Tuesday, November 16, 2010

Tips for a successful induction

A reader emailed me yesterday with questions about how to increase her chances of a successful induction. I thought this would be a good opportunity for a discussion. Let's look at her situation in particular, and inductions in general, and share ways to make them more likely to succeed--i.e., to end in a spontaneous vaginal birth.*

My reader has a few extenuating circumstances: a previous cesarean section (followed by a VBAC), which means prostaglandins are out of the question. She also has a history of malpositioned babies, so she wants to keep her bag of waters intact.

I am wondering if you have information on how to minimize intervention during an induction and tips on how to have a successful induction.

I am 42 weeks 2 days today and my OB is letting me prolong the induction for 2 more days, so I'll be 42 and 4 days. My first child was an induction at 41 weeks with the OB rupturing membranes and then Pitocin. It ended in a C- section for fetal distress. My second child was a VBAC with a spontaneous labor at 42 weeks 2 days.

Mentally I feel that 42 and 4 is as long a I can go, but I am so anxious about an induction. My OB said he could rupture my membranes and see if labor starts, but I have had poorly presented babies in the past (both posterior) and I think this third one is following suit. So I do not want my membranes ruptured; I want them kept intact as long as possible. I will be induced with Pitocin because my OB feels the cervical gel has too great of a uterine rupture risk. So my question is: what can I do to promote a successful, safe, vaginal birth with a Pitocin induction? 
I already emailed her back with some ideas. I'd like to hear from you now!

*Meaning a birth without cesarean section, forceps or vacuum extraction


  1. I was 41 wks 5 days w/ my fourth, and was induced for decelerating heart tones (the midwives' reason) and a bad feeling (my reason before the NST). I had a Bishops' score of 9.

    We did pit at 4 for one hour, w/ breaking the waters in the middle of that, then we unhooked everything, I had a bath, moved around, pushed for about an hour kneeling and then lying on my left side, and had a baby 4 hours and 15 minutes after checking into the hospital.

    Turned out that baby was my only posterior kid; I didn't notice that pain-wise during the labor. I had a sore tailbone for a few days after, and it was more work pushing w/ her than with the two previous (all three before her were with epidurals; my third kid I pushed twice).

    I was really hesitant to get induced bec. I was so wanting a natural birth, and was worried about withstanding the pitocin-contractions w/o an epidural.

    The most important factor for my "success" was having a trust-worthy midwife(who turned off the pit and unhooked me from everything like she'd promised) and a very supportive nursing staff. It also helped that I was Group B neg, so my midwife urged me to get in the tub after my water was broken and I didn't need the IV continually. So even though she was poorly positioned, I think moving around so much from tub to bed to floor to bed, helped her come through anyway.

    Good luck!

  2. Maybe the best option (and one not mentioned), is to do a mechanical induction with a catheter. I'm SUPER short on time right now, but it carries fewer risks. Best source for more info is Ricki Lake's Your Best Birth.
    If she has lots of posterior babies, spend lots of time on hands and knees before the induction.

  3. Stay mobile - try many different positions. A new one that I've tried to good effect with a doula client was marching during contractions to help effecement. Eat and drink as much as possible. Rest whenever possible. Have good support people - supportive husband, doula, anyone knowledgeable and who wants to support the goal of vaginal birth. As much nipple stimulation as possible. If exhaustion and pain are overwhelming, remember that sometimes an epidural can be helpful.

  4. heres my advice as a doula and a VBAC mom myself...

    The best things you can do to insure a VBAC naturally is before you get to the end of your pregnancy - such as finding a care provider who is understanding of your goals and wants to help you achieve them. if you have that, you're in a good place! Secondarily, is to decide what you will and wont do... at least as a foundation. because once you're in an emotional whirlwind (such as being in labour!) it can be hard to make decisions when others may be contradicting your plans. (which is why it's important to only let supportive people into your childbirth "circle"). You can always change your mind in emergency situations! But have a plan in the meantime of what you will and wont do. (such as i wont rupture my waters until and unless the baby is low in the birth canal and my labour hasn't been picking on it's own) etc. Rupturing the sac too early is a common cause of "fetal distress" c/s.

    Pitocin will not work unless your body is ready. This is why it's super important to never try to induce before the rest of you is on board. As you're 42 weeks, that should be an issue... but it's worth taking into consideration. It's also unusual in the US (not sure where you are) to do a pit induction on a VBAC mom... maybe it's different where you are. But keep in mind the more you do to prepare for birth (mentally, emotionally and physically) the less Pit it will take to induce... and the easier it is on your uterus, lowering chances for an emergency.

    if the mom is familiar with self checking, she could see how the baby is sitting... but if not, she could ask for her OB to do so.

