EBB 412 - Induction Tips for Families with High-Risk Doula Jennifer Anderson, RN

0:00Hi, everyone. On today's podcast, we're going to talk with Team Edie Beans' Jen Anderson about what parents need to know when planning for an induction.

0:13Welcome to the Evidence-Based Birth Podcast. My name is Rebecca Decker, and I'm a nurse with my PhD and the founder of Evidence-Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com slash disclaimer for more details. Hi, everyone, and welcome to today's episode of the EBB podcast. I am Shantae Perryman, and I am the director of programs here at Evidence-Based Birth, and I will be your host for today's episode. Jen, it's time for me and you to take over the podcast.

0:58All right. We're in the candy store. All right. So let's hop right into it. I know that you have been supporting families as a doula and before that as an RN and also as a childbirth educator. And so you're very familiar with the induction scene and all that takes place. And so you have five tips, right? Mm hmm. I came up. I came up with a golden tip too. Five and a golden ticket bonus tip. There you go. Okay, so what's tip number one that you would share on induction? So when we're talking about navigating, this is what I like to say, like navigating induction. So and hi, everybody. It's always awesome to be here with all of you.

1:45As Shante said, I am a nurse and doula and I tend to do a lot of inductions because my patient population, my client population tends to have more high risk diagnoses. So lots of people don't kind of equate doulas with inductions, but they are the best friend you will ever have if you are having an induction. And it's something that I have the privilege of walking families through on a regular basis. So I kind of came up with, there's many more than just five, but I kind of came up with my five favorite tips that I find I use every single time with my clients in helping them navigate an induction and really kind of personalize it.

2:24help them have a little bit more agency in the experience. So before we go into my five tips, I like to call the first one my golden ticket. We talk about the golden ticket and advocacy skills in the EBV childbirth class. And this is kind of along those lines, which is your golden ticket tip is take a childbirth class and take a childbirth class that is not affiliated with your hospital. Hospitals will very often offer free classes or very low-cost classes, and they are a very easy, low-barrier way to get childbirth information. However, those classes are, a lot of times, I like to say, what you pay for.

3:05You pay a little bit, you're going to get a little bit. You're going to get just the facts, man. And I will also say that very often, hospitals will teach to their hospital policies. So what you're going to learn in a hospital childbirth class very frequently can be many lessons on how to be a good patient. When you arrive, we're going to do this, then we're going to do this, then we're going to do this. And we kind of go in thinking like, well, that's it. That's the only options I have. I'm going to hand this over to my providers and let it go. Well, if we do that, then we are going to have your provider's birth.

3:36And with an induction, there are many decisions that we need to make in order to personalize that. So in order to even have those ideas in your head, taking a childbirth class that isn't affiliated with the hospital so that you get unbiased, unkind of hospital-based information on things like the stages of labor, understanding medical interventions, knowing, like in this topic today, what all your options are in an induction. And if you take a childbirth class from me, then you're going to learn everything that is in my head. I'm not teaching to the hospital policy. I'm going to teach you everything that you need to know.

4:11And a lot of those things might be things that your hospital doesn't want you to know. So, for example, I'll talk about some things that are going to kind of fall under this category today of why take a childbirth class from something like EBB. And I'm not saying that this is the only class out there. There are many. But in most of these classes, advocacy begins with that evidence-based care. And we have to know what evidence-based care is in order to ask for it. So in the childbirth class, when we're talking about inductions, the very first step before you consent to an induction is knowing why you're being induced.

4:46And is this a good reason to be induced? Does this line up with my values? The childbirth class with EBB talks about inducing at 39 weeks with the ARRIVE trial, talking about inducing for post-dates, for gestational diabetes. What about if you're being told that you have a big baby or you're overweight? What's the evidence for inducing when my waters break or when my waters break when I'm GBS positive? The induction pocket guide that we have in the EBB store is a fantastic resource that can kind of serve as a childbirth class. It's the cliff notes of this topic, and it actually goes over all those diagnoses that I just listed there.

