Failed Inductions: What You Need to Know

Wednesday, October 28, 2020

Failed Inductions: What You Need to Know

When we talk about inductions, we often speak of them like they are 100% guaranteeing us a baby at the end. While this is true most of the time, you’d probably be surprised to learn that indcutins can fail and you may be sent home to wait it out a bit longer. Or, if the option isn’t presented to you, you can ask or take yourself home. It is important to ensure that you and your baby are safe to go home.There are thousands of women each year that experience a failed induction and it can be very hard emotionally. 

What is a failed induction?

A failed induction is the inability to reach active labor while being induced.

There is a certain process we want to take when it comes to induction. I call this your ‘individual induction equation.’ It’s truly individual to you and you get to introduce various induction methods as you see fit which makes your equation unique to you. First we want to ripen the cervix--it needs to be soft. You have options of how we achieve this. Then we need to begin dilation. Many times in undisturbed, unmedicated (no narcotic use or induction) labor, the first few centimeters are accomplished with little or no pain. Many times birthing people will unknowingly walk around a few centimeters dilated in late pregnancy--this is completely normal! You’re that much closer to your goal and didn’t have to work for it! That’s amazing!

If your cervix is effaced and not dilating at all, it’s possible you aren’t ready to have a baby. If you choose to keep going, the next step is to get contractions going. You have a few choices of how you can do this! You can try walking and physical movement. You can try natural oxytocin like nipple stimulation, intimacy with your partner or visualization. You can also try pitocin which is artificial oxytocin. Your body metabolizes it differently so it will impact your contractions. Finally you can break your waters. This is an especially important decision for birthing people who are GBS+ as you will no longer have the option to leave because you will need to begin receiving antibiotics. You can also choose (GBS+ or GBS-) to save this for later in labor plus it allows you to return home.

When using Pitocin, be very mindful of how much you are using, for how long and how your body is reacting. Pitocin is a drug that needs to be used with respect (25% of people who receive Pitocin will have a c-section). If your body is truly not ready to birth a baby, you may find yourself experiencing a failed induction. You want to be educated on a reasonable amount of time to try to induce before you call it and say, “we’ll try again later because my body is clearly not ready.” There is evidence to support the idea that the longer it takes a laboring person to reach 6cm, the less likely they are to have a vaginal delivery. If your body is not responding to medical induction (and you + your baby are safe), instead of forcing it, you could consider going home and giving your body more time. Also, your baby would probably appreciate the extra time, too! That same study also shares that women who were in the latent phase and receiving pitocin for 12 hours still were able to achieve a vaginal delivery meaning we should not call it ‘failure to progress’ before at least 12 hours of pitocin.

TIP: Failure to progress is defined as 6 hours with no cervical change after 6cm. Failure to progress cannot be deemed before 6cm. It is also evidence based to expect a “pause” in labor around the 6cm mark for women who have very long labors. We should be patient as their bodies are typically just resting for active labor and pushing. Evidence Based Birth says, “if more care providers begin using evidence-based definitions of labor arrest and failed induction, we will begin to see fewer of these diagnoses, and a simultaneous, safe lowering of the Cesarean rate.”

A few reasons your induction may fail:

Your baby is not ready. Check out the science on what actually initiates the start of labor (if you were not induced). It will probably be surprising to you! It has quite a lot to do with your baby! Inductions increase your risk of further interventions, including c-section, and this is called ‘the cascade of interventions.’ As c-sections rise, so does infant mortality and NICU stays for respiratory distress since babies were born before spontaneous labor started. Obviously there are tons of evidence reasons to wait for your labor to start on it’s own and one of the most important is your baby’s lung development!

You were induced with a low Bishop Score. You can see here that it is flawed, but also the best tool we have at the moment to predict your chance of a successful induction. Read more about the Bishop Score here!

If you are wondering if a 39-week induction is for you, here is a breakdown of what you need to know about The ARRIVE Trial. If you doctor mentioned this to you, make sure you read this breakdown so you understand why it may not be applicable to you!

The Bottom Line

Be mentally and emotionally prepared when you go for an induction that it is not guaranteed to work! You can have a ‘failed induction’ and I highly suggest you listen to your body and baby on this one. Remember, your baby’s development is very much a driving force of labor starting! There are also things you can do to check your chances of having a successful induction like knowing your bishop score and having a plan of when to call off a failed induction.

If you want to learn more about your birth choices or how to advocate for your birth goals, join The Birth Lounge!

The Arrive Study

Wednesday, October 21, 2020

The Arrive Study

I get asked A LOT about The ARRIVE Study. It’s a hot topic. For some people they are thrilled to hear there is science backing up an induction and some folks are terrified because they feel pressure from their provider and don’t feel aligned with a 39-week induction. Before we dive into the issues with this study. Let’s take a look at the history that you should know. 

