An intervention is any action taken to alter the course of your labor or birth. Modern medicine is amazing, and there is no doubt that interventions have saved the lives of both mothers and babies. Although many interventions are routine, there is no one-size-fits-all. Your job is to make informed decisions based on what is best for you and your baby. Just because something is routine or suggested does not mean it is mandatory or the right choice for you. You always have options as long as you are informed and you know what those options are. This article gives you a 10,000-foot view of the interventions that can take place during your labor and birth and tools you can use to navigate your options.
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What is an Intervention?
To intervene means to come between to prevent or alter a result or course of events. An intervention is an action or process of intervening or an action taken to improve a situation, especially a medical disorder. When you apply these definitions to birth, an intervention is any action taken to alter the course of your labor or birth.
Modern medicine is amazing. Undoubtedly, interventions have saved the lives of both mothers and babies. Although many interventions are routine, there is no one-size-fits-all. Your job is to make informed decisions based on what is best for you and your baby. Just because something is routine or suggested does not mean it is mandatory or the right choice for you. You always have options as long as you are informed and you know what those options are.
This episode is intended to give you a 10,000-foot view of the interventions that can occur during your labor and birth. Interventions include vaginal exams, inducing labor, IV fluids, antibiotics, electronic fetal monitoring, assisted delivery, and episiotomy. Most of these interventions have separate full episodes that dive into much more detail on the evidence. Additional episodes are linked throughout this text and listed at the end of this article. (Other interventions, including pain relief during labor and cesarean birth, will be covered in separate episodes.)
A vaginal exam is precisely what it sounds like. Your care provider will insert a gloved finger into your cervix to examine it. A vaginal exam allows your care provider to determine whether your cervix has begun to dilate or efface. This exam can also help them determine the position of your cervix and the station and position of your baby. This intervention may be offered within the last few weeks of pregnancy or during labor.
Internationally, the consensus is to offer vaginal exams every four hours during labor. Unfortunately, I could not locate any published guidelines from ACOG on the recommended frequency. The National Institute for Health and Clinical Excellence (NICE) in the UK recommends expecting mothers are offered a vaginal examination when they enter a hospital in suspected established labor and every four hours as labor progresses. The World Health Organization states vaginal examination at intervals of four hours is recommended for routine assessment of the active first stage of labor in low-risk women.
Vaginal exams during labor are routine for most providers. The medical community likes metrics and exams. Measurements to predict labor are very attractive to medical professionals. The main reason vaginal exams are done is to give your doctor or midwife clues to two things. The first is how your labor is progressing. The second is to determine you are at 10 cm before you start pushing.
A doctor or midwife measures cervical dilation by placing two fingers on either side of the vaginal opening and estimating the distance between their fingers in centimeters from 0-10. This is not an exact science. One study compared back-to-back exams by a researcher and clinician. In 49% of the exams, both agreed on dilation measurement. In 51% of cases, the two did not agree, and in 11% of these cases, their findings differed by 2 cm or more.
A vaginal exam cannot accurately predict when labor will start or how long you will be in labor. You could be dilated to 2 cm for weeks and still go past your due date before entering labor. If you are in labor and progress from 2 to 3 centimeters in an hour, there is no guarantee that you will be at 4 centimeters in another hour. You may still be at 3 centimeters, or you could be at 6 centimeters or more. Remember that your body is working very hard to get all the pieces in place for your baby to be born. There is a lot of progress you and your care provider may not see or be able to measure.
It is accepted in the medical community that you should be dilated to 10 cm before you start pushing. The thinking behind this is that if you are not fully dilated, pushing isn’t going to help your baby get out because they do not have enough room to exit. In general, you get an urge to push with an unmedicated birth, which likely happens around 10 cm. If you have an epidural, you may not have as much feeling and may not have the same urge to push.
Along with dilation, other measurements can be taken with a vaginal exam. Cervical effacement is measured as a percentage from 0-100%. At 0%, your cervix feels like the tip of your nose. At 100%, it will feel soft like your lips and is paper thin. Near or in labor, the cervix position will change from a posterior (towards your tailbone) position to an anterior position. This provides your baby with an easier path to get out. This position of your baby’s head in relation to your pelvis is measured in stations. The station is measured on a scale of -5 to +5. At a station of -5, your baby’s head is not yet into your pelvis. A zero station means your baby’s head is engaged in your pelvis. A +5 station is when your baby is crowning.
