I'm glad you found this Forum useful, and I hope you will continue to participate. As far as finding research for your papers, PubMed is the website that indexes the U.S. National Library of Medicine. If you would like  tutorials to teach you how to construct searches, you will see a link in the sidebar of the page the link will take you to. The national doula organizations such as DONA International and CAPPA might be able to help you with your interest in outreach and forming connections with medical professionals.  You may get some ideas as well on the "Changing Birth Culture" topic on this Forum. If you would like to e-mail me privately, my e-mail address is goersitemail@aol.com.

-- Henci

Henci,

I stumbled across your site and love it.  I'm ordering the book.  I am 48 and about to get my first college degree.  I am doing my applied research senior project on Doulas.  I was a Doula for several years and the program was not promoted effectively

I love what I'm reading on your site  but need references for my project.  I am noting the ones you mention in the forum,  could you give me a source for such info as in this topic of induction and risks of breaking of the membranes or any others?

I would like to find an effective way to let women in this area (central Indiana) know the benefits of having a doula but to also bridge the gap of respect and acceptance of the Doula between the doctors and hospital staff.   I would like to find a way for doctors and staff members to routinely encourage women in open and respectful dialogue to consider using Doulas in the birth process - communicating what intervention really means and what it brings. 

your input is much appreciated.  I am hoping I can find the correct forum to read your reply.  If I'm not imposing, would you mind emailing me at jamter@sbcglobal.net?

many thanks,

Teri

Congratulations! I am so happy for you both! It sounds like your wife is a real trooper. I know from an earlier post that having an epidural was not what she planned, but that was a really tough labor, and I am glad she was able to make good use of her resources to get herself to the finish line.

-- Henci

She started pushing a few minutes later and by 6am she delivered a beautiful baby girl!

Interesting note. We were 2 days shy of 42 weeks. The nurse showed my wife the placenta and said "look how healthy this placenta is!".

Woo hoo!  Great job!

Whenever water breaks prior to labor starting I always think "poor fetal position."  And "Mrs. NotSure" had alluded to a possible poor position in an earlier post--baby looking to the left.  Add on really strong contractions without expected progress and vomitting, and those tend to add up to "poor fetal position."

But rather than give up, Mrs. NotSure wisely chose to use an intervention to allow her to rest.  Which ultimately kept her out of the OR...not that we wouldn't have been thankful for the OR if it were truly necessary.

As a point of encouragement for Mrs. NotSure...my first baby was posterior and resulted in a 33 hr labor.  My next baby was NOT posterior, and labor was 6 hrs.  Next was 3 hrs, next was 2 hrs...and I'm really hoping the next is NOT 1 hr, because I need a bit more time to process that the baby is coming out than that!  ;-)

I'm posting this for my wife. Last Tuesday at about 1am her water broke. What a relief! Contractions came on right away, however the water was clear so we decided to stay at home as long as possible. We eventually went into the hospital around 7am when they were consistently 3 minutes apart.

Labor seemed to be progressing at a manageable pace for most of the day, however they did multiple checks and the baby still hadn't dropped. By 9PM (19 hours into labor) my wife was having some pretty intense contractions and had not progressed past 8.5cm's for the past 3 hours.

The contractions had also been coming one after another with seemingly no break. At one point it looked like she had 4 contractions in a row with no break in between (I heard the nurse comment that she had never seen that before). To top it off she was vomiting after each one. Her coping techniques were now unable to get her through each contraction and she was tensing up with each one. 

By 9:30pm this became too much and we agreed to an epidural. By 10:00 my wife was able to relax and recover some of her strength (we had both been up for the last 37 hours with no sleep). By 2am her last check showed she had finally dialated to 10cm and was almost fully effaced, but the baby was still too high. The contractions started to slow down to about 7 minutes apart, so they gave her Pitocin to increase the frequency of the contractions.

A little over an hour later she was fully effaced and the baby had dropped. She started pushing a few minutes later and by 6am she delivered a beautiful baby girl!

Interesting note. We were 2 days shy of 42 weeks. The nurse showed my wife the placenta and said "look how healthy this placenta is!".