Around 41% of all pregnant people will have an induction suggested to them and 44% of those will be because you’re close to your due date or ‘full term.’ (quotations because we think one absolute date determines a baby’s readiness to be born and that’s simply not how it works) This means almost half of all labors are suggested to be medically initiated….where has our trust in ourselves gone?! 

Let’s take a quick pause for one moment and think about birth for what it actually is--a natural event. Without human intervention, there would be so much less birth trauma, so many less c-sections, far fewer inductions, and our trust in our bodies (and in nature) would be restored. Pregnancy is not an illness. Birth is not a medical event (90% of the time with a healthy respect for the 10% cases who truly require medical support and intervention). You are doing a very natural thing that billions of women have done before you for millenniums before you. Truly, take a moment to think about that. Millenniums. 

There are a few things to know when discussing The ARRIVE Study with your provider!

Number 1: The ARRIVE study set out to prove something and it did just that. That shouldn’t be a surprise. That’s exactly what experiments and science are supposed to do. But don’t stop there. Challenge it. Look into it. Ask questions. Make sure it is applicable to YOU and YOUR birth goals. 

My thoughts: That is true with all research. Listen, research is funded--you can’t hold that against them. However, you can (and should!) look into the funding of research and look into how the study might have shown bias in any way. Again, it doesn’t make it bad science or a bad study necessarily, but it does make it something you want to know just to keep in the front of your mind. 

Number 2: There are some pretty big holes in this study like the criteria you need to meet to yield these same results for yourself is pretty strict—people who feel strongly about a low intervention birth, people who have care by a provider with a high c-section rate, and people who do not feel like induction is aligned with their birth goals are all not recommended to use this approach. This can be seen in their recruiting—22,533 women were invited to participate and only 6,106 did.

My thoughts: Yikes! That’s a huge number of folks who said, ‘no thanks!’ I believe this is because you are hard pressed to find birthing people who don’t have preferences on how their labor begins, how long their pregnancy goes, or the outcome of their labor. That’s a very specific type of birthing person to not have preferences on all of that. Therefore, if you do care about one of these, these results might not be applicable to you.

Number 3: There was a slight decrease (3%) for 39-week inductions compared to spontaneous labor. We must balance someone’s birth goals with such a small decrease. Lastly, the researchers did not specify an induction protocol so all of these inductions were done in whatever way each provider felt was best. That’s a lot of variability to try and generalize to every birthing person.

My thoughts: For so many birthing people, when they consider the small decrease and the idea of benign induced, they just don’t line up. Most folks would rather take on the 3% risk for the chance to go into labor naturally. Since we don’t have a single method for induction, this is going to be highly dependent on your provider--what their preferred method is, their c-section rate, their comfortability using varied methods--and your education and preferences--do you know about balloons and cervical ripeners. What standard protocol for pitocin is and what your alternatives are for that? The more educated you are on your options, the less risk you have for a c-section.

Number 4: Many providers aren’t actually presenting it as an option--rather the recommended route. In addition, most providers are not taking into account or having intentional, informed discussions about the three criteria The American College of Obstetrics and Gynecology set’s forth: the values and preferences of the pregnant woman, the resources available (including personnel), and the setting in which the intervention will be implemented. In addition they also state, “A collaborative discussion with shared-decision making should take place with the pregnant woman.” This is direct instruction to offer it as an option, discuss risks and benefits, and share about the criteria to determine if the patient is a good fit. Finally, another issue with the way providers proceed with The ARRIVE Study is that many providers take into account the Bishop Score. While it’s not the best scoring system, it’s at least helpful data! Read more about the Bishop Score here!

My thoughts: I’ve actually never seen a provider do a bishop score as part of this. While it’s not recommended by ACOG or included in the criteria, it makes logical sense to see what someone’s cervix is up to before we induce them.This would be a fantastic place for providers to think outside the box in order to give easy, individualized care that truly makes a big difference in patient satisfaction and, possibly, outcome---just imagine if we stopped inducing people without checking their cervix first. A simple conversation with the patient about what the bishop score is, what it tells us, and why it may be helpful to evaluate before moving forward with the ARRIVE trial findings would probably be a game changer in so many lives. 

What about a failed induction?

Did you know you can leave and go home after a failed induction? It’s true, you can. If you and your baby are safe, and you have not made any decisions that require continuous monitoring, you have the option to go home. (You always have the option to go home, but that obviously wouldn’t be advised if you or your baby weren’t safe.)  Read more about failed inductions, here.

