Induction is the term used for artificially starting the labor process.  This is used for babies that are “post dates” or “late”, are expected to get too large before the expected due date, are experiencing certain complications (either mom or baby), or for moms who want to plan the date of their baby’s birth.  As with everything that changes the course of nature, induction certainly has its side effects.

As a general rule, induction should only be used when absolutely necessary to protect the mother and baby.  It carries serious risk and can create additional problems.

There are a variety of ways labor can be induced.  It is a great idea to study up on induction while pregnant so you are aware of your options and the process should this happen to you.

Here are some questions you should ask, when faced with the suggestion of an induction from your care provider:

Questions to ask before an induction: 1.   Why is this being recommended?2.   What are the benefits of inducing labor and what are the possible risks?3.   Is this something that I need to make a decision about now or can I have time to think about it and discuss it with my partner?4.   Are there ways that I can get more information about how my baby is doing? 5.   What is my time frame?6.   If I did agree to the induction, how would it be done?7.   If I did agree to the induction, would I be able to use a telemetry unit?  Would I be able to move around, use the shower or get into the labor tub?

8. If Pitocin is used, would we be able to turn it off once the labor got active and see if I could continue laboring without it?
9. What are my options?

Prenatal Panel

In the first trimester, you will probably receive a group of tests known in many health centers as the “prenatal panel.”  This panel of tests usually includes, but is not limited to, a complete blood count (CBC), blood typing (including Rh screen), rubella viral antigen screen, and hepatitis panel.  

Other tests may be obtained based on your health and previous pregnancy history. What is the CBC?A complete blood count (CBC) offers clues about your general health by analyzing three components of blood: red blood cells, white blood cells, and platelets. If any of these cells is out of balance, you may have a condition that needs to be addressed. For example, a CBC estimates the volume of your red blood cells. This measurement is called the hematocrit. If your hematocrit is low, you may be anemic, which is a common condition during pregnancy. Your health-care provider may recommend you boost your iron stores eating more iron-rich foods such as liver, lean red meat, dried fruits and nuts, leafy green vegetables, and iron-fortified breads and cereals. An elevated or low white blood cell count may indicate infection or inflammation because these cells are the body’s infection fighters. Platelets are very small cellular components of blood that help the clotting process. 

What is Blood Typing?A blood test will disclose your blood type if you don’t know it already. Each of the major blood types — A, B, AB or O — comes in two different varieties: negative and positive.   People with a negative blood type lack a certain protein called an Rh antigen. People with a positive blood type have this antigen. This information is important because complications can arise if your baby is Rh positive and you aren’t. What is Rubella?Another blood test will confirm whether your blood has antibodies to the rubella virus. Antibodies are special proteins produced by your body’s immune system as a response to a foreign substance, such as a virus. If you previously had rubella you develop “natural immunity,” or protection against the illness and you’re unlikely to get it again. If you don’t have any immune defenses against rubella, your doctor will advise you to steer clear of anyone who might have the disease. This is because the disease can cause serious complications during pregnancy, especially during your first trimester. Potential complications include miscarriage, stillbirth, or significant birth defects such as deafness, stunted growth, heart irregularities and mental retardation. These complications are called congenital rubella syndrome, and although your doctor may give you antibodies to help fight off infection, they won’t entirely eliminate the possibility of your baby developing the syndrome. If you aren’t immune to rubella, pregnancy is not the time to get vaccinated because the virus in the injection could be passed on to your fetus. Consider getting vaccinated after your baby is born if you’re planning to have more children.What is Hepatitis B?A blood test is the only surefire way to tell whether you’ve been infected with hepatitis B, a virus that attacks the liver. Hepatitis B usually spreads through sexual contact, shared needles, or bodily fluids. Although many people with this disease are entirely symptom-free, you can pass on the infection to your baby during childbirth. Hepatitis B doesn’t usually cause problems during pregnancy for either you or your unborn child.   However, during labor and delivery, large amounts of blood and other fluids are exchanged between mother and child, putting your infant at greater risk of exposure to the virus. If you are infected, To lower the risk of spreading the infection to your baby, he/she will be given hepatitis B immune globulin, as well as a vaccine immediately after birth. What is Syphilis?A blood test is also the best way to diagnose syphilis, a sexually transmitted disease that can easily go unnoticed in women. This uncommon but serious infection can also be transmitted to your developing child during pregnancy and delivery. Syphilis can cause miscarriage, stillbirth, or premature rupture of the amniotic sac or membranes. An infant born with the disease may have brain, liver, spleen, skin, bone, ear, or eye problems. If you are infected, it’s important to get treated with penicillin –particularly during the first few months of pregnancy — to greatly lower the risk of long-term damage to your developing baby. Treating a newborn immediately will prevent further harm in many cases.