My wife and I both appreciate all of the advice and help you have given, and Henci's book was a great resource (I referenced it constantly). We wish we could have done without some of the interventions, but we think we will be more prepared for the next time around

Thanks again,

NotSure

If you choose to agree to the induction, here are two reasons why you may want to think long and carefully before agreeing to rupture of membranes: First, it isn't recommended when the head is high because of the increased risk of umbilical cord prolapse (the umbilical cord coming down ahead of the baby). This will result in an immediate cesarean. Second, as long as membranes are intact, you have optons. If the induction doesn't result in progressive labor, the oxytocin drip can be turned off, and you can go home and try another day. But if membranes are broken you are committed to delivery. If the induction doesn't take, you will end up with a cesararean.

To Maria's list, I would add nipple stimulation, which can ripen the cervix and can initiate labor. Nipple stimulation causes your body to secrete oxytocin. You can do this or your partner can. Begin by stimulating one nipple. If you feel a contraction, stop the stimulation until the contraction subsides, then begin again. If stimulating one side doesn't produce contractions, then move to stimulating both nipples. Again, if you feel a contraction, stop until it is over. In the studies, women did this for 2-3 hrs per day. There is also an acupressure point (Spleen 6) on the inside of your calf four finger breadths up from the top of your ankle bone. Feel around a bit. The right spot will feel tender to pressure. Simkin, Whalley, and Keppler in Pregnancy, Childbirth and the Newborn suggest applying finger pressure "in on-off cycles of 10-60 seconds each for up to 6 cycles" (p. 269). This same point can be used to strengthen contractions in a labor already underway as can nipple stimulation.

-- Henci

41 weeks and 3 days.  I had another NST and AFI.  Everything looks great!  The heart rate is strong and there is plenty of fluid.  After this visit I saw my OB and he is still very concerned that we have decided to wait until after 42 weeks (this Friday).  My dilation and station of the baby has not changed since two weeks ago.  How long should one wait before inducing?  Am I jeopardizing my baby's health by waiting?       

My Ob wants me to pick a date early next week for induction.  His recommendation is to come in the night before to ripen/dilate my cervix with the foley balloon.  In the morning he will rupture my membranes and then start the pitocin.  He mentioned that because the baby was still so high (-4 station) that labor would not start without breaking the membranes.  He doesn't think the baby will drop without rupturing membranes.  Would appreciate any advice/information.  Thanks! 

. . . and an easy birth to a beautiful, healthy baby!

-- Henci

That's great! Those contractions are the real thing, just early in the real thing. They can do good work for you softening the cervix, effacing it, and pulling it forward in line with the baby's head. They may even get dilation started. Trust your body. It knows how to do this. You're just along for the ride. It's great too that your OB is willing to listen to you and work with you.

-- Henci

We just returned from doc office and the NST and ultrasound looked really good, but baby is still on side facing left. I also still have plenty of fluid, and the baby's weight / size is right at the 50 percentile, so doc seems to be OK with waiting (even though they think I'm strange for doing so).

While I was hooked up to the monitor I was suprised to see that I was having regular contractions every few minutes. The nurse had to point them out, as I couldn't really feel them. Hopefully they will turn into the real thing soon.

I'll keep you updated as soon as things progress.

I don't know the answer to that. I do know that induced labors are more stressful for the baby than spontaneous labor. You can see why that would be. If the body isn't ready to labor, then it tends to take harder contractions over a longer period to move labor along. Also, strategies to ripen the cervix do a good job, but there is more to effective labor than a softened cervix, so even with cervical ripening, the cesarean rate is higher than with labor that starts on its own. Induction is most likely to work when the cervix is soft and effaced, but that is when it is least useful because the woman will likely soon go into labor on her own.

-- Henci

I hope so too. As for when to allow rupture of membranes, I would say as a routine measure, never. Sometimes, though, when progress has stalled late in the dilation phase, rupturing membranes may be recommended as a remedy to bring the head against the cervix without the cushion of fluid so that when contractions press the baby downward, the head can help to open it. (Think pulling a turtleneck sweater over your head.) The most common time for membranes to break on their own is late in first stage or with the first push, so breaking them at this point in labor would be in line with normal physiology.

Breaking the bag should not be done when the head is high because of the chance of the umbilical cord coming down ahead of the baby. This is an obstetric emergency requiring a cesarean because it will get pinched between the baby's head and the mother's pelvis. Once the head is low in the pelvis, it is like an egg in an egg cup. There is no room for the cord to get ahead of the baby's head.