It’s also important to know that ACOG recommends “if the maternal and fetal status allow, cesarean births for failed induction of labor in the latent phase can be avoided by allowing longer durations of the latent phase (up to 24 hours or longer) and requiring that oxytocin be administered for at least 12–18 hours after membrane rupture before deeming the induction a failure.”

The Bottom Line

We are not treating pregnancy as a healthy medical event, rather something that is uncontrollable and dangerous. We aren’t providing birthing people with individualized care, rather blanket statements that leave them with emotional and physical scars. 

Evidence Based Birth says “Current research evidence has found that elective induction at 39 weeks does not make a difference in the rate of death or serious complications for babies. For mothers, induction at 39-weeks was linked to a small decrease in the rate of Cesarean compared to those assigned to wait for labor (19% Cesarean rate versus 22%)” 

It’s ultimately up to you! You know your baby and your body! You are the most qualified person to make this call!

If you want to learn more about your birth choices or how to advocate for your birth goals, join The Birth Lounge!

The Bishop Score

Wednesday, October 14, 2020

The Bishop Score

Have you ever heard of a Bishop Score? This is the ‘rating’ that we give a pregnant person’s cervix in order to determine its readiness for induction. There are a few key flaws in this scoring system and I want to chat it out! 

The History of The Bishop Score

The original Bishop score (Developed by Dr. Bishop, OBGYN in 1964) is based on 5 criteria: dilation, effacement, station of baby, position of cervix, consistency of cervix. You will be given a score of 0 to 3--0 being not progressed and 3 being the cervix is showing favorable progress-- for each of these criteria(Note: the highest score for position and consistency of cervix is 2). You will be given an overall Bishop Score which will indicate if you are a good candidate for induction or if you are not. The highest score is 13 and any score 9 or above is considered ‘favorable’ for induction meaning the numbers suggest your body will be receptive of induction. (Note: some providers will use 8 and this will be up to you as to what number you feel most comfortable)¹. You can see a Bishop Score card here! 

However, this 2012 study used a ‘Simplified Bishop Score’ that only considered dilation, effacement, and baby’s station. It showed a similarly high predictive rate to the original bishop score. This means if you are favorable in those three out of five, you may be a great candidate for a 39-week induction (if it aligns with your birth goals). 

The Problems with The Bishop Score

Interestingly enough, it is not a great tool for people who have had a baby before. Since your body has already done this a time or two, your cervix can change on a dime. Anyone’s cervix can rapidly change (which is why this is flawed to begin with), but a person who has already given birth is more likely to have faster cervical change making the Bishop score less reliable for second and third (and beyond) time mothers.²

One final problem is--and I eluded to it above--but providers are not consistent in their expectations or usage of the Bishop Score. Some use 8, some use 9 as an indicator of a ‘favorable’ cervix. Some use a 8 or 9 until they realize that the patient isn’t achieving that score then they throw in a ‘well, by the simplified bishop score you meet criteria’ which is equally confusing and infuriating. Many women leave feeling confused if they are a good candidate and infuriated with a provider that was not clear on such a big decision. 

Here’s the thing: it is a flawed tool, but it is the best we have at the moment.³ It does a pretty good job of indicating your body’s receptivity to a medical induction. This is definitely a tool to be aware of and to know your personal boundaries of what you consider a good number to induce your body. Remember consent is a discussion with your provider--make sure that is being done around the topic of induction especially. 

What you need to know as a consumer?

First and foremost you should understand the reasons for medically necessary indcutions. As a consumer, you have a responsibility to take control of your birth experience and this includes being an informed consumer. You need to know the evidence behind bogus reasons for inductions like ‘big babies,’ ‘advanced maternal age,’ or ‘late babies.’ You also need to understand how to navigate sticky places like Gestational Diabetes. It doesn’t always mean you have to be induced or that you’re doomed for a ginormous baby that’s going to rip you to shreds. (Note: Sometimes, GD does require an induction to keep parent and baby safe) Those are fear-based approaches and I hope dearly your provider isn’t trying to pull this with you. Here is a list of medically necessary reasons to consider being induced.

This is a good study to be aware of! It is older (2006) and shares that if you have a positive Bishop score, and use a specific method of induction (This is really nice to know exactly what protocol to follow--unlike The ARRIVE Study!) This study had 99 participants, 47 first time moms, 52 moms who had given birth before (did not decipher second, third, etc). The median time of labor time for first time moms was 15.5 hours and for those who have given birth before, median labor time was 12.5 hours. 20/47 first time moms got an epidural and 11/52 moms who had birthed before got one with 83 vaginal births. They had 16 total c-sections with 8 due to fetal distress (funky fetal heart tones). There were also 8 first time parents and 8 parents who had birthed before. 45% of participants were in labor after only one Misoprostol and 45% were in labor after two doses. This left 9 participants whom seven need 3 doses and two needed 4 doses. 11 newborns required a NICU stay.⁴

If you are facing pressure from your provider about The ARRIVE Study (a study that shares a 39-week induction may lower your risk of a c-section). You can read more about that study and how to understand whether it applies to you and your birth goals, here.