    Another thought that really helps move things along is to have an "aggressive" exam. Sometimes stirring things up by touching the cervix and pulling at the protective membranes (not rupturing the sac) will get things moving along when you are late in pregnancy. and also... never forget sex! this is usually unappealing and sometimes uncomfortable in late pregnancy-- but it can be VERY effective at agitating that cervix! :)

    good luck mama!

  5. Try lots of sex, that is the same thing as cervadil!

  6. As a general rule, women should NOT be induced to go into labor, especially if this decision is being based on a "due date". That said, the best and safest way to induce labor is to "try lots of sex" (as Anonymous suggested). If a woman's body is ready for labor, this will work: If a woman's body is NOT ready for labor, then it won't hurt.

  7. The midwives at the birth center where I live do a breast pump induction (shown to be quite successful!). Pump for 15 minutes on each breast (one after the other, not at the same time) with a manual breast pump, then walk for 30 minutes. Complete up to 3 rounds of this, and see what happens. Frequently, moms are contracting regularly after 2 rounds. It seems that a multiparous woman who is 42.4 would have good luck with this technique.

    If a breast pump is not available, a baby would do the trick (generally at 6 weeks or younger a baby will latch on to any breast available). Or a husband, if you're both so inclined!

  8. For my induction at 35 weeks, we did use a catheter for mechanical dilation. That did get me to 2cm before falling out with a bowel movement. Thinking back, we probably could have put it back in, as that was not uncomfortable for me at all.

    We were using pitocin at the same time.

    I refused for my water to be broken, until a day and a half into the process. I was still at 5cm, and it seemed like the best possible option left.
    She was a small baby, so my cervix really needed her head pressed down on it to dilate very well.
    She was born 4 hours later vaginally (no doctor in sight lol).

    It sounds like she has a doctor on her side that is willing to work with her.

    I hope the best for her. =)

  9. I have no expert advice of any kind, but I like the suggestions to try non-medical methods. Maybe the mother can do them before the magic date.

  10. things to try at home:
    evening primrose oil (vaginally and orally)
    nipple stimulation
    castor oil

    I did manual nipple stimulation to try and get my VERY slow to progress 60+ hour labor to speed up. I had to hold a burp cloth under my breast as it got colostrum flowing like crazy- but that let me know I was doing it right! It creates surges of natural oxytocin, and bumped up my contractions to every 2-3 minutes and 1+ minute long after 1 round!

    I am usually a strong advocate against induction, but at 42w2d (as long as it's based on your LMP or ovulation date) is considered overdue. The risks of a hospital induction are higher since you're wanting a VBAC so pitocin, cervadil, or any other synthetic induction methods should be used as a last resort. I personally would not be concerned since you have a history of 42 week long pregnancies! Here's a great resource:

    Sending lots of labor vibes your way!!!!!!!!!!

  11. All I can offer is that my last came out posterior despite waiting for the membranes to rupture on their own (which didn't happen until he was crowning). And in the past rupturing for me always got them out quite fast, but mine are small so they sort of slip out.

  12. What about seeing a chiropractor? Getting the pelvis aligned may encourage a better fetal position--sometimes posterior position will prevent labor from starting on its own.

    Accupuncture induction may be another option to look into.

  13. I've had a pitocin induction and a midwife's induction, both of which resulted in safe vaginal births.

    With the pitocin induction, it took a long time, babe tolerated labor but just barely, and I got stuck at 4 cm for quite a while. I really think being able to move and change positions throughout the labor helped me have a vaginal birth. A big problem for women being induced in the hospital is that there will be continuous fetal monitoring, and moving around can disrupt the strip. I had a nurse that was really pressuring me to stay in bed, then, fortunately, a shift change, and a nurse who was willing to work with me so they could get the strip and I could still move. Try to get them to work with you on this.

    When I got stuck at 4 cm for several hours, the midwife had me lie on my left side for a while, and that seemed to get things moving. This seemed to change the baby's position so he was working with me.

    But the main thing I credit with my vaginal birth was patience. It sounds like your OB already is pretty patient, so I think you have a good shot.

    With the second one, I did a membrane sweep, then the balloon catheter two days later, then cohosh and castor oil the next day. I don't know how safe herbs and castor oil are for VBACs. The balloon catheter didn't do it on it's own for me, though I know it does for many women, so I would definitely consider it. If it doesn't actually get you into labor, it should help put your cervix in a much more favorable/receptive position. I did eventually have AROM in that labor (contractions seemed to be spacing out/getting weaker for several hours), but it was when I was at 7 cm and the baby was very low. Maybe it could be something to hold in reserve? Anyway, all of that allowed me to have the baby without needing pit, and they are things you could now, in the time before your deadline.

    Good luck!

  14. I don't know if this is backed up by research, but anecdotally, it seems that inductions are easier for multiparous women (not necessarily the pain from the pitocin, but in terms of length of labor and likelihood of a vaginal birth). That's not a tip, exactly, but maybe something to alleviate some of the anxiety?

