60 Tips for Healthy Birth: Part 4 – Avoid Interventions that Are Not Medically Necessary

In this six-part series, we are sharing 10 tips for each of the Lamaze six Healthy Birth Practices that help guide women toward a safe and healthy birth. The Lamaze Healthy Birth Practices are supported by research studies that examine the benefits and risks of maternity care practices. Learn more about each practice, including short, informative videos at Lamaze.com. To read the rest of the 60 tips, check out the other posts in this series.

10 Ways to Avoid Interventions that Are Not Medically Necessary

1. Learn why avoiding interventions that are not medically necessary is important for you and your baby.

2. Ask your care provider (the earlier, the better) about the kinds of interventions they use and when they use them. You can ask about their rates of interventions, but you’ll  most likely get more accurate and telling answers with more open-ended questions, like, “For what reasons would you recommend an induction?” and “Why would I need a cesarean?”

3. Take a quality childbirth education class to really get to know different interventions and how they interplay with one another. For example, you cannot be induced without having continuous external fetal monitoring and IV fluids.

4. Learn about the interventions used regularly at your chosen place of birth. Sometimes, those rates are available publicly and sometimes (more often), they are not. You can also ask during your hospital tour or at a prenatal visit with your care provider. But your best bet is to ask local doulas and childbirth educators, who will most certainly have insider knowledge.

5. Research and practice a variety of coping and comfort measures, as well as position changes, to use during your labor and birth.

6. Consider hiring a doula, who is trained on the use of interventions and can offer additional resources for you to make the best informed decision about your care. A doula will not advocate on your behalf, but can help you be a better advocate for yourself.

7. When you hit 40 weeks and there is no sign of labor, remind yourself that 40 weeks is not a deadline but a vague estimate and that a healthy pregnancy can go to 42 weeks and beyond. Also remind yourself that you will not, in fact, be pregnant forever. As uncomfortable as you may be at 40 weeks of pregnancy, the healthy choice in most cases is to let labor begin on its own.

8. If faced with the decision to induce your labor, first find out why, and second, find out your Bishop’s Score. And, learn why an induction might be necessary and when it is not.

9. Make sure your partner or birth support person (spouse, partner, friend, family member) knows about your birth preferences and understands how best to support you during birth. Your birth partner will be an invaluable asset to your birth experience.

10. Interventions can be medically necessary and life-saving. If interventions become necessary, find out how you can keep your labor as healthy as possible.

 

photo credit: Rick Bolin via photopin cc

The Straight Scoop on Inductions

The holidays are upon us. If you are due on or near a major holiday, you will be more likely to face the decision of whether or not to get induced to go into labor. But before you succumb to the pressure of planning your baby’s birth date to avoid a holiday, first consider the realities — and risks — of induction. Lamaze created a the following infographic to illustrate the problems with, pressures of, and decision points surrounding induction. For more information on induction, check out the resources on Lamaze.org.

 

 

Thinking of Getting Induced? Know the Odds

39 weeks pregnant can be a tough time. You’re so close and yet, you’re not in labor. Perhaps you don’t even have any signs of labor, or worse — you’ve thought you were in labor three separate times now. Forget the physical discomfort and exhaustion — the difficulty now is all mental. Your spouse, your mother, your best friend are all checking in on you, watching you, waiting for you to report any sign, any contractions… anything at all! And as if that isn’t enough, a friend, your sister, even your doctor starts talking about getting induced. You are, after all, at 39 weeks. Why wouldn’t you?

The thought of getting induced near the end of your pregnancy can sound alluring. You get to plan around your baby’s birth day, you can stop wondering if you’ll know when you’re in labor, and you’ll finally be done with being pregnant! But before you jump so quickly on the “getting induced because I can” train, let’s take a look at the odds.

Getting induced nearly DOUBLES your chance of having a cesarean. (Source)

Cesarean surgery (or c-section) significantly raises your and your baby’s risk of complications. See this complete list. Beyond cesarean, different methods and medications used to induce carry additional risks. Unless you are considering induction for a true medical reason, take some time to think about the implications that induction could have for you and your baby. If your care provider is recommending induction, ask about your Bishop score. If you are a first-time mom and your Bishop score is less than 6, your risk of cesarean is the highest at 50%.