These measurements all factor into a Bishop score. This is a scale of one to ten that predicts your likelihood of going into labor. A score of one means you could be weeks away, and a score of ten is supposed to indicate that you will go into labor soon. There has been some controversy over Bishop scores as a predictor of labor. While your Bishop score may not be the best predictor of when you enter labor, it may be relevant if you consider an induction. Inductions tend to be more successful when your cervix has already started to dilate and efface. This study shows that lower bishop scores are associated with higher rates of cesarean birth when labor is induced.
Risks of Vaginal Exams
While data from an exam may be useful, there are some risks involved with vaginal exams. Vaginal exams can be physically uncomfortable. A study found 82% of women reported pain or severe pain, and 68% reported discomfort during a vaginal exam. You may have spotting or additional discharge afterward. There is a risk of infection due to bacteria from the vagina being pushed up into the cervix. It is also possible you could have a premature rupture of your membranes.
We often don’t talk about an intervention or procedure’s psychological impact, which can be a big deal. Depending on how the exam results are communicated, you could be excited that labor is starting soon or disappointed that it isn’t. If you are under the impression labor will begin soon, and it doesn’t, that can be a disappointment or cause anxiety that your body is not going into labor as quickly as you or your care provider expect. Please ensure you understand the exam results, and if you have questions, please bring them up with your doctor or midwife.
Your Options for Vaginal Exams
You may want to know the status of your cervix purely out of curiosity, even after you understand that this cannot accurately predict when or how long you will be in labor. As with any procedure, you have several options for a vaginal exam. You can refuse the exam altogether or ask that they be limited. You can request a vaginal exam if you want the measurements taken. You can also request to delay the exam until your due date or until you are further along in your labor. See this episode for more in-depth evidence on vaginal exams.
Your due date is an estimate of when your baby will arrive, and it is not an exact science. In a perfect world, your body is ready, your baby is fully mature and ready to enter the world, and you naturally go into labor. Everything doesn’t always go as planned, and many women get an induction to jump-start labor.
Reasons for Inductions
Inducing labor is any procedure that stimulates uterine contractions during pregnancy before labor begins. There are many reasons why your doctor or midwife may offer or suggest an induction. This includes going past your due date, low amniotic fluid, a suspected large or small baby, a medical condition that puts you or your baby at risk, such as high blood pressure or gestational diabetes, an infection in your uterus, or if your placenta has begun to deteriorate. The last reason for induction could be choice or convenience. Perhaps you live far from the hospital or birthing center and have a history of speedy deliveries. You may prefer to give birth with a specific practitioner and want to go into labor when they are present. For each of these circumstances, there is evidence with varying levels of support.
There are some instances in which a care provider does not recommend inducing labor. One reason is a prior C-section with a classical incision, a major prior surgery on your uterus, placenta previa, a transverse baby, or an active genital herpes infection.
The ARRIVE trial (A Randomized Trial of Induction vs. Expectant Management) is a randomized controlled trial that compared elective induction at 39 weeks with expectant management. Expectant management is watchful waiting instead of immediate treatment or intervention. The trial included 6,106 low-risk women split into two groups. The recommendation was that if a patient had a favorable cervix, they would undergo an induction with oxytocin. Participants with an unfavorable cervix were expected to undergo cervical ripening in conjunction with or followed by oxytocin.
The main conclusion was that labor induction at 39 weeks in low-risk women did not result in a significantly lower frequency of a composite adverse perinatal outcome. Still, it did result in a significantly lower incidence of cesarean delivery. (18.6% of the induction group had cesarean births, compared to 22.2% of the expectant management group.) The data suggested that one cesarean delivery may be avoided for every 28 deliveries among low-risk nulliparous women who plan to undergo elective labor induction at 39 weeks.
This study was a big deal. From an evidence-based standpoint, it provides a lot of data to support offering an induction at 39 weeks. As a result, there is some push in the medical community to routinely induce labor at 39 weeks in low-risk women. The American College of Obstetricians and Gynecologists previously stated that “labor should be induced only when it is more risky for the baby to remain inside the mother’s uterus than to be born.” With the publication of the ARRIVE trial in 2018, they changed their guidelines to offer elective induction to low-risk nulliparous women at 39 weeks.