-- Henci

Without medical indication?  10 cm, fully effaced, +20 inch station.

Seriously...there is not a medical need to rupture membranes prior to birth in most cases.  It generally will make your labor more painful for mom (possibly baby as well?), may put the baby in a poor position, can result in more head molding, can increase the odds of a pinched umbillical cord.  There are also the extremely rare complications of possibly causing the cord to prolapse, or causing a cord rupture with a cord that has a "velatamous insertation"--that is, the cord goes through the bag then implants in the placenta rather than implanting directly in the placenta and being completely encased in the bag (this is extremely, EXTREMELY rare because you are combining an extremely rare natural complication with then a rare Dr. caused complication).  It is of limited benefit in speeding up labor--research shows that it really isn't effective at that until you are past about 7 cms, and you might not WANT to be sped up at that point, understanding that speeding up labor will make it more intense.  Some care providers will argue that they want to rupture the bag to check for meconium...but I had a client with spontaneous rupture for over 40 hrs prior to birth, and we didn't know that there was THICK meconium until after the baby's head was born!  Research has repeatedly shown that suctioning for meconium is ineffective in preventing complications, and may actually cause some of its own.

I find in my doula clients that if they didn't have spontaneous rupture prior to the onset of contractions, they typically have rupture as they enter transition, and birth happens very soon after.  I've only had one client get to pushing stage with intact membranes, and her OB was really insistent on breaking the water at that point, so the mom decided it just wasn't worth the fight so let the Dr. break the membranes--ironically, this baby had a velatamous insertation!

Yes, I am definately going to try to avoid an epidural. The baby has been moving around a lot since we started these techniques, but it still hasn't dropped at all (still feels like -4 station).

Question, how many centimeters should I be at (approximately) before I allow them to rupture the membranes?

My OB is scheduling me to come in next Wednesday to induce if nature hasn't run its course. This will be 42 weeks + or - one day. Hopefully it will come before then.

To Maria's suggestions I would add avoid an epidural so you can be walking and changing positions. If you have one, choose upright or side-lying positions; stay off your back. Refuse having your membranes broken early in the dilation process. As long as they are intact, the cushion of fluid ahead of the baby's head allows the baby room to wriggle and swivel into a better position, and the forces of labor will tend to guide this process as well. If someone ruptures membranes, the gush can pull the baby prematurely into the pelvic inlet in the unfavorable position, where it will be more difficult to maneuver. Of course, if membranes rupture on their own, it can't be helped.

Please let us know how everything goes.

-- Henci

Unless there is a compelling medical reason to induce, I recommend waiting. Here are my reasons why:

• The recommendation to induce routinely at 41 weeks is controversial. The main trial that supports it has major problems. I have done an analysis of it on the "When Research Is Flawed" section of this website.
• The median length of pregnancy in 1st-time mothers who reach full term is 41 wks 1 day, meaning half of first-time mothers go into labor before 41 wks 1 day and the other half after this length of pregnancy. In other words, induction is being recommended for a healthy pregnancy in the middle of its normal range.

and most importantly,

• Elective induction of labor, which this would be, is associated with an increase in cesarean surgery rates.

  Goer H, Sagady Leslie M, Romano A. Step 6: Does Not Routinely Employ Practices, Procedures Unsupported by Scientific Evidence. J Perinat Educ 2007;16(1):32S-64S. 

I would also be concerned about an ob--however low his cesarean surgery rate--who is already predicting a cesarean for you. There are any number of studies that show that what the care provider thinks about the woman's likelihood of cesarean affects judgment. You can see how this would play out: "Well, she's not going to deliver this baby vaginally anyway, so why not just get it over with, and I can go home." 

Of course, you don't know whether the new ob will think any differently, but at least you have a few more days to go into labor on your own. You are likely to do that. The same study that found that half the group of healthy 1st-time moms were still pregnant at 41 wks 1 day also found that only a few percent still hadn't had their babies by 42 wks.

And if you want your best shot at avoiding an unnecessary cesarean, you can't go wrong with Lamaze's "Six Care Practices that Support Normal Birth."

-- Henci