Waiting can be really, really hard. And uncomfortable. And long. But waiting until your baby initiates labor has so many benefits (see here, it’s worth 5 minutes of your time). Think of the trade offs. Putting in the hard time now can really pay off in the end.

 

 

 

Early Induction: What You Should Know

In line with last week’s post about recommendations against elective induction before 39 weeks, let’s talk about what an early induction means. Below are some basic points with links to more in-depth information from evidence-based resources.

How early is an early induction?

An “early induction” is any induction that is performed before 39 weeks of pregnancy. Experts from several recognized organizations, including the American College of Obstetricians and Gynecologists (ACOG), Childbirth Connection and March of Dimes, state that a baby needs at least 39 completed weeks in order to fully develop their brain and other vital organs.

What are the risks of early induction?

Induction in and of itself carries risks to mom and baby. Because induction is an artificial process for starting labor, your body may not be ready to follow its cues. As a result, inductions can cause a cascade of additional medical processes (interventions) to keep labor going, which can ultimately lead to an increased risk for cesarean surgery. Unless there is clear medical indication (see below), letting labor begin on its own is the safest decision.

Induction before 39 weeks brings an additional risk of prematurity. Babies born even a little too early can experience complications like problems with breathing, feeding, maintaining body temperature and jaundice. In most cases, babies know best when it comes to being born.

What if I need to be induced?

There are solid medical reasons for induction before 39 weeks. Being done with being pregnant, isn’t one of them. ;)  There are also several reasons given for induction that are not true medical reasons. It’s important to know the difference. Click through and read up on the two links provided above on the new induction resource page on Childbirth Connection, a not-for-profit organization founded that works to improve the quality of maternity care.

If you’re pregnant and faced with the decision to induce — and even if you’re not — read up! Inform yourself. Learn all that you can, from sources in addition to your care provider and other than well-meaning family and friends. Start here:

“Choosing Wisely” & Reading the Fine Print with Maternity Care

Did you know there are organizations out there that work to set checks and balances for our system of medical professionals? The ABIM Foundation, founded by the American Board of Internal Medicine, has made it their mission to enhance quality of care by encouraging regular assessment and improvement of our physicians, bringing diverse groups and leaders together, and promoting research. In line with their mission, ABIM Foundation developed the Choosing Wisely® initiative. Choosing Wisely aims to promote conversations between physicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

As a result, ABIM  developed a list, with input from national medical organizations, of  “Five Things Physicians and Patients Should Question.” The idea is that these lists (separated by medical specialty) will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments. This is great news for us as consumers — what more do we want than transparency with our care? We want to know if the test or treatment that’s been prescribed is truly necessary and helpful. We also want to know the risks, weighed properly against the benefits. With regard to maternity care, Choosing Wisely developed the following recommendations:

Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age.
Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.
Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

Considering the high rates of elective inductions, often prior to 39 weeks, these recommendations are a breath of fresh air. Of course, this is not the first stand that has been taken against unnecessary inductions (the American College of Obstetricians, ACOG, has included this directive for some time). But with these particular recommendations, there is added stress on the importance of not inducing unless there is a favorable cervix, and the added emphasis that “labor should start on its own initiative.”

While these recommendations represent a healthy step forward in improving our maternity care, there are some concerns about how they could be misunderstood. In a review of these guidelines on the Lamaze blog, Science & Sensibility, Amy Romano of Childbirth Connection questions, “will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe?” In other words, Romano cautions:

The best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

 So, while the Choosing Wisely recommendations are important and helpful in our quest for the best maternity care, it’s vital to keep in mind that, unless medically indicated, a date or length of pregnancy (ie, 39 weeks) should not be the reason for induction. It’s still best to allow labor to begin on its own. For a better understanding on the importance of labor starting spontaneously, check out the Lamaze Healthy Birth Practice video:

 

Have you experienced pressure to induce? What did you do? How did you discuss it with your care provider?