5:23So we're not going to get into induction methods or diagnoses or reasons for inducing because that is a much bigger topic that is covered in the EBB childbirth class. I strongly recommend that you take that class from any of our number of instructors all over the world. many around the U.S., in states personally as well, in person as well as virtual. So that's my golden ticket. The childbirth class, knowledge is everything. Can't get going until we kind of start with that. So having said that, let's look at my five ways that I very frequently, topics that I will bring up with my clients when we're talking about how do we want to navigate this.

6:02So hack number one, or my advocacy skill number one, is outpatient cervical ripening. Right. So, Shante, what is kind of the, I know you've stepped back a tiny bit from work, but you have not had your toes in it. What is kind of the scene of outpatient cervical ripening where you guys are in Kentucky? It's still relevant. Do you see it? Do you see that your patients are being offered it? And in what forms do they get to go home with? Just balloon or do you see other things too? We started in Dr. Long, we send you home for a little bit. Do you ever see that? no okay yeah a lot if we're starting so if we're starting an induction and you're going home you're think we're thinking more along the lines of like membrane suites but anything besides that like you're going in and you're being put on the monitor and yeah yeah and so in many regions that's the only option that you have i'm here to tell you that there are other options that are very commonly practiced in various places in the U.S.

7:08And a hospital is a hospital is a hospital. The evidence is the same no matter what state you are in. And so these options can be available, tends to be whether your hospital has these policies or not. But outpatient cervical ripening. Cervical ripening is that first step in an induction. And again, we discussed that pretty in detail in the class. But cervical ripening doesn't necessarily always mean that we need to be watched with four eyeballs, monitors, nurses, doctors looking over us in the beginning of an induction. It really does depend on what the diagnosis is as to why we are being induced.

7:42And so for certain diagnoses, outpatient cervical ripening, that initial stage of an induction where we do something and then we send you home and you go home and you wait a little bit longer to see if that something worked. That is an option in many hospitals and many facilities. Many patients don't know that they could go home. So you named the very first one, membrane sweep. That is a very common, I don't like to call it an induction procedure because it rarely works on its own, but it is in that cervical ripening category where it's a cervical exam that's done in the office that it's a little bit different than just the checky looky how far dilated you are.

8:21A membrane sweep is a little bit more intense. We're up there a little bit longer trying to kind of make that cervix mat, release the prostate gland, and then kind of start that cervical ripening process. So that one is one that is automatically, we do it in the office, yeah, we're going to send you home. Most people think that that is the only induction procedure that we can go home with, but that's not true. So around our region, and I'm in Northern California, during COVID, outpatient cervical ripening with the balloon catheter became all the rage. And we still see this today where we put a catheter, a balloon catheter in, you go into the hospital for the beginnings of an induction.

8:57We do all the intake and the labs and all the kind of fun stuff. And once we establish that your baby looks good and that you're a candidate for going home, they can put that balloon catheter in, which is a catheter that just sits around your cervix. The end hands hangs out like a big gigantic tampon string, but there's no medications involved with it and it just mechanically can start contractions. So they'll put that in, say at seven o 'clock at night, they send you home, you sleep in your own bed that night, you return in the morning either in labor with the catheter in or if it fell out, or you return in the morning not in labor and they'll take the catheter out and then we start with the next part of the process.

9:40So that is still common in many places. I have seen some hospitals kind of shut that down, the balloon catheter because they were starting to notice that those patients were having increased risks or rates of infection. One of my local hospitals has done this. I don't know if that comes out in the evidence or not, but you may seem some no's in that regard simply because maybe that evidence is starting to bubble up and they're looking at it. But Jen, I would say depending upon where someone lives, that's a great question to ask if that's even an option. Yeah. Yeah. Asking if going home with a balloon catheter or a base is an option.