If you have a failed induction, you are allowed to leave the hospital. We will be covering this SOON!

If being induced is not aligned with your birth goals and you have a preference to wait or to wait for labor to initiate unassisted, then that is absolutely your right. You can read all about due dates here and how your due date is a guess! Science is on your side if you decide waiting is best for you! 

If you want to learn more about your birth choices or how to advocate for your birth goals, join The Birth Lounge


Social Call with a Newborn?

Wednesday, October 7, 2020

Let’s be honest - there’s nothing quite like the excitement of brand new baby rolling into town. Whether it’s a friend, family member, or neighbor who has added a new tiny human to their home, you may be waiting on the edge of your seat to meet the new babe. Before you go running to get your share of baby snuggles, there are a few unspoken rules you should keep in mind when it comes to visiting a newborn and we’re going to break those down for you today.
  • - First of all - when exactly is it okay to come knocking on their door? Ask when it would be a convenient time for them and never come over unannounced. 
  • - Definitely come with a practical gift in tow - you can never go wrong with food for a busy new family! Maybe pick up some fruit or something else fresh as they’re probably relying on the freezer for most of their meals.
  • - Always lend a helping hand during your visit. Offer to take care of those dishes in the sink or throw in a load of laundry or even just to wipe down the counters - it will be much appreciated! Consider some one-handed snacks for mama!
  • - Don’t take pictures of the baby or post them on social media unless you get permission from the parents. They may not have had a chance to share pictures themselves or just may not be comfortable with having their baby’s face on the internet, and that’s okay!
  • - Don’t push the new mama to talk about her birth experience. She may have had a traumatic experience that she’s not ready to talk about yet, and hormones and exhaustion can make talking about the birth even more upsetting. However, if she does want to talk, be prepared to be a great listener!
  • - If there’s an older sibling around, make sure to give them some love too! All the attention on a newborn can be upsetting to the new big brother or sister and they’ll really appreciate a bit of the spotlight on them. 
  • - Most importantly, do NOT step foot near that house if you are sick or have been recently! Newborns are so susceptible to bugs and the last thing the tired family needs is a sick baby! Even if you’re not sick at the moment, make sure to wash your hands often during your visit, and although it’s hard, avoid giving baby kisses! On this note, leave your kids at home - the presence of more children in the house can be overwhelming for the new parents, not to mention all the germs that come along with them.
  • - Finally, don’t overstay your welcome - the new family is exhausted and is probably trying to stick to whatever bit of a routine they manage to put together. Keep the visit short and sweet while reminding the new parents that you’re only a phone call away if they’re ever in need. 
These are our general guidelines for newborn visits.  But if you are reading this in the present- 2020 has thrown us some whoppers.  We urge you to be especially cautious around newborn babies and their families.  Please respect boundaries if families are not welcoming to visitors at this time.  In these unprecedented times parents are left making choices their parents, grandparents- heck even most of their friends have not had to make with a newborn baby.  Give new parents grace! Ask them how you can support them right now. Ask them how they are doing. 

Some ideas for socially distant support in 2020:
  • - Porch or door front meal drop offs/meal trains that encourage parents to leave a cooler outside or with a defined drop off time from parents where they know they can easily get to the door and get food inside. 
  • - Gift cards to a local restaurant or delivery app for easy food/coffee/meal delivery. (Hello! A $5 Starbucks gift card sent in app MADE MY DAY Postpartum - it doesn't need to be big! Just thoughtful and practical.)
  • - Sending or dropping off older siblings craft kits, activity boxes, etc. that show them a little love and may give mom and dad a break to relax
  • - Offering to pick up groceries if the family is avoiding shopping trips/just because!
  • - Checking in! It can seem so small, but loneliness amongst postpartum parents is high generally speaking, never mind right now when isolation is more of the norm. Send a sweet text, a voice message, a funny video- let mom/dad know you are on their mind and there if they need something!
If a family is willing to have you in their home or at their home, please make sure to respect their comfort levels. This may mean a visit outside, with masks, or other extra precautions that bring them peace of mind.  Remember, this is not personal or about you, it is just a new family trying to make sense of the world their baby has entered and keep them as safe as they can!

Mama-to-be? Check out our blog post on why you may want to say 'no' to your visitors, here!

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