In contrast to ACOG, the American College of Nurse Midwives released a statement after the ARRIVE trial that they recommended no change in their opinion in response to this study. The ACNM holds that spontaneous labor offers substantial benefits to the mother and her newborn. Disruption of this process without an evidence-based medical indication represents a risk for potential harm.
Options for Inducing Labor
There are multiple methods for inducing labor. All these procedures occur at a birth center or hospital where your care provider can monitor you and your baby. Your care provider may recommend a combination of these methods.
Ripening the Cervix
If you have a vaginal exam and your cervix is not considered favorable for induction, your care provider may suggest ripening your cervix with a mechanical dilator or a synthetic prostaglandin.
Mechanical dilators manually force your cervix to open. The two options for a mechanical dilator are a balloon catheter or a hygroscopic dilator. For the first, your care provider inserts a small balloon-tipped catheter beyond your cervical opening. They inject saline through the catheter to expand the balloon and cause your cervix to widen. The other option is a hygroscopic dilator commonly made from laminaria seaweed. For this, your care provider inserts small rods made from seaweed into your cervix. As it absorbs moisture and gets thicker, it opens your cervix.
The hope is that your cervix is favorable within 12 to 24 hours after employing one of these methods. Both of these procedures can cause some cramping. In one study, they compared these different types of dilators with over 17,000 participants. The researchers concluded that cervical ripening with a hygroscopic dilator appears to be a safer method, with fewer instrumental deliveries and lower rates of postpartum hemorrhage and umbilical cord prolapse.
The alternative to a mechanical dilator is a prostaglandin. There are two basic types of prostaglandins: misoprostol (brand name Cytotec) and dinoprostone (brand names Cervidil and Prepidil). Both medications ripen the cervix and cause uterine contractions.
Misoprostol was initially approved as a medication to prevent ulcers. While it is commonly used for labor induction in the U.S., it does not technically have approval from the FDA for this use. While off-label use of some drugs is common, warnings about risks associated with using misoprostol for labor induction remain on the label.
The other prostaglandin to induce labor is dinoprostone, which goes by the trade names Cervidil and Prepidil. Dinoprostone is approved for labor induction by the FDA. Similar to misoprostol, it also softens the cervix and causes uterine contractions.
Evidence on Prostaglandins
In comparing the two prostaglandin options, a systematic review and meta-analysis showed that misoprostol was more effective but that dinoprostone was safer. In the misoprostol group, uterine hyperstimulation was more common, and fewer women required synthetic oxytocin. The other outcomes of both drugs, like APGAR scores and C-section rates, were similar.
Concerns about risks associated with Cytotec include hyperstimulation of the uterus, prolonged contractions, postpartum hemorrhage, and uterine rupture. Ina May Gaskin, the most respected figure in midwifery, has been outspoken against using misoprostol. Click here to read an article from Ina May Gaskin on misoprostol.
While the benefit of prostaglandins is a possible successful induction, there are also risks. In addition to the risk of uterine hyperstimulation are side effects like nausea, vomiting, diarrhea, and fever.
Sweeping the Membranes
Another method your doctor or midwife can employ to try and start labor is to strip or sweep the amniotic membranes. To do this, your care provider inserts their gloved finger beyond your cervical opening and rotates it to separate the amniotic sac from the uterus wall. This doesn’t induce labor, but it might speed the beginning of spontaneous labor, especially if your cervix has already started to dilate. This procedure can cause some intense cramping and spotting.
Rupturing the Membranes
Your care provider can also break your water. This is also known as an amniotomy or rupturing of the membranes. An amniotomy is typically done if the cervix is partially dilated and thinned and the baby’s head is deep in the pelvis. Your doctor or midwife does this by making a small opening in the amniotic sac with a thin plastic hook, similar to a knitting needle.
One randomized controlled trial compared two groups, one with an amniotomy and the other without. Unfortunately, this did not compare amniotomy alone for induction, and 73% of women in both groups received more than one agent for induction. The average time from induction to delivery was 19 hours in the amniotomy group, compared with 21.3 hours in the standard group. The rate of chorioamnionitis (an infection) was 11.5% in the amniotomy group compared to 8.5% in the standard group. There were two cord prolapses in the amniotomy group and none in the standard group. The rates of cesarean delivery did not differ. A Cochrane review looked specifically at amniotomy for shortening spontaneous labor and found the evidence does not support routinely breaking waters for women in labor. For many interventions, their use should rarely be routine and evaluated on a case-by-case basis.