Amniocentesis

An amniocentesis is available for women over 35, for women with a family history of genetic disorders, and for expectant mothers who have had a quad-screen suggesting the possibility of a genetic disorder.   

Amniocentesis diagnoses the possibility of:

• Chromosome problems (such as Downs syndrome)
• Genetic diseases (such as cystic fibrosis, sickle cell disease)
• Neural tube defects (such as spina bifida)

Aside from testing for chromosomal abnormalities or birth defects, an amniocentesis can also test the baby’s lungs to see if they are mature if the mother is showing signs of premature labor, or if the mother will need to be induced early.  The amniocentesis can also determine the sex of the baby. 

How is it done?A needle, guided by ultrasound, is inserted through the abdomen into the amniotic sac to collect fluid surrounding the baby.  The amniotic fluid holds cells shed from the baby, and is an accurate way to test for chromosomal abnormalities and some birth defects.   

Results can be had in about 2-4 weeks, and findings are quite accurate. 

Amniocentesis is not without risk.  It can cause miscarriage in about 1-2 pregnant women out of 200.  There is also an increased risk of infection.

Chorionic Villus Sampling (CVS)

Having a CVS done will diagnose chromosomal abnormalities, such as Downs syndrome, Tay-Sachs disease, cystic fibrosis, or sickle cell anemia.  Because the placental tissue does not include amniotic fluid, some birth defects, such as spina bifida, can not be tested for. 

How is it done?A thin tube, guided by ultrasound, is inserted through the cervix and up to the placenta where a small amount of the placental tissue is removed (B) OR tissue is removed via a needle inserted through the abdomen (A) similar to the amniocentesis.   

This is generally done between 10-12 weeks, and  is available for women who will be 34 years of age or older when they deliver, or for those with a family history of genetic disorders diagnosed by CVS.  The CVS is not routinely available for pregnant women, and a meeting with a genetics councilor is required prior to the procedure.                                                                                                    CVS is considered more risky than the amniocentesis, causing more miscarriages, limb defects, and also carries the risk of infection.  Results can also be confusing to read, requiring more testing to understand the results. CVS is not as accurate as the amniocentesis, but the benefit for some is the chance to learn early in pregnancy that there could be chromosomal abnormalities.

So there are ways to try and reduce the possible side effects you or your baby may experience from an epidural.  here are a few ways:

• Labor as much as possible naturally before you accept the epidural.  While it may be more painful in the end to have to sit still for the procedure, the longer you can stay up and active (which helps reduce pain on its own) the length of labor time you have left (and as a result, the amount of exposure to the medication), will be less.
• Request lighter medication
• The staff will monitor you and your baby

The following intervention can/will take place:

• Restriction to bed
• frequent checks of blood pressure and oxygenation
• Monitoring mothers heart w/ EKG
• Restriction of food & usually drink
• IV fluids
• Bladder cath
• continuous electronic fetal monitoring
• aggressive use of pitocin to prevent a stall in labor
• additional drugs to counteract itching, nausea, low blood pressure
• forceps, vacuum, cesarean, episiotomy
• if mother has a fever, baby will be taken to nursery for observtion, septic workup and IV antibiotics
• issues with breastfeeding may occur as a result of the medication

For many women, epidurals are the pain relief of choice during labor and birth.  Unfortunately, many women are led to believe that they are completely safe, work effectively every time, and are nothing to worry about.  Many women and sometimes doctors claim they enhance the labor and birthing process and make for a happy, memorable event for the parents.  Some women decide early in their pregnancy that they want an epidural as soon as they go into labor.  It seems to be a growing trend that women “shouldn’t have to” experience pain during labor.
While epidurals are used nearly routinely in most hospital environments, they are not without their side effects to mom and baby, nor are they something to be worry-free about.  I am very surprised by the frequency of doctors claiming they are safe while there is evidence documenting the opposite.  The more I teach and follow up with my students and talk with pregnant women who are not students but have questions, the more frequently I run into women who have had short term or long term problems as a result of their epidurals, or their labor was effected in such a way from the epidural that a cesarean section or instrumental delivery had to be done. 
I’d like to start blogging about epidurals, doing little parts at a time. I think it makes for easier reading instead of putting everything out there at once.  This is something women need to know about, and need to educate themselves from a variety of sources.  There are a variety of ways to reduce pain during labor – both medical and non-medical – and each is capable of enhancing your labor and birth experience, while still making for happy memories.
Epidurals DO have their place in labor and delivery, and I will get into that.  But first I’d like to start off with what an epidural is and how it’s used, so we’re all familiar with it before I go into more detail.

