Sunday, July 15, 2012

A Guide For Parents-To-Be: Part 2 (Interventions)


Interventions in Labor

When you go into labor you will be so excited, THIS IS IT!!! Many women time every single contraction and anticipate the moment they get to go to the hospital. Lets talk about some things that may happen once you get there. What can you anticipate? 

Many interventions are used in Hospitals today. For example, About 81% of women who birth in a hospital receive Pitocin. Pitocin can double your chance of a cesarean birth. That's where education comes in. The more you know, the more control you can have during your labor. Below are common interventions used. I encourage you to do further research on your own in order to help make educated decisions
Always remember, you have choices.

1. Induction
2. Electronic Fetal Monitoring
3. Other Interventions

Here is a sample document to help you share how you feel about each intervention.

1. INDUCTION- Labor should only be induced if it is more risky for baby to remain inside the uterus than to be born. (American College of Obstetricians and Gynecologists)

  • Artificial Rupture of the Membranes (AROM)- AROM is when the care provider breaks your bag of waters.  The care provider will insert a tool called an amnihook and 'catch' the edge of the amniotic sac. This method is often used to induce labor, allow the care provider to see if there is meconium (baby's first poo) present, and for use of an internal fetal monitor. 
    • Pro's- Labor may be shortened by an hour, allows amniotic fluid to be examined for presence of meconium which could cause fetal distress. 
    • Con's- Baby could turn into breech position making birth more difficult and cesarean birth more likely (if head isn't engaged), umbilical cord could slip out first (prolapsed cord), possibility of infection increases, more intense contractions.
  • Prostaglandin Gel- Medication applied to the cervix prior to induction. Used to thin and shorten (efface/ripen) the cervix which prepares it for birth. There are three types, a gel, oral dose and a tampon-like dose . Prepidil is a gel while Cervidil is applied like a tampon. If over stimulation occurs cervidil can be easily removed, Prepidil can be wiped away but the oral form cannot be removed.
    • Pro's-  Minimally invasive, No IV required, Can be an overnight administration (administered, then sent home).
    • Con's- Ripens cervix but does not induce. Possible symptoms, oral form cannot be removed in case of over stimulation
  • Cytotec- Cytotec or Misoprostol is intended to soften, efface, and assist in dilation as a means of induction. The dose is given in pill form. The pill is placed vaginally against the cervix and cannot be removed once given. It is NOT approved by the FDA for use in labor but still used today. Below are two links, an FDA warning and the Cytotec label.
    • FDA Warning
    • Cytotec Label
    • Pro's- Fast acting, considered reliable
    • Con's- Not FDA approved for use in labor, Has highest reported incidence in all of induction methods, Used with continuous fetal monitoring, cannot be removed once administered
    • Side Effects-  fetal cranial nerve palsies, fetal death, maternal death, severe postpartum hemmorhage, uterine tetany, decreased uteroplacental blood flow, uterine rupture, necessitating hysterectomy, amniotic fluid embolism, placental retention, maternal and fetal shock, fetal bradycardia, uterine tachysystole, higher incidence of infection vs Pitocin and higher incidence of c-section
  • Pitocin/Oxytocin- Pitocin is a synthetic form of the natural hormone Oxytocin. It is used to induce labor and is considered the safest method of induction as it can be regulated. Pitocin is administered through an IV to initiate and regulate contractions. It can be accelerated, reduced or stopped at any time. Many care providers will start an induction using Pitocin then turn it off when things get moving. Many others administer Pitocin after baby is born to stop/prevent hemorrhage.
    • Pro's- Considered safest form of induction, can be mobile, low risk of infection, can stop post-natal  hemorrhage
    • Con's- Aggressive and invasive, Continually administered (use of IV pole and bag), Usually used with continuous fetal monitoring or intermittent monitoring, Labor can progress quickly resulting in need of pain medications, Side effects
2. ELECTRONIC FETAL MONITORING- When admitted into a hospital you will typically go into triage and have monitors strapped to your belly to monitor babys heart beat (typically for about 20 minutes or so). If all looks well some will allow intermittent monitoring. If fetal distress is evident or if mom is high risk, continuous monitoring will be used. 