  15. Most important of all is that if there is an emergency and you have a c-section, don't feel like a failure! You are a strong woman that knew what you wanted and did the best you could to achieve your birthing goal!

  16. Most of what came to my mind has already been recommended, but as an LD nurse I will recap and then recommend some additional things to consider and request in the hospital.

    Before you go to the hospital (and once you are there)
    • Nipple stimulation either manually or with a breast pump, willing partner or baby is also an option to start your body releasing it's own oxytocin (the synthetic version of this hormone is Pitocin, a common induction agent).
    • Sex can help get things going because semen has natural prostaglandins in it. So ejaculation in the vagina needs to take place for this to have optimum benefit.
    Once you are in the hospital (or things to discuss with your provider BEFORE you go in).

    • A foley blub induction is a great way to start. (if your care provider knows how to do them)
    • If the induction is not taking, don’t give up! I have seen low dose Pitocin run through the night while mom is sleeping (hopefully) and then beginning to turn up the Pitocin during waking hours. If baby is looking good (reactive tracing with good heart rate variability and accelerations, and no late or persistent variable decelerations) but you are not making progress there is usually no reason why you can't turn off the Pitocin and try again the next day. I used to see midwives do this a lot when I worked in a big city LD. If your water is not broken and baby looks good this can be a good option. It gets you rested and then you can try again. Once you water is broken, you are pretty much commited to a vague timetable for delivery. I agree that this should be your last method to get things going.
    • Once you are in the hospital ask for as much privacy and as little interruptions as possible. As mammals we need to feel safe, private and unobserved (think of a cat who is giving birth). If you feel observed, your body may not respond well. For more on this go to Sarah Buckley’s website, specifically about the hormones of birth.
    • If possible request telemetry monitoring (for fetal heart rate and contraction monitoring). This allows you to move around, get in the tub etc while the Pitocin is running. Most hospitals have policies that if you are receiving any medications to induce or augment labor you have to be on continuous fetal monitoring. Hopefully the hospital you will be delivering at has telemetry.
    • Having an experienced doula at the birth is highly recommended.
    • Finally check out this website on what positions you can do to promote optimal fetal positioning with this baby. http://www.spinningbabies.com/

    Best of luck!

  17. I'm surprised no one has suggested accupressure to start the ctx. This site has descriptions and diagrams: http://acupuncture.rhizome.net.nz/Acupressure/induce.aspx

    I have triggered contractions (just to see if it worked) by using the accupressure point on my hand, in the web space between the thumb and index finger.

    And, chignona, being multiparous does add one point to a woman's Bishop score, so I believe that the research does suggest that a multiparous woman would "take" to induction much better.

    I like Althea's low-dose pit suggestion. Hopefully, it will stimulate the cervix to start contracting on its own, without getting the mother too worn out or too greatly in pain.

  18. Okay ... so I just looked up Bishop's score and see that, as you say, they add a point for a previous vaginal birth, but they subtract a point for postdates. I don't get that. Why would you be less likely to go into spontaneous labor if your due date has passed? I would think it would be the opposite. What am I not getting?

  19. In addition to all the comments about non-medical forms of intervention, I would add thinking about trying to find an acupuncturist. I had a wonderful woman with lots of experience with pregnant and laboring women do a very gentle treatment to encourage labor (she was anti-induction, philosophically, and thought the body should do what it would do) - it worked amazingly, and I had a gentle, lovely labor.

    Another option is to have your membranes stripped - that worked for me as well. It's not as invasive or dramatic as a medical induction or even having your waters broken.

    But practically, I imagine the advice from women re: handling pit inductions will probably be the most helpful to the OP.

  20. Addendum to previous post: It occured to me this morning that if your hospital does not have telemetry monitoring, it might be helpful to have some other suggestions. You can still stay out of the bed as much as possible. Sit on the birth ball next to the fetal monitor, in a rocking chair, on hands and knees in the bed or even standing and leaning forward onto the bed that has been raised up high in the air. Staying in bed, especially in a reclined position does not help the baby rotate into an occiput anterior position, which is easiest for birth.

    If for some reason you are confined to the bed (epidural), be sure to change positions frequently, every half hour if possible. There is a technique we often use called the cork screw position where mom is almost laying on her belly with her bottom leg out straight and her top leg curled up and over. Going from side to side using this position will help "corkscrew" the baby down the birth canal.

    There is another resource I thought of for labor positioning. Injoy vidoes made a "Positions for Labor" DVD. Check with your local library or the hospital childbirth educator to see if they might have a copy.

    Listen to your intuition and to your body. Many blessings on your journey!

  21. I work as a doula, and lately (as others have mentioned) I've had a lot of luck with the foley catheter inductions. Oftentimes the catheter can get women to 4cms relatively easily (although you may already be dilated with this your third child) which along with nipple stimulation, and being nearly ready generally, can kick them into labor.