Stay tuned…

Many babies - about 60% of full term and about 80% premature - develop jaundice.  This is the end result of too much bilirubin in the baby’s system and the liver is not able to break it down effectively when they’re born.  The yellowing of the skin is due to the bilirubin being absorbed and the circulatory system carries the excess to all the body tissues.

No on really knows why some babies develop jaundice and others don’t.  It seems to be a pretty common occurance!  Babies tend to have a higher chance of jaundice when there are medicines used during labor such as pitocin and epidurals, infection, hemorrhage, too much acid in the body and Rh incompatibilities.

For most babies, regular feedings and exposure to sunlight is all the treatment a baby will need.  If you are breastfeeding, your pediatrician will likely suggest you feed your baby formula in the early days to help “flush out” the bilirubin.  Avoid formula if at all possible especially during the early days and weeks.  Jaundice babies need to eat often to assist removal of the bilirubin - and breastmilk will digest faster than formula, leaving baby ready for more.  Breastmilk is also the gentlest on your baby’s digestive system, and of course superior nutiriton compaired to formula.  Your baby needs those antibodies and the other live properties of breastmilk that formula lacks.

If your baby develops jaundice within 24 hrs. of birth, it may be pathologic in nature, requiring treatment.  If your baby develops jaundice during the first few weeks of birth, it may be breastmilk jaundice from a substance in mothers milk that interfers with bilirubin metabolism.  It is still safe to breastfeed in most cases!  This will usually dissapear in a week or two.

Physiologic jaundice (as mentioned above from an immature liver) and breastmilk jaundice usually require no actual treatment other than frequent feedings and exposure to sunlight.

Babies may have daily blood draws to measure the bilirubin level to make sure it doesn’t get too high.  If your baby does require treatment, typically babies undergo phototherapy, which is exposure to flourescent lights.  Some hospitals have fiberoptic phototherapy blankets which enable the baby to be held and fed while still undergoing treatment. These blankets can even be taken home so your baby doesn’t have to stay at the hospital (under certain circumstances).  In severe cases, newborns may need a blood transfusion.

In hospitals all over the US, umbilical cords are cut right after the baby is born.

In birth centers or at homebirths around the world, typical protocol involves letting the cord stop pulsing before it’s ever clamped and cut.

Why the difference?

First let me clarify - we’ll be talking about vaginal deliveries of full term, healthy infants.  Medical reasons on the part of mother or child may require quick seperation. That being said, these are the babies who need their blood the most, and may undergo more intervention than they would have if they would have gotten all of their blood in the first place.  talk to your doctor before you are in labor about this and ask about emergency protocol - there is a lot that can be done bedside while baby is still attached.

Some may argue that doctors are short on time and as a result, cords need to be clamped and cut right away.  Other silly myths surround this issue including the blood draining out of the baby if you wait to clamp and cut.  Another one is that the baby will get too much blood and jaundice, plethora, hyperviscosity, or polycythemia, etc. (which has been proven false) Still more research tells us to leave the cord alone until there is no activity in it - something many hospitals seem to ignore.

Delayed clamping and cutting actually holds benefits to the baby.

First of all - if the cord is still intact, is not clamped, and is still pulsing, the baby is still getting oxygen.  This is one reason that a baby not breathing directly after birth isn’t a huge emergency - baby is still getting oxygen.  The placenta can continue to “breathe” for the baby for about 5 minutes after birth, giving the baby time to acclimate and “unfold” its lungs before taking that first breath.  The blood contains maternal antibodies, iron and other nutrients that are important for the baby.

The baby is still getting the all-important blood that is actually his or hers to begin with which helps the brain, heart and lungs.  It’s not “extra” blood, “placenta” blood, or even the mother’s blood.  It’s the baby’s blood that happens to be running through an organ within it’s mothers body.

Actually, delaying the cord cutting can actually help mom too - when the placenta is given time to rid it’s self of the blood within, it seperates more easily from the uterus and there is less blood loss for mom!

When the transfer of blood is complete, the cord will collapse and it is safe to cut the cord at that point.  It took about 15-20 minutes when I had my son at home, but it can be longer or shorter in many instances. Most umbilical cords are around 2 feet in length, long enough for mom to hold the baby skin to skin on her chest so the baby doesn’t get cold (in fact, moms body does a better job of keeping baby warm, anyway… forgo the warmer - hold your baby!), mom can even nurse during this time and get aquainted with her baby.