When you naturally go into labor, the hormone oxytocin is responsible for causing contractions. There is a synthetic version of this, most commonly known by the brand name Pitocin. Pitocin is most effective at inducing labor if your cervix has already begun to dilate and thin. Your care provider may also recommend Pitocin to augment or stimulate contractions if your labor is not progressing. You receive Pitocin through an IV, which allows the dose to be adjusted as needed.
A Cochrane review examined oxytocin alone for inducing labor. This review included 61 studies with more than 12,000 women. The review concluded that oxytocin is an effective method for induction. Compared with expectant management, oxytocin results in more births within 24 hours. Oxytocin induction appears safe, with very few reports of severe adverse effects. The downside is that active management with oxytocin will result in more cesarean sections and epidurals. In comparing oxytocin with prostaglandins, oxytocin was less effective and resulted in more cesareans. Of the 61 included studies, only three have been published since 2000. The authors noted that using oxytocin alone appears to be of decreasing interest to researchers.
Weighing the Risks and Benefits of an Induction
Best case scenario, an induction leads to a successful vaginal birth with no side effects or complications. Whether or not an induction goes as planned, you get to meet your baby. Your job is to make the best-informed decision for you and your baby.
Risks of induction vary depending on the method. One risk all methods have in common is premature birth, putting your baby at higher risk of respiratory problems, low blood sugar, jaundice, irregular heart rate, and the inability to stabilize temperature. They are also more likely to have difficulty establishing breastfeeding.
Some medications used to induce labor might provoke too many contractions, diminishing your baby’s oxygen supply and lowering your baby’s heart rate. Rupturing your membranes increases your risk for infection. Labor induction increases the risk of the umbilical cord prolapse. This is when the umbilical cord slips into the vagina before the baby, which can compress the cord and decrease your baby’s oxygen supply. Uterine rupture is a rare but serious complication in which the uterus tears open along the scar line from a prior C-section or major uterine surgery, which causes significant bleeding. Lastly, labor induction increases the risk of uterine atony, which occurs when your uterine muscles won’t properly contract after you give birth, and this can cause severe bleeding after birth.
It isn’t easy to synthesize all the data that compares one type of induction method to another. If you are considering an induction, you should talk to your doctor or midwife about your options and work through which method has the best risk-benefit analysis for your situation. See this episode for more in-depth evidence on inducing labor. You can also see this episode to explore the evidence on methods to induce labor naturally.
IV is short for intravenous fluids. These are fluids that are delivered via needle directly into a vein. In the U.S., it is common practice to routinely use IV fluids during labor, especially in hospitals. The main goal of administering IV fluids during labor is to ensure your body is adequately hydrated. The American College of Obstetricians and Gynecologists does not support eating during labor and only recently changed its stance on drinking fluids in labor. ACOG states that although safe, intravenous hydration limits freedom of movement and may not be necessary. Oral hydration can be encouraged to meet hydration and caloric needs.
Evidence of IV Fluids
The few studies comparing IV fluids to oral intake show a reduced labor length with IV fluids. In one review, researchers note that when comparing IV fluids to no liquids by mouth, IV fluids did result in shorter labor. They also note that it may be possible for women to simply increase their oral intake rather than being attached to a drip. A meta-analysis found that labor times were shorter when IV fluids were administered at 250 ml/hour compared to 125 ml/hour. The higher rate also resulted in a reduced risk of cesarean sections. The researchers did note that further study is needed regarding the risks and benefits of increased hydration among women with unrestricted oral intake.
Labor is a marathon. Imagine trying to run 26.2 miles dehydrated and without water. Most labors last much longer than the slowest marathon runners to complete a race. The main benefit of an IV is that it will hydrate you, which research has shown may reduce your time in labor or the cesarean rate. As with any intervention, there are some downsides. First, being hooked up to an IV can restrict your mobility. You can still move around, but you need to be aware of the IV. If you have an epidural, you may already have mobility restrictions, and an IV wouldn’t make a difference. The other downside is that over-hydrating with IVs can cause edema, which is swelling due to excess fluids in your body. This can be uncomfortable if you have swelling until your body gets rid of these excess fluids in the days after your birth.