10:16Absolutely. All three of these things I want you to ask for, is this an option at my facility? The third one is outpatient misoprostol. Okay. That is the medication that we can give that also works to ripen your cervix. It's a pill. We can give it in three ways, vagina, oral, or under the tongue. The best method for sending you home would be to just swallow it orally. And my hospital and a number of other hospitals in our region will bring you in that day, put you on the monitor. We give you a dose or two doses of misoprostol throughout that day. And by the time that last dose has kind of run its course, instead of giving you a third dose, we say, go home.

10:55Go home and sleep in your own bed. Let's see what happens tonight. You had all day on the monitor. The baby looks fantastic. We are not inducing you for a reason that gives us any concern for sending you home. So there are three ways that we could potentially do some of this induction process in our own homes. Membrane sweeps done at the doctor's office could definitely get that started. But usually, as I said, it's not the only thing that will work. Outpatient mesoprostol or being sent home with a balloon catheter in place are two other options. Now, these options won't be available if you have a more critical diagnosis.

11:32So you have high blood pressures. no, we're not going to be doing outpatient cervical ripening. We want to keep an eye on you. Cholestasis, other disease processes where we're concerned about mother or fetal well-being or the birth date person. So post-taste inductions are a perfect example of where this can come into play. And given the fact that most first-time parents are going into their post-taste and post-taste inductions are the most common reason for an induction, outpatient cervical ripening for those parents is a godsend. The other one that I will say is that 39-week induction that a lot of providers like to do just because we have risk factors, like we're older, we're pregnant with IVF, it's our first baby, the timing works out well.

12:18Those folks benefit tremendously well with a more of a slow walk induction process over a few days versus being on that board the entire time. One last little tip on this, and I heard this from a nurse at a recent webinar I was at, which is, no, I was actually a physician. And they were talking about how outpatient ripening takes you off of the radar. If you are a name that that doctor sees day after day after day on the board, and you're still there, they're gonna start getting more aggressive with why is this taking so long. But if you go home and come back and you're not there and you haven't been that presence in that room for three days, a lot of times providers just kind of lose track of time And we're given a little bit more freedom to work this labor and not necessarily have the cascaded interventions hit us hard.

13:07So the induction pocket guide is, again, a great resource here for looking at what is involved with a membrane suite, with oral misoprostol, with balloon catheters, and understanding what those procedures are to get your cervix right. And consider asking whether that might be an option at your hospital. Yeah, that's a great tip, the guide. yeah the pocket guide you know especially the client may or may not have a doula and in those instances where a doula is not present like that like you said that's a great resource to be like oh you mentioned x y and z let me go on to see what the hell yes and the pocket guides are great because they come in physical version but they also come in a pdf or like a electronic version and honestly for the parents and everybody out there i just say grab the electronic version because it's always in the store and it lives on your phone and the table of contents you see page 10 you scroll to page 10 and you can go straight there i tend to like toss the the physical kind over my shoulder because i can't find the pages so um both are very user friendly but everything that you need if you don't have a doula this pocket guide is kind of like a pocket doula especially when it comes to inductions if you know you're having one i highly suggest grabbing that product from the store.

14:22Let's go into advocacy scale number two, which is timing. Okay. We all think that we have to go on the provider schedule, the hospital schedule. We're just like floating around like a pinball in their pinball machine. And no, we actually have some say here, folks. So first and foremost, if we're doing or scheduling what I like to say is an elective induction, so 41 weeks elective, but yet the evidence still supports it. But it doesn't have to be one day or the next. We're scheduling it 40 weeks for 41. Hey, I really love my doc. I want to make sure that my doctor that I love that I'm seeing right now is actually involved in my birth experience.

15:01And most of us have are involved in physicians that are in group practice. So they rotate on call and your doctor might not be on the day that you're induced or the day that you deliver. So I always say, if you really like your doc, ask them to look at the call schedule or ask when they will be on call if you want them to start your induction or if you want them to actually catch your baby. And I will usually say one is one day, one is the next day. Like an induction usually is going to be about 24 hours. So what side is more important? Do you want to make sure that that doctor is present to execute your very personalized induction plan?