    Even if the catheter alone doesn't start labor, beginning a pitocin induction at 4cms is a good place to start. I'd make sure you advocate for the pitocin getting turned up very slowly to allow your body and baby to adjust to the dose, if you do end up with a pitocin induction.

    I'd also look into acupuncture to stimulate contractions, and possibly castor oil. I've had two clients go to 42 weeks and have castor oil "milkshakes" be the thing that they attributed to getting their labor going.

    I'll be sending you lots of good birthing energy--hoping that this babe makes up it's mind to come in the next day or so!

  22. Stay as mobile as possible.
    See your chiropractor.
    Use evening primrose oil.
    Sex. the deeper the ejaculate the better.
    Nipple stim combined with squat and push. Push as in labor pushing, not shoving down on your belly with your hands.

    When you feel you can stave off intervention no more, talk to your baby about it.

    Follow your intuition. Listen to your body. You do not have!! to go if you are not ready. Granted, if your dates are right you need to be careful about that but do not go just bc someone said you had to "right now".

  23. A few thought if a pitocin induction is what you choose:
    Start low and increase slowly. It can be routine to increase every 15 min, but I would suggest every 30 min. You want to try to mimic labor with the pitocin. Once you reach a rate that you are contracting every 2-3 min, ask to turn off the pitocin. Often a womans body will continue to contract on it's own without further pitocin. Happy labor day!

    1. Some continue to contract and some do not. It is not a mathematical equation.

  24. So, Rixa, what DID you suggest to her? And, am I understanding correctly that this is Natalie's birth (M & N + C), to which you refer in your most recent blog post?

  25. No, this wasn't Nathalie, but someone else. I haven't heard from her yet and figure she's probably busy with her new baby at this point!

    What did I suggest? I'm trying to recall what I wrote, but I remember I talked about various options instead of/in addition to pharmacological that she might want to look into (i.e., breast pump induction). I wrote about the importance of remaining mobile and upright, looking into telemetry (preferably waterproof, so she can get into the shower), asking about her Bishop score, keeping her waters intact until they rupture spontaneously (especially with her history of posterior babies, plus if waters are intact you have the option of stopping the induction and trying again the next day, if nothing is happening). A lot of the things I mentioned came up in one or more of the comments.

  26. There is a lot of great advice and hopefully she has gone into spontaneous labor and not needed it. I just wanted to throw out the idea of "optimal fetal positioning" to help prevent malpositioning - http://birth-smart.com/2010/07/12/assisting-your-little-navigator/
    Also avoiding the medical induction would be advantageous with a cesarean scar. Best wishes to her!

  27. I was shocked to read that Pitocin was considered gentler than cervidil. When you read stories about "Pit to distress" and horrible contractions caused by Pitocin with no dilation....
    I had two inductions with Cervadil and they went great....almost entirely unmedicated. I was "very favourable", and stayed up and mobile, kept water intact, etc, and the birth itself was quite quick and the labour was almost painless!

  28. @TracyKM--the reason most providers consider Cervadil inappropriate for women with a previous cesarean is that here is no way to "stop" it if the uterus over-reacts to it, whereas with pitocin, you can turn it off if the contractions get too strong and it is usually out of the system very quickly.

  29. Another reason to avoid prostaglandins (Cervadil) is that research shows that a combo of prostaglandins plus pitocin raises the risk for rupture significantly in a VBAC mom.

    Most of my suggestions have been mentioned but I will reiterate them.

    First, see if you have any more wiggle time. You have a history of longer gestations so going "over" is not such a big deal, esp if you have longer cycles too. Plus, I have a hard time believing that the risk of going past dates is greater than the risk of inducing a VBAC mother. If there's any wiggle room, I'd rather go postdates a bit than risk inducing a VBAC.

    Second, see a chiropractor if you have a history of malpositions. Although it's not a guarantee of a well-positioned baby, it probably increases the chances of it.

    Third, do acupuncture to bring on labor. Like other inductions, this will only work if you are close anyhow, but can help bring things on a little faster, or help a mechanical/chemical induction work better.

    Fourth, if you feel you must induce, try a foley catheter induction first, before adding pit. It's statistically less likely to cause a rupture, although it's still more risky than spontaneous labor. Chances are you will need pitocin at some point too, but a foley induction means less pitocin than you might have otherwise.

    Fifth, keep those waters intact so baby doesn't get 'stuck' in a poor position. Also, if waters are intact you keep the option of serial induction (turning off the pit for a while, then trying again the next day). I've seen serial inductions work a number of times.

    Last, mobility, mobility, mobility. Keep as much movement as you can under the circumstances, so you can move to help baby's position and get baby moving down.

    Please let us know how things turned out.


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