IV fluids can also cause your baby to maintain higher fluid levels at birth, leading to more excess fluid loss after birth. The issue is that your doctor may see it as weight loss due to not eating enough. Babies will naturally lose weight after birth. In general, your care provider doesn’t want to see your baby lose more than 10% of their birth weight, and your baby should be back at their birth weight within two weeks.
An observational study published in the International Breastfeeding Journal found that timing and amounts of maternal IV fluids are correlated to newborn weight loss. The authors of this study recommend using the 24-hour weight, rather than the weight at birth, as the baseline weight when following infant weight over time. This recommendation has yet to gain traction in the medical community. This may be something to keep in mind if you receive IV fluids during labor. Weight gain is an important indicator that your baby is getting enough nutrition, but also look for other signs that your baby is eating well, like output in their diapers.
Most hospitals require a saline lock, sometimes called a hep lock. This is an IV catheter that is put in on the top of your hand. The needle is taped in place with a small tube that is capped off. With a hep-lock in, you are not hooked up to an IV pole. If you need something intravenously, your care provider can simply connect an IV tube to the hep-lock. If you do receive an IV, you may request an IV pole with wheels so you can walk around and still maintain mobility. Whether or not you plan to receive IV fluids during your birth, drinking fluids is still a good idea. Staying hydrated by drinking water may allow you to reduce the overall amount of IV fluids you are receiving. There is an entire episode on the evidence of IV fluids if you want to get into more details.
Antibiotics are a microbial drug used to treat bacterial infections. Antibiotics can certainly be lifesaving, but their use has some downsides, like disrupting your gut microbiome. Antibiotics administered during pregnancy or labor cross the placenta and transfer to your baby.
In the U.S., antibiotics are prescribed more than any other medications during pregnancy. In most European countries, 1 in 5 expecting mothers is prescribed an antibiotic during pregnancy, and in the United States, nearly 1 in 3 expecting mothers is prescribed an antibiotic when including the three months before becoming pregnant. Presumably, that number would be lower when just including pregnancy only. During pregnancy, antibiotics are frequently prescribed for urinary tract infections and some sexually transmitted diseases. During labor, antibiotics are given to treat group B strep or other infections or to reduce the risk of infection with a premature rupture of membranes or cesarean birth.
Treating Group B Strep with Antibiotics
It is routine in the United States to test expecting mothers for GBS (group B strep) between weeks 35-37. GBS is a bacterium that naturally lives in the gastrointestinal tract. GBS is common and is in 10%-30% of pregnant women. Typically, GBS isn’t an issue, but it may become a concern for your baby at birth. If you are colonized with group B strep, it is routine to treat you with antibiotics. According to the CDC, if you have GBS without antibiotics, there is a 1 in 200 chance your baby will develop GBS disease. With antibiotics, your baby’s risk decreases to a 1 in 4,000 chance.
Antibiotics are given to you at the beginning of your labor through an IV, then every four hours during active labor until your baby is born. See this episode for in-depth information on GBS, including what is involved in the testing, how to treat group B strep, and how to reduce the risks to your baby. This episode also explores the evidence on whether you can decrease your risk for group b strep during pregnancy.
Reducing the Risk of Infections with Antibiotics
Antibiotics may be suggested if your water breaks before going into labor (premature rupture of membranes) or after a certain period between your water breaking and your baby being born. A Cochrane review didn’t find evidence for the use of routine antibiotics for term premature rupture of membranes. Researchers found antibiotic use did not reduce the risk of infection for pregnant women or their babies compared to the control group.
An epidural raises your risk of running a fever in labor, which affects about 23 out of 100 women. A fever does not increase your or your baby’s risk for an infection. However, since a fever is a sign of an infection, your care provider may recommend antibiotics as a precautionary measure.
Antibiotics are routine for cesarean birth to prevent infection after the operation. A review of 95 studies involving over 15,000 women found that routine use of antibiotics at cesarean section reduced the risk of infections in mothers and serious complications of infections by 60% to 70%. The review notes that although there are benefits for the mother, there is some uncertainty about whether there are any important effects on the baby. If antibiotics are given before the cord is clamped, they also go to your baby. If you have any concerns about how antibiotics could affect your baby, talk to your care provider to ask them about it and find out if it is their practice to administer antibiotics before or after clamping the umbilical cord.
