News: PQI News

Let Healthy Babies Pick Their Birthdays

Monday, October 30, 2017  
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Authors: Debra Bingham, DrPH, RN, FAAN and Lilly (not her real name)

Overuse of induction of labor increases the risks of a woman having a postpartum hemorrhage. Below is Lilly’s (not her real name) story, which illustrates that women may be pressured by medical providers to have an induction of labor, even when there isn’t a medical indication. Waiting for labor to begin on its own and letting babies pick their birthdays reduces the overuse of inductions of labor.

Lilly’s Story

In April 2012, while on a trip to Boston, I found out I was pregnant with my first child. After trying for some time to get pregnant, we were SO excited. I quickly began researching obstetrical providers in Washington, DC where we live.  My gynecologist had recently stopped providing OB services, so I needed to find someone new.

I consider myself a well-educated consumer of healthcare.  I’m fortunate enough to have financial resources like private insurance and a two-person income household. At the time, I was working for a women’s health organization, and I was blessed to personally know some of the most dedicated, thoughtful OB nurses in the country. I asked them for suggestions. I attended educational sessions at area hospitals, met with midwives and physicians.

I did my homework. I know how important prenatal care is. I know that the choice of a hospital and an OB provider can greatly impact pregnancy and birth outcomes. I ultimately selected a physician who practiced at a large academic medical center. He worked in a practice with nurse-midwives and seemed very interested in understanding the kind of birth experience I wished for. He said he would be at my birth come “hell or high water.”  That each prenatal visit would be with him. I liked the idea of establishing a personal relationship with him and throughout the course of my pregnancy, I was able to do just that. He was fantastic. 

At my last prenatal visit – the day before my due date – I went to his office.  I was feeling great; there were no signs of labor.  I was secretly happy about this. I wanted my parents, who lived 12 hours away, to be present for the birth. They were en route and I felt confident that they would not miss a thing.

At that prenatal visit, my doctor, who I trusted so much, said, “Well, everything looks great. Why don’t you call your husband and have him meet you across the street at the hospital? I’m working tonight and we can go ahead and induce you now.” I was shocked. I called my husband in tears. This was not what I wanted. I had a perfectly healthy pregnancy. I wanted my labor to start on its own. I knew the risks associated with non-medically indicated induction of labor and yet, I didn’t have the courage to question my doctor. I couldn’t muster the strength to tell him, “no.” Or to ask him, “why?”

I got to the hospital and was hooked up to the monitors. I told the nurse that I didn’t want to be induced. She called the doctor; he came in to tell me that the risk of stillbirth increases with “each passing day” and that induction was the “safest” next step. When he left the room, I talked to the nurse about what he said. I asked if the baby looked okay. If I was okay. If I should get an induction. I texted a midwife colleague. I asked her if I was going to have a stillbirth if I waited for labor to start on its own. Both reassured me that I did NOT have to get the induction. That it was my decision. The nurse told me the baby and I looked good and I went home, grateful for that nurse and my midwife co-worker. I also wondered what happens to the people who don’t have all of the resources I do.

From there, the doctor said that I would need to come to the hospital every-other-day for a non-stress test. In the meantime, I was taking long walks, eating spicy foods. I even tried castor oil to get labor started. Two days later, with my parents and husband in tow, I went back to the hospital per the doctor’s instructions.  After an hour or so of monitoring, the doctor came to tell me that my fluid levels were low. That I needed an induction.  Now. Again, I cried. I didn’t have the strength to push back. My parents were worried that I was questioning the doctor’s advice.

Again, it was a nurse who came into the room, saw me crying, and asked, “What’s going on here?”  My husband told her than I didn’t want to be induced, but my fluid levels were low. She asked how much I had to drink that day, fetched an enormous pitcher of water, and with a twinkle in her eyes said, “Start drinking mama.” My fluid levels came up and an hour later, I was walking out of the hospital once again, thanks to a nurse.

This pattern of activity – the non-stress test, a recommendation for induction coupled with a conversation around still birth, happened one more time. Until January 20th, when I woke my husband up in the middle of the night to tell him that I was in labor.  He kept track of my contractions, called the hospital, and woke my parents who had made it safely to my home.  It was time to go into the hospital again, but this time on my terms. 

My daughter was born less than an hour after we arrived at the hospital, perfectly healthy, surrounded by family and so much love.

Now three years old, my daughter often asks me to tell her the story about the day she was born. I tell her about how excited we were to have a baby, how she’s perfect in every way. About her pretty, long fingers and brown hair. I also tell her about the “silly doctor” who wanted to pick her birthday, and even more important -  the wonderful nurses who knew that SHE should be the one to pick her birthday. She picked January 21st. 
Facts about Postpartum Hemorrhage

According to research by Bateman et al., about 78 percent of all postpartum hemorrhages are due to uterine atony. Women with long inductions of labor are at greater risk of having uterine atony. Obstetric hemorrhage remains a leading cause of maternal deaths and a cause of death where there is a strong chance of altering the outcome.There has been a lot of work nationally to reduce hemorrhage-related maternal morbidity and mortality, including the release of the Council on Patient Safety in Women’s Health Care’s Obstetric Hemorrhage Maternal Safety Bundle. Implementing the maternal safety bundle elements in your hospital, clinic or practice is a great way to reduce hemorrhage-related morbidity and mortality.

We also need to work upstream to prevent obstetric hemorrhages. One of the simplest ways to reduce the need to rescue women from a postpartum hemorrhage is to stop inducing labor without a medical indication. Inductions and augmentations of labor should be reserved for situations when the health of either the baby or mother indicates there is a need. Women with healthy pregnancies do not need an induction of labor when they are at term and their baby is healthy. Consumer Reports recently quoted Debra Bingham, Founder of PQI, in an article titled What to Reject When You Are Pregnant in recommendation #4, to reject "inducing labor without a medical reason." As Debra stated in the National Institute for Child Health and Development video, "Is it Worth It?," why add risks to your health if you don't need to?

Waiting for spontaneous labor is safer for healthy moms and babies. Healthy babies are better at selecting their birthdays than anyone else is. 


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