Another clarification: delayed cutting of any time length has it’s benefits.  Whether it’s just a few minutes, or waiting until the cord has stopped pulsing completely.

What are the risks of early cord clamping? Early cord clamping has been shown to cause: newborn anemia, respiratory distress leading to brain damage and/or death (rare, yes, but it happens), inadequate blood supply resulting in a need for transfusion, possible heart defects resulting from problems closing off the hole in the heart valves following birth, and more.  There are also suggestions that the rise in autism is due brain damange resulting from early cord clamping.

There is even the possibility that early cord clamping in Rh- moms causes them to develop blood sensitization in their next pregnancies as a result of the clamp creating a backflow of sorts, of the babys blood into the maternal “wound” create by the placenta as it detaches.

Whew!  Some practitioners are still stuck on the belief that early cord clamping is best and they may not budge… Luckily, there are others out there who will, or who are already doing this.  Whatever you choose, be sure your care provider is someone who shares your beliefs about the type of birth YOU want to have and is willing to help make it happen.  There is nothing worse than having to dread the upcoming birth because you want it to go one way and you know it simply won’t happen, even in the best of circumstances due to “protocol”, staff, care provider or otherwise… 

An episiotomy is a surgical incision in the perineum (the area of the skin between the vagina and the anus).  It is one of the most common surgical procedures in childbirth and is quite surprising considering that in most cases, they are unnecessary and can do more harm than good.  Episiotomies DO have their place in birth, but only as needed and not routinely.

Episiotomies and tears are measured in degrees.  The most common episiotomy is a 2nd degree, midway between the vagina and anus), and the least common and biggest being a 4th degree tear that extends through the rectum (ouch!).   There are also different types of episiotomies - the midline is the most common (extends directly towards the anus)  and the mediolaterial which is a diagonal cut toward either side of the anus.

Why an episiotomy?

These incisions are cut to enlarge the opening as the baby comes out to deliver a baby quickly or to try and prevent a woman from tearing naturally.  Most commonly claimed ”benefits” are: speedy delivery (in the case where birth is immenent, but the baby must be born quickly due to distress or other complications), it prevents tearing, protects against incontenence, heals easier than tears, and protects against pelvic floor relaxation.  Many women are cut because doctors claim the skin is too tight to stretch over the baby’s head and as a result, tearing is going to happen unless she is cut.  Or the baby “needs” to be delivered quickly because birth is taking too long (when there are no complications or fetal distress - we must remember birth is not a timed event).  In many cases, episiotomies are simply routine procedures that our insurance pays for (or that we pay for out of our own pockets).

Surprisingly, many of the above cited benefits have never been proven true by medical research and many of them are actually false.

Did you know that in study after study, one of the most common risk factors for 3rd and 4th degree tears is an episiotomy, the very procedure used to protect women from large tears!

Our skin becomes more prone to tear when it has already been cut.  So, if you have an episiotomy, your skin will be more likely to rip deeper as it is stretched from the baby’s head crowning.  If women were able to birth their babies nice and slow, in positions that would allow better fetal position and delivery,  with perineal support, the chance of tearing reduces dramatically.  If a tear does occur, in most instances it will be small unless your birth involves forced pushing, instrumental delivery (in which case an episiotomy will be cut), poor positioning and rough handling.

Episiotomies are not without their risks.  The most common risks and side effects reported include infection, increased pain, increase in 3rd and 4th degree vaginal lacerations (an extention from the episiotomy), longer healing times and increase discomfort when intercourse is resumed.

That being said, episiotomies do have their place.  For delivery where instruments are required (forceps, vaccum), an enlarged opening will be required.  In many cases if a quick birth is needed to deliver a baby, getting into a squat can enlarge your pelvic opening to allow that baby more space to flex/extend/rotate his way out of your body.  But if assistance is required, an episiotomy has it’s place to enlarge the opening and allow what needs to be done to be done.

Your position during birth can have a lot to do with tearing…  If your doctor suggests a cut, you might suggest changing position if you are able to, or perineal support to see if that helps things at all.  I know with my daughter, I birthed her in the classical “on your back” position and I did tear slightly delivering my 6 lb. baby.  Then delivering my son at home on hands and knees, my 7lb 5 oz baby was born without so much as a skidmark!  This is very common.

Prenatally, you can do the following to help prevent tearing in the first place: eat a healthy diet (healthy skin stretches more easily), kegals (exercises for the pelvic floor), prenatal perineal massage, slowed second stage (careful pushing), warm compresses, perineal massage and support during delivery.  Reducing the chance of tearing will reduce the possibility that your doctor will suggest an episiotomy to prevent tearing