Induction of Labor (IOL)
Many times I have heard and seen my birthing community cringe at the mention of the IOL as if it is some type of @#!@# word. Induction of labor is a very useful tool in the hands of the gentle OB. I will admit that the use of IOL has definitely gotten OB's in trouble several times but I want to give my guidelines for the usuage.
Indications: simply put, a solid medical reason. Whether my mom has Pre-Eclampsia, the scare of it via elevated BP's (150's+ SBP or 100+ DBP), uncontrolled diabetes (gestational or pre-exsiting), cardiac disease, IUGR, oligohydramnios, too mention a few off the top of my head. I feel as though under circumstances where the potential is harm to mom and/or baby this is a no-brainer. As with the process of Pre-E the outcome can be so devastating (Hypertensive disease is the #1 cause of maternal mortality) that anything less than delivery would constitute mal practice.
Now where the argument arises in the community is the idea of elective IOL. Here is where I will expose myself (cover your eyes :). I have yielded to the crying, sobbing, and pitful mom who is begging to be done with the pregnancy. The times when I have done so the following criteria have been met:
1. 39+ wks gestation by solid dating (LMP c/w a 1st trimester sono)
2. Favorable cvx (as determined by a Bishop score of >8)
3. Vertex fetus
4. Counselled mom explaining that she will be at an increased risk of c-section
My method of induction will fluctuate.
Unfavorable, Medically indicated IOL:
I have used cytotec before in the past but prefer cervidil (can pull the medication if any signs of tachysystole or hyperstimulation). Most times I will place a foley bulb. The foley bulb is almost always very effective and by the time it comes out the patient is usually around 4 cm dilated so pitocin can be increased. Will use 2-4 mu of pitocin with the foley bulb to provide the starter contractions (the pitocin is not increased until the foley bulb comes out).
Elective, Favorable cvx IOL
Because I have gotten away from doing these types of inductions on a regular basis I will mostly perform a membrane stripping for patients who are anxious to get started and don't want to wait and let their body do what it should naturally. I usually will strip a cervix that is 3-4 cm dilated and > 50% effaced. If the patient's cervix is very favorable and she is not in active labor I have found the membrane stripping to be very effective in starting the laboring process. Most of these moms will not need a milliunit of pitocin.
The patients that I am particularly hands off with are my first time moms. I explain to them that they should be given every opportunity to go into labor on their own. Some are crying to me by 41 weeks. My postdates cut off is 41 1/2 wks to 42 wks. I will intervene and do an IOL by that point. I'm sure that I will hear plenty on that point but that is what I do.
As always I love the discussion. Fire away.
Dr. Harris, you do all the right things by your patients... I can assure you that. There should be no issue with these plans for IOL... (however, I do hope that you think of the potential slow progress of a "foley bulb" 4cm cervix especially on primips, and yes, even multips... as many doctors do not and are ready to put the cervix "on the clock" once the patient reaches the dreaded "foley bulb" 4cm)... regardless, all your reasonings for IOL and their potential outcomes are completely reasonable.
ReplyDeleteStill, I'm sure you educate your patients on the fact that just because 37 weeks is considered 'full term', by no means does that mean delivery is imminent. Often, when given a DUE DATE, people are appalled by the fact that doctors let them go over-due (or even reason with people that their "friend gave birth to a baby 3 months premature it it turned out fine"... When, in fact, people's bodies have their own internal clock of when the cooking timer is done for baby (speaking from experience, as a grand-multip who is currently 37 weeks pregnant and KNOWS that I'm not delivering for AT LEAST another 3-4 weeks UNLESS an induction of labor is done).
I am glad... no, ecstatic that you educate your patients on all of this, if not once, but several times! If only we had more doctors like you in the city of Dayton.
I think the same reason some people feel negatively toward inductions is the same reason why some people feel negatively toward doulas...or even childbirth education classes: some that practice outside of the evidence make it difficult for those who practice within the evidence. Plus because what you have said here indicates you DO practice within the scope of the evidence and might I add, sanity and respect, I wouldn't expect to hear much backlash. If you do, those should remember that obstetrics exists for those times when the woman's body NEEDS intervention, and NOT when other need convenience or control.
ReplyDelete