Side Effects of Antibiotics
While the side effects of antibiotics will vary depending on the type of antibiotic, some common side effects are nausea, vomiting, abdominal pain, and loss of appetite. Changes to your gut microbiome can cause diarrhea, bloating, and indigestion. Yeast infections are also common because antibiotics can lead to an increase in candida in your vaginal flora. If you are breastfeeding, antibiotics can increase the risk of thrush, a yeast infection in your baby’s mouth that can also affect your nipples.
The decision to take antibiotics is a matter of weighing the risks and benefits. It is not just the risks of taking antibiotics but of not treating a possible infection with antibiotics. While you do not want to take antibiotics unnecessarily, they are effective when needed.
Electronic Fetal Monitoring
Labor and birth will be the most physically stressful events of your baby’s life. Each time you have a contraction, the blood flow to the placenta is temporarily diminished, and this reduces your baby’s oxygen supply. This might sound scary, but remember, your body is designed to do this, and your baby is built to cope with this. The decrease in oxygen supply to the placenta is short, and the oxygen supply will increase as soon as your contraction is over.
Your doctor or midwife will monitor your baby’s heart rate during labor to assess their well-being. The goal of using electronic fetal monitoring is to recognize babies who are short on oxygen and identify what the underlying cause is to correct it. Examples of measures to correct a decelerating or slowing heart rate are changing your position, administering oxygen, changing your medications, discontinuing Pitocin, or alleviating compression of the umbilical cord. A tachycardic (too fast) heart rate could indicate an infection, hyperthyroidism, or placental abruption. Monitoring heart rate can also alert a doctor or midwife if an emergency arises in which a baby needs to be born immediately via cesarean section or through an assisted birth. Electronic fetal monitoring is the most common obstetric procedure and standard procedure in hospital labor and delivery units. According to ACOG, 85% of births in the United States use electronic fetal monitoring.
Types of Fetal Monitoring
Your care provider monitors your baby’s heart rate through either auscultation or electronic fetal monitoring. The method of monitoring your baby’s heart rate depends on your doctor or midwife, the policy of the venue where you are giving birth, your risk of complications, and how your labor is progressing.
Auscultation is a method of periodically listening to the baby’s heartbeat. With a Doppler transducer, a fetal stethoscope, or a Pinard, which is a trumpet-shaped device that amplifies sound. A Doppler is most commonly used and looks similar to a microphone. When it is held up to your belly, you can hear the heartbeat amplified through a speaker. With intermittent monitoring, they will check about every 15 minutes during the first stage of labor when you are dilating. During the second stage of labor or the pushing stage, they will check about every five minutes or more.
Electronic Fetal Monitoring
Electronic Fetal monitoring uses instruments to record the heartbeat and contractions continuously. The machine used is an electronic fetal monitor, also known as a cardiotocograph or CTG. An electronic fetal monitor provides an ongoing record so your care provider can review the results of how your contractions and the baby’s heartbeat have changed over time.
External and Internal Electronic Monitoring
Electronic Fetal Monitoring can be external, internal, or both. With external monitoring, a pair of belts are wrapped around your abdomen. One of the belts uses a Doppler to detect your baby’s heart rate, and the other measures the length of contractions and the time between contractions. This is by far the most common method of monitoring. There are some instances in which external monitoring is not working well or if your doctor or midwife has concerns and wants a more accurate reading. In this case, your care provider may recommend internal monitoring.
With internal monitoring, a wire called an electrode is placed on the part of the baby closest to your cervix, usually the scalp. A tiny screw holds the electrode in place to record the heart rate. Your contractions may also be monitored intermittently by using an intrauterine pressure catheter. This is a tube that is inserted through your vagina into your uterus. Internal monitoring is only used after your water breaks and you are dilated at least 1-3 centimeters. Internal monitoring is often used with twins to differentiate the heartbeat of each baby. This method is also more effective at detecting a heartbeat when a mother is significantly overweight.
Internal monitoring carries a slight risk of infection and the possibility that the electrode can cause bruising on your baby. There may also be some discomfort when the electrode is put in place. With internal monitoring, you will be required to stay in bed and unable to move around very much.
Consideration for Electronic Fetal Monitoring
If you have a home or a birth center birth, your care provider will monitor you intermittently via auscultation. If you have your baby at a hospital, you may have some options for monitoring and whether it is intermittent or continuous. Your care provider may prefer continuous monitoring if you get an epidural Pitocin or if you are at high risk or run into any complications. You are probably thinking, why wouldn’t I want to be hooked up to a monitor that ensures my baby is doing well? That’s a good question, and there are some reasons why some expecting parents may want to minimize or avoid continuous monitoring.