 

To Induce or Not Induce

Are you approaching your due date or sitting, waiting past your due date? If so, it’s possible that you may be considering an induction. Before you mark your calendar, be sure to do your homework. An induction can be a helpful procedure for moms & babies who need it for medical reasons, but when induction is used outside of necessity, you should know about the risks. The following is reprinted from the Lamaze “Push for Your Baby” campaign website

An increasing number of hospitals are working hard to reduce the number of inductions they are doing, and for good reason. Artificially starting labor may be good for a care provider juggling a busy calendar, or your mother-in-law who wants to book her plane tickets, but it can make labor harder and more painful for women, and stress babies and jeopardize their health. Studies have consistently shown that the risk of having a C-section for first time moms nearly doubles with induction. It also increases your baby’s chance of being born premature. That’s because due dates aren’t an exact science. Even if you and your care provider are positive about your dates, every baby matures at a different rate. Inducing labor can mean your baby is born before he or she is ready.

Aside from the risks of induction, there are specific benefits to letting labor start on its own. During the last part of your pregnancy, your baby’s lungs mature and get ready to breathe. He or she puts on a protective layer of fat, and develops critical brain function through 41 weeks of pregnancy. Cutting the pregnancy short can be tough on your baby.

Before going through with an induction, tell everyone to hold their horses, and take time to learn more about benefits of letting labor start on its own.

What’s Next?

So, how do you get a better idea of the care your doctor or midwife will provide? Ask good questions! Take a look at some suggestions.

Talk Back

How about you? Are you hoping to avoid certain interventions in your baby’s birth? Have you experienced interventions that made your birth harder? Did you successfully avoid an intervention that helped make your birth easier and safer? Tell us your story in the comments.

Are You Due on Christmas? Don’t Be Pressured into an Induction!

In the rush of the holiday season, most people worry about on-time delivery of important gifts and packages for friends and loved ones.  But if you’re a pregnant woman due around the holidays, there’s an added worry about when your baby will arrive.

Around the holidays, many pregnant women experience pressure from family or their healthcare providers to “schedule” their baby’s birthday around festivities and travel plans.  Be aware, however, that scheduling a baby’s delivery without a compelling medical reason can put your baby at risk.

“Few doctors want to be pacing the halls on Thanksgiving or Christmas, waiting for a mother to deliver,” said Marilyn Curl, CNM, MSN, LCCE, FACCE and president of Lamaze International.  “So it’s not uncommon to see a surge of women with normal pregnancies being told that there might be an issue and that they should consider scheduling the delivery, coincidentally, right before a holiday.”

It’s not just your healthcare professional who may try to rush your baby’s arrival.  Families often can feel stressed about the uncertainty of the baby’s arrival and feel it may compromise the celebration of holidays.  Some women also fear that their preferred healthcare provider won’t be available and will agree to a scheduled early delivery to guarantee that their provider will be available for the birth.

“I really understand that pressure.  You build a relationship with your care provider over the course of a pregnancy.  Plus, you build up expectations about your holiday celebration.  So it seems like ‘no big deal’ just to get the birth over with,” said Sue Galyen, RN, MSN, HCHI, LCCE, FACCE, a Lamaze childbirth educator from Brownsburg, IN.  “But it’s so hard to think that a scheduled delivery, whether through induction or cesarean, was worth it when either the mother or baby experiences a complication as a result.”

One complication of scheduling your baby’s birthday is that often, baby is delivered just a little too early.  A growing body of research shows that giving a baby those last few weeks or days inside the uterus can be crucial to the baby’s health.  Babies born even a “little” early face risks including breastfeeding difficulties, learning and behavioral problems, breathing problems, increased chance of time in the neonatal intensive care unit (NICU) and risk of death.

You can play a key part in driving down avoidable prematurity.  “Red flags” that might signal being pressured into an unnecessarily early delivery include:
• The care provider suggests that the baby is too big and will be easier to deliver “a little early”
• The suggestion is made that the care provider won’t be available for a holiday delivery or will be “booked up”
• The timing of the delivery is centered on travel and celebration schedules
• Holiday stress is driving feelings of wanting to get the pregnancy “over with”

Here are some things you can do if you feel you are being pressured into an early delivery:

  • Ask your provider if you need to make a decision right now.  If not, ask why not?  Few decisions need to be made on the spot unless the mother or baby are clearly doing poorly.
  • Research your options.  Use credible sources of information, like LamazeChildbirth ConnectionMothering Magazine’s online forum or your doula to see what the research says and talk to other moms about their experiences.
  • Make a pro/con list.  Label your pros and cons with “medical” vs. “personal” and weigh the “medical” pros and cons more heavily.  If you are talking about a major medical intervention like cesarean or induction and you don’t have a good list of cons, it’s a good sign that you need to do more research.
  • Trust your gut.  Your instincts are geared to protect you and your baby from risk.  Listen to what your gut is saying in the context of the research.
  • Find support.  It’s hard to disagree with your health care provider, so be sure that you go into your appointments with someone who can help you have an informed, evidence-based conversation about your best options.

Inducing labor without a compelling medical reason is one of many routine interventions that has not proven a medical benefit to mothers and babies and can impose harm.  Other common routine interventions include continuous fetal monitoring, coached pushing, being positioned on your back during labor, requiring repeat cesarean surgeries for women with a prior cesarean and separating mothers and babies after birth.

You can learn more about the Lamaze Six Healthy Birth Practices by enrolling in a Lamaze childbirth education class and visiting www.lamaze.org/healthybirthpractices.

Finding Your Most Accurate Due Date

Calculating your due date can be tricky. Unfortunately, it’s not as simple as knowing the date of your last menstrual period (LMP), a tool used by most online due date calculators and care providers. Even the high-tech ultrasound, which can be helpful in detecting some things, is not the best at figuring out your due date.

Knowing your most accurate due date is important as you near the time of birth. Many care providers impose limits for how long a woman can go past 40 weeks before scheduling an induction (despite guidelines from the American Congress of Obstetricians and Gynecologists stating that a full-term pregnancy is 42 weeks). If your due date is calculated for July 1, but your actual due date is July 10, you may receive unwarranted pressure to induce when in reality, your baby has not even reached 40 weeks gestation. Inductions carry a host of risks and interventions and should be scheduled only if medically necessary for the health of you and your baby.

So how do you calculate your most accurate due date? Childbirth Connection has created a simple worksheet to answer questions and use in conjunction with your care provider to determine your due date. The form is below, and it can also be downloaded on the Childbirth Connection website.

 

 

 

Induction and the Holidays: Part 2

In case you missed the first post in this special holiday series, we are talking about induction and the holidays. Women may feel the pressure to schedule an induction if their due date falls on or near a major holiday. Pressure can come from all sides — care givers, family, and even from within. If you’re feeling the pressure to schedule an induction that is not medically necessary, we urge you to do your homework and ask questions.

Today, we’re talking about where to find the best, evidence-based resources on induction.

Resources for Information on Labor Induction

Childbirth Connection – Childbirth Connection is a not-for-profit resource center dedicated to helping women and health care professionals make informed maternity care decisions. Among the many topics on their site, they have an in-depth section called “Induction of Labor.” Questions addressed include medically necessary reasons for induction, tips for avoiding induction, and the safest point in pregnancy for babies to be born.

 

March of Dimes – March of Dimes is a not-for-profit group that helps moms have full-term pregnancies and researches the problems that threaten the health of babies. March of Dimes has a resource on their site that explains why at least 39 weeks is best for your baby, including detailed information on the important development that babies undergo in the final weeks and days before they are born.

 

ACOG – The American Congress of Obstetricians and Gynecologists is the organization responsible for developing guidelines by which most OB/Gyn offices are expected to follow. Their site offers a basic FAQ section on labor induction that, most notably, states, “Unless a problem occurs, labor induction is not done before 39 weeks of pregnancy.”

 

If you’re looking for more information on induction and would like to talk to an expert, Lamaze International is hosting a live web seminar on December 12 called, “Is Labor Induction Right for You?“ During this one-hour interactive session, you will:

1. Receive unbiased, research-based information to help you in your decision-making process regarding labor and elective induction.
2. Interact with a professional Lamaze educator and other expectant parents.
3. Learn about indications for induction and what to expect during labor induction.
4. Discuss “talking points” to aid communication with your care provider on induction of labor.

Whether you’re facing induction or considering it, we urge you to learn more to make the best decision for you and your baby.

