducing with Pitocin and increased use of internatl monitoring and epidural and use of other pain medicines)

Increased levels of pain

Increased rate of spotting/bleeding

It may not start labor (remember, labor is trigger once those little lungs secrete the "I'm ready!" chemical!

This link discusses the increased risk of PROM with sweeps.

If I consent to this procedure, how do I mitigate the risks involved? 
Make sure your Bishop Score is above a nine, as with any other form of induction.
Make sure you are comfortable with what interventions are likely if your water does break before labor starts. This includes a Pitocin drip, to start labor- which will often include the use of constant fetal monitoring (which restricts movement), increased levels of pain, increased risk of a number of other things. CLICK HERE for information on the package insert for Pitocin.

What are my other options for inducing labor, without Pitocin or other medicines?

Induction Options (besides Pitocin)

If you need an induction for medical reasons or you decide to allow an elective induction, there are methods to consider other than pitocin- particularly for elective induction. The manufacturer of Pitocin states their product should not be used for elective inductions. SEE MORE INFO HERE (,0)

If your Bishop Score is below a nine (What is a BISHOP SCORE?, then you will need cervical ripening with Cervidil or Foley Bulb. One way the body prepares, naturally for labor is this step and if you do this step before working to get contractions going, it drastically increases your chances of a successful induction.

Please, do NOT let them use Cytotec as your cervical ripener, because the manufacturer AND the FDA has stated it is too dangerous to use for inducing women and should NEVER be used for that purpose!

While waiting for your cervix to ripen, you can use a breast pump to stimulate contractions. The pump will have your body release oxycotin, which is what pitocin mimics. PLEASE do NOT let them break your water. That puts you on the clock and you will be fighting them to not do a c-section to "prevent infection". Artifical rupture of the membranes drastically increases the chances of cord prolapse, which is an emergency situation. It also makes it more difficult for baby to move into an optimum position for labor, since they will have less fluids to manuver easily- causing a more painful labor for mom and increase the risk of baby going into distress, since they no longer have a cushion to protect them during contractions. (The best way to prevent infection and reduce the amount of pain you are in and not slow labor is not allow any vaginal exams. 
You can also using pressure points between pumping sessions, to help get contractions going. These pressure points can, supposedly, also help baby to turn into a better position.  (Inducing with a breast pump)  (Vaginal exams, when are they needed and helpful?)

Benefits/Risks of Inducing "post" date babies

Here is some great information on post-dates, if you are interested in learning more about the subject.  (This author has gone PAST 42 weeks with at least two of her pregnancies.)  (Pregnant patient's bill of rights, per the American Hospital Association)

Induction increases your risks of not only c-section, it also raises the risk of abnormal fetal heart rate, shoulder dystocia and other problems with the baby in labor, as well as the baby's chances of needing stay in NICU, and and increased risk of forceps or vacuum extraction used for birth. There are also increased risks to the baby of prematurity and jaundice. 

Please read these and mention them to your doctor before going with elective induction or if you feel you are being scared into an induction. 

If you are pregnant and would like a private place for support and encouragement, feel free to request a join to this group, where you can post and comment privately and no one outside of the group can see (a big deal in today's Facebook world where nothing is private). I used the word "private" a lot, its a big deal!

As usual, happy researching!