Monitoring Upon Hospital Admission
Hospitals routinely use an electronic fetal monitor upon your arrival in labor. One study found no evidence of benefit for using an electronic fetal monitor compared to intermittent monitoring upon admission to a hospital. The researchers found electronic monitoring increases the cesarean section rate by approximately 20%. This review supports recommendations that the admission CTG not be used for women at a low risk upon admission. It goes on to recommend that women should be informed that admission CTG is likely associated with an increase in the incidence of a cesarean section without evidence of benefit.
Effects on Mobility
One big issue with electronic fetal monitoring and continuous monitoring is that it impacts your ability to move around because you are tethered to a machine with wires. There is a lot of evidence that the best labor positions are not lying on your back in a hospital bed. The ability to move around and try different positions may help your labor progress or even shorten your labor. In addition, continuous electronic fetal monitoring may not allow you to labor in the shower or to have a water birth. If you plan to utilize water therapy, please talk to your doctor or midwife about your monitoring options.
Options for Electronic Fetal Monitoring
Electronic fetal monitoring is often continuous, but it doesn’t necessarily have to be as long as you and the baby are doing well. Ultimately, this is something you will need to discuss with your care provider. If you want to know what your options are for monitoring the heart rate of your baby during labor, talk to your doctor or midwife and find out what their policy is and what the policy is where you are planning to have your baby. It is all about working with your care provider to balance what you want with ensuring your and your baby’s safety.
Like any intervention, you have options for electronic fetal monitoring. You may have the option of a telemetry monitor, which uses a transmitter on your thigh to transmit the baby’s heartbeat via radio waves. It is continuously transmitted to a nurse’s station so you can walk around and have more mobility.
There is a volume and a display on an electronic monitoring machine. You may find it helpful to pay attention to it, or it may distract you or your birth partner. You can always turn the volume down or turn the monitor away from you.
An assisted delivery is a medical procedure to help a baby pass through the birth canal. This is used when a complication arises, and your baby needs to be born quickly or if they are having trouble making it through the birth canal on their own. There are two instruments that your care provider can utilize for assisted delivery: forceps or a vacuum device. Forceps look like two large spoons. These are placed into the vagina around the baby’s head. A vacuum device is a suction cup with a handle applied to the top of the baby’s head. With either of these tools, a care provider gently applies traction to help guide the baby’s head while the mother pushes. This is not a routine procedure and is only used in about 3 in 100 vaginal births.
The main benefit of an assisted birth is that it can allow your baby to be born vaginally rather than by cesarean. Both vacuum devices and forceps are associated with a small increased risk of injury to the vagina, perineum, and anus tissues. This can also result in urinary or fecal incontinence. There is also the possibility of injuries to the baby’s scalp, head, and eyes, bleeding inside the skull, or problems with the nerves in the arm and face.
A Cochrane review examined randomized controlled trials of assisted vaginal birth using different instruments. This included 31 studies involving a total of 5,754 women. Overall, forceps are more likely to achieve a vaginal birth and cause maternal injury, including 3rd and 4th degree tears, but less likely to cause fetal trauma. Even within the categories of forceps or vacuums, there are different types of these instruments that vary in their design. A significant determining factor in what instrument is used is the availability and the experience and skill level of the practitioner.
Your perineum is the area between your vaginal opening and your rectum. This is a sensitive area. Your perineum stretches during birth. Especially when your baby’s head is emerging. Your baby’s head has the largest circumference, and once it is out, there is less stretching, and it is a very short time until the rest of its body is born.
It is very common to tear your perineum during birth. Research shows the rates of tearing with a first baby are 90% and decrease to 69% in subsequent births. According to the American College of Obstetricians and Gynecologists, the rate of some lacerations during all vaginal births is between 53-79%.
In the past, doctors believed that a routine episiotomy, a surgical incision to the perineum, could prevent a more significant tear. As more recent evidence has demonstrated that routine episiotomies are not evidence-based, organizations like the American College of Obstetricians and Gynecologists and the World Health Organization recommend against their routine use. Although this is no longer a routine procedure, there are instances in which an episiotomy can be used during labor and birth.