 

Induction and the Holidays: Part 1

Throughout the rest of this month and December, Giving Birth with Confidence will be posting information on inductions. Why now? Well, if you are pregnant and due around one of the major holidays, you might be feeling the pressure to induce so that you’re not giving birth on Christmas day, for example. We want to give you some solid reasons to think twice about induction as well as information to use if your care provider or well-meaning family and friends start mentioning the “i” word.


Is Your Baby Due on a Holiday? Don’t Be Pressured into an Early Delivery!

In the rush of the holiday season, most people worry about on-time delivery of important gifts and packages for friends and loved ones.  But if you’re a pregnant woman due around the holidays, there’s an added worry about when your baby will arrive.

Around the holidays, many pregnant women experience pressure from family or their healthcare providers to “schedule” their baby’s birthday around festivities and travel plans.  Be aware, however, that scheduling a baby’s delivery without a compelling medical reason can put your baby at risk.

“Few doctors want to be pacing the halls on Thanksgiving or Christmas, waiting for a mother to deliver,” said Marilyn Curl, CNM, MSN, LCCE, FACCE and president of Lamaze International.  “So it’s not uncommon to see a surge of women with normal pregnancies being told that there might be an issue and that they should consider scheduling the delivery, coincidentally, right before a holiday.”

It’s not just your healthcare professional who may try to rush your baby’s arrival.  Families often can feel stressed about the uncertainty of the baby’s arrival and feel it may compromise the celebration of holidays.  Some women also fear that their preferred healthcare provider won’t be available and will agree to a scheduled early delivery to guarantee that their provider will be available for the birth.

“I really understand that pressure.  You build a relationship with your care provider over the course of a pregnancy.  Plus, you build up expectations about your holiday celebration.  So it seems like ‘no big deal’ just to get the birth over with,” said Sue Galyen, RN, MSN, HCHI, LCCE, FACCE, a Lamaze childbirth educator from Brownsburg, IN.  “But it’s so hard to think that a scheduled delivery, whether through induction or cesarean, was worth it when either the mother or baby experiences a complication as a result.”

One complication of scheduling your baby’s birthday is that often, baby is delivered just a little too early.  A growing body of research shows that giving a baby those last few weeks or days inside the uterus can be crucial to the baby’s health.  Babies born even a “little” early face risks including breastfeeding difficulties, learning and behavioral problems, breathing problems, increased chance of time in the neonatal intensive care unit (NICU) and risk of death.

You can play a key part in driving down avoidable prematurity.  “Red flags” that might signal being pressured into an unnecessarily early delivery include:
• The care provider suggests that the baby is too big and will be easier to deliver “a little early”
• The suggestion is made that the care provider won’t be available for a holiday delivery or will be “booked up”
• The timing of the delivery is centered on travel and celebration schedules
• Holiday stress is driving feelings of wanting to get the pregnancy “over with”

Here are some things you can do if you feel you are being pressured into an early delivery:

  • Ask your provider if you need to make a decision right now.  If not, ask why not?  Few decisions need to be made on the spot unless the mother or baby are clearly doing poorly.
  • Research your options.  Use credible sources of information, like LamazeChildbirth ConnectionMothering Magazine’s online forum or your doula to see what the research says and talk to other moms about their experiences.
  • Make a pro/con list.  Label your pros and cons with “medical” vs. “personal” and weigh the “medical” pros and cons more heavily.  If you are talking about a major medical intervention like cesarean or induction and you don’t have a good list of cons, it’s a good sign that you need to do more research.
  • Trust your gut.  Your instincts are geared to protect you and your baby from risk.  Listen to what your gut is saying in the context of the research.
  • Find support.  It’s hard to disagree with your health care provider, so be sure that you go into your appointments with someone who can help you have an informed, evidence-based conversation about your best options.

Inducing labor without a compelling medical reason is one of many routine interventions that has not proven a medical benefit to mothers and babies and can impose harm.  Other common routine interventions include continuous fetal monitoring, coached pushing, being positioned on your back during labor, requiring repeat cesarean surgeries for women with a prior cesarean and separating mothers and babies after birth.

You can learn more about the Lamaze Six Healthy Birth Practices by enrolling in a Lamaze childbirth education class and visiting www.lamaze.org/healthybirthpractices.