  • Continuous Fetal Monitoring- Continuous monitoring for low risk women has a lack of benefits. It has shown to increase use of other interventions such as vacuum extractor, forceps use and cesarean section. For high risk women though, continuous monitoring can be the safest way to labor. It can let the care provider know whether baby is in distress or an emergency may arise.
    • Pro's- Safe way of monitoring baby in high risk women, can be reassuring to parents, lets doctors and nurses measure contraction length and duration.
    • Con's- False positives are very common, confines you mom to bed, may be uncomfortable, sometimes machine gets more attention than laboring mom
    • Alternatives- Intermittent monitoring, hand held doppler
Doppler Monitoring- Source
  • Intermittent Fetal Monitoring- Intermittent monitoring is safer for low risk women. This involves monitoring baby for 15-20 minute intervals every hour. Mom is often confined to bed for the time of monitoring. Occasionally hospitals have mobile units but you must ask for them and the nurse must be compliant. 
    • Pro's- Helps doctors and nurses keep track of contractions and determine whether fetal distress may be present. Can be reassuring to parents. Easier on mom than continuous monitoring.
    • Con's- False positives are common, confines mom to bed for intervals, can be uncomfortable.
    • Alternatives-Hand held doppler
  • Internal Fetal Monitoring- Requires the amniotic sac to be broken and at least 2-3 cm dilated. A scalp electrode is entered through the birth canal and placed on the baby's head. This from of monitoring is the most accurate. Often mom can be mobile with this form of monitoring. 
    • Pro's- Most accurate form of fetal monitoring, can be mobile while in use, can  determine whether baby truly is in distress.
    • Con's- Water must be broken, increases chance of infection, can be uncomfortable
  • IV (Intravenous drip)- An IV is a clear plastic tube inserted into a vein in the hand or arm. They are often given in labor to hydrate women and to keep the vein open for administering medication in case of an emergency(ICE). Some OB's and midwives routinely use an IV on all laboring women. 
    • Alternatives include hydrating with clear liquids, ice chips, Popsicles, etc. (some hospitals have a nothing by mouth policy). Another alternative is using a Heparin Lock, which keeps the vein open in case of emergency but is not accompanied by an IV bag or pole. 
    • Pro's- Keep mom hydrated, Keep vein open ICE, Easy access ICE
    • Con's- Fluid overload resulting in fluid in mom and baby's lungs, diluted blood/anemia/reduced blood oxygen supply to baby, newborn jaundice, hinders moms movement in labor, usually used with continuous monitoring.
  • Heparin Lock- Also known as a Hep or saline lock. Most facilities require having at least a Hep lock when in labor. Usually it is inserted into the vein on the top of your hand. It can be uncomfortable at times but is a nice alternative to an IV. Like an IV, a Hep Lock is used to keep a vein open in case of emergency. It can also be used to administer pain medication, administer antibiotics if the Strep B test was positive, or Pitocin in case of induction or postpartum hemorrhage.  
    • Pro's- No pole/bag unlike IV, Easy access ICE, Keep vein open ICE, Administer antibiotics then close for remaining labor.
    • Con's- Can be uncomfortable
  • Vacuum Extractor- A vacuum extractor is used to assist in birth. This tool uses suction to either turn the baby's head or pull baby through the birth canal. As shown above, it looks like a suction cup attached to a handle. This is often used if the mother has an epidural, is physically exhausted, the baby is in a difficult position or the baby is getting a lack of oxygen.
    • Pro's- Helps baby descend through birth canal in case of an emergency or if mom is not able to push him/her out on her own.
    • Con's- Baby may have a red area or small bruises on face. Scalp may have blood blister or small bruises. There rarely can be trauma to the facial nerves.
  • Forceps- Forceps are also used to assist in birth. This tool looks a bit like salad tongs which are placed around baby's head and baby is gently pulled from the birth canal. These are often used if the mother has an epidural, is physically exhausted, the baby is in a difficult position or the baby is getting a lack of oxygen.
    • Pro's- (See Vacuum extractor)
    • Con's- (See Vacuum extractor)
If you really want to see an episiotomy, google it!
(I'm thinking about those with a weak stomach)
  • Episiotomy- An episiotomy is a surgical incision used to enlarge the vaginal opening to help birth baby. At one time it was common practice to perform a routine episiotomy with first time mothers. Some old-school doctors still follow this procedure! Ask your OB or midwife how they feel about them to determine your chance of receiving one. 
    • Pro's- Quicken delivery in case of emergency. Used in an assisted delivery (forceps/vacuum extractor). Easier to stitch up than a tear.
    • Con's- Infection, bruising, swelling, bleeding, longer healing time, painful scarring, a period of remaining abstinent, incontinence. Raises risk of tearing.
    • Alternatives- Place clearly in your birth plan that you do not want to have one unless absolutely necessary. Perineal tear. 
    • Prevention- Kegals, exercise (including squatting), controlled (by mom) pushing, perineum massage, avoid  lying on back while pushing, warm compresses
If you really want to see a perineal tear, google it! 
(I'm thinking about those with a weak stomach)
  • Perineal Tear- A perineal tear is a tear in the tissue found between your vaginal opening and anus. They range from small nicks to deep lacerations. Often, women would rather tear than have an episiotomy. 
    • To illustrate: Try to tear your shirt in half, it is pretty hard to do right? You have to put forth A LOT of force in order to do so. Now put a little cut in it and try to tear it in half again. It happens so much easier now right? 
    • Pro's- Heals faster than an episiotomy. 
    • Con's- Can take longer to stitch up than an episiotomy. Uncomfortable or painful healing, Swelling, bleeding, bruising.
    • Alternatives- Use prevention Techniques in  preparation of birth, Episiotomy.
    • Prevention- Kegals, exercise (including squatting), controlled (by mom) pushing, perineum massage, avoid  lying on back while pushing, warm compresses

Interventions aren't always needed. However, in case of an emergency it is best to be educated in what is going on. Doctors don't always clue you in so make sure your partner or support person is paying close attention in order to intersect any unwanted interventions. Knowledge is your friend. Don't forget to check out the free download above to help you convey your wishes!

Sending Easy Birth Dust Your Way!!

                              (Vaccinations, feeding baby, circumcision, discipline, and routine procedures)
To be covered in part 4: Making Decisions on Raising Baby
                             (Babywearing, Day Care, Montessori Method, Co-Sleeping, Introducing Solids)
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  1. The ABI test is fast and painless, and does not require entering the body so Vascular Doppler is must.

  2. If the blood pressure is lower in your legs than in your arms, it may indicate that PAD is restricting blood flow in your legs, so arterial doppler is must.


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