A surgical incision to your perineum will give your baby more space to come out and allow for a quicker birth. Episiotomy can be used in an emergency, with shoulder dystocia, or an instrumental delivery. Shoulder dystocia describes when your baby’s head makes it out, but their shoulder gets stuck. If your baby’s head is stuck and your care provider uses forceps or a vacuum, an episiotomy can allow more room for the instrument to help your baby get out. A study showed that in a forceps delivery, the performance of an episiotomy decreases the risk of perineal tears of all degrees.
Preventing Tearing and an Episiotomy
The good news is that there are some things you can do leading up to and during your labor and delivery to help prevent tearing. Methods focus on pacing your birth or applying techniques to allow your perineum to stretch safely without tearing. Theoretically, if you can avoid tearing, you may also prevent an episiotomy. See this episode for more information on episiotomy and an in-depth review of preventing and healing your perineum after birth.
Any intervention or procedure should always come with informed consent. The North American Registry of Midwives and the American College of Obstetricians and Gynecologists emphasize informed consent as Shared Decision Making and Informed Consent. It is essential to keep in mind that you are working with your doctor or midwife to make shared decisions. Still, there are a lot of birth procedures and interventions that are typical, routine, and may not be evidence-based. It takes a lot of time for attitudes to shift, for new doctors to be educated and trained, and for existing practitioners to see and do things differently. I acknowledge that this is a complex problem. The good news is that you can educate yourself to make informed choices, even if you are not getting the time and attention that every decision deserves from your doctor or midwife.
The Challenges of True Informed Consent
Proper informed consent means that you fully understand the procedure, intervention, or treatment, are made aware of all of the risks and benefits, and can opt-in or opt out. The last part of that is tricky. The truth is that you can opt out of anything. For a doctor or midwife to honestly give you a choice can be challenging because they, and the entities like hospitals they work for, have policies about what is required and routine. While it may not always feel like it, you always have a choice, which is crucial to true informed consent.
Numerous constraints can make it challenging for care providers to give proper informed consent. Limited time during a prenatal appointment or in labor can make it challenging to discuss procedures at length. How knowledgeable your care provider is about particular topics can affect their ability to assist you in navigating interventions. If your care provider is not consistently educating themselves, there may be areas where they do not have the most up-to-date information. While every procedure should come with informed consent, many care providers gloss over procedures they consider routine.
All of these constraints can make it challenging for doctors and midwives to provide proper informed consent for everything with every patient. Some care providers prioritize true informed consent more than others. If you ever feel like you need more information, please advocate for yourself and ask questions.
A Tool to Navigate Any Intervention
The BRAIN acronym is one of the most versatile tools you can apply to any birth intervention. Each word in this acronym is the key to a question you can ask to help you figure out whether any intervention or procedure is the right choice for you and your baby.
- Benefits: What are the benefits?
- Risks: What are the risks?
- Alternatives: What are the alternatives?
- Intuition: What does your gut or intuition tell you?
- Nothing: What happens if you do nothing?
The power of asking the questions in the BRAIN acronym is asking all five. While each one is helpful, they cover every aspect of the pros and cons together.
Including Your Preferences in Your Birth Plan
Creating a birth plan is an excellent exercise to get clear on the interventions you want to include or avoid. A birth plan is your plan of how you envision your birth and what happens directly following the birth of your baby. This is much more than a piece of paper you hand to your care provider. It is the process you go through to prepare for your desired birth experience. This process will lay the foundation for preparing for the scenario in which everything goes as planned and what should happen if things do not. The value of a birth plan has a lot more to do with the process of creating it than it does with the finished product.
The Pregnancy Podcast has several resources to help you create your birth plan:
The time to discuss birth interventions with your doctor or midwife is during your prenatal appointments. You do not want to discuss the risks and benefits of a procedure in between managing contractions in labor. The more you prepare during your pregnancy, the more confidence you will have to make decisions during labor. Working on your birth plan with your care provider throughout prenatal care is an excellent way to prepare.
- The Evidence on Vaginal Exams Before and During Labor
- Inducing Labor
- Inducing Labor Naturally
- IV Fluids and Drinking During Labor
- Antibiotics During Pregnancy, Birth, and Breastfeeding
- Group B Strep
- Electronic Fetal Monitoring
- Vaginal Tears and Episiotomy: Prevention and Healing
- Informed Consent
- Five Essential Questions to Navigate Procedures & Interventions
- Guide to Creating Your Birth Plan
Thank you to the amazing companies that have supported this episode.
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