15:39Like I really do want to go home without patient cervical ripening, but I know that doctor on call won't do it, but my doctor will. So maybe I'm going to choose that doctor to start my induction because this is where I feel like I'm going to hit some sticking points. Maybe I really want that doctor at the end because I really trust them at the final moments when my baby is going to be put on my chest. So asking for their call schedule so that you can work with the person you trust is a very strong advocacy skill for those of us who have the luxury of picking an induction date. choose daytimes to start your induction okay the day of the week or the time of the day with your provider is important but the time of the day is so important and this is kind of a quandary and a catch-22 because i do get it the evidence really does support inducing people at nighttime or in the evening hours because that's when our oxytocin is in our bloodstream that's why all of you are going to go on a labor at night at least we start contracting overnight it works with our body's circadian rhythm by or inducing at night.

16:39However, what it does not work for is the circadian rhythm of sleep. If you are a stressed out first time parent, and we're telling you come on in at 10 p.m. for your induction, are you going to nap that day? No, probably not, even though I tell you guys all to do it. So what do you do? You go in at 10 o 'clock at night. We, you know, you haven't slept at all. We finally get to midnight or 1 a.m. where you swallow the first pill. And then we tell you where we put the catheter. And then we say, okay, now go ahead and go to sleep. But I'm going to come in every five minutes and adjust your monitor.

17:07You don't sleep that first night there. And maybe the induction method doesn't allow you to sleep that first night there, such as if you had a balloon in place. So I hate nighttime inductions for that reason, because the exhaustion can have an implication on how the rest of your labor goes. When you wake up that next morning, you're two centimeters and you've been off for 24 hours and we're just getting started. So try Try as hard as you can to get that daytime induction. Even though it doesn't work with the circadian rhythms, I will also tell you that providers schedule that because it also works very well for the doctor's schedules.

17:42They start you at nighttime because they know darn well that you're probably not going to deliver that baby at night. So they get to sleep through the night and they'll be there for you in the morning or the afternoon. And the doc says, oh, you'll sleep all night long and then you'll have your baby by lunchtime and I'll be there. And the mom is at the end going, that's not how I worked out. And it wasn't even my doc that was there. So I don't really kind of don't fall into the predictions of how wonderful this is going to go. Think about where your strong suits are. If we're going to put a balloon catheter in, I want you to be up and moving around and doing it during the daytime when it's kind of doable.

18:18So that kind of takes the outpatient cervical ripening with the balloon off the table if we're going to send you home at night. But also, I want you to be able to kind of move around freely when the body is working hard. but I want you to be able to sleep when the body isn't. And in the starts of an induction, the body's not working hard. We could sleep if we are given the opportunity to. So I have a couple other hacks for nighttime induction. But the one thing I will say is if you do have to start a nighttime induction, if we don't win that bottle, they will not give you a daytime. Or very often, you're sent over from the clinic.

18:51You got high blood pressures and we diagnose you that day. you're not going home the decision is correct to say hey let's go ahead and do this and so we're inducing tonight we didn't really have a choice so those kind of scenarios can present themselves too so we don't always get that choice of a daytime induction so in those scenarios there's two hints i always say is make sure kind of like yeah two get everything that you can to block out all the stimulation in your hospital room so earplugs white noise app or white noise machine and a very thick, cushy, wonderful eye mask that literally puts you into your birth cave and can allow you to sleep really well and help your nurses also leave you alone because the eye mask is kind of a, hey, I'm not looking, don't wake me up.

19:40So it's kind of like a force field. It's a little bit of a barrier. The other thing, if we have to be there at nighttime, is to ask for a dose of Vistril. So Vistril is spelled V-I-S-T-I-R-I-L. it is a sleep aid that is available by prescription it is a cousin to benadryl so it kind of has the it lives in the exact same family so if you don't have an allergy to benadryl visceral is just fine it is non-narcotic and you're only going to get one and it just helps i like to say it slows down the hamster wheel because our mind is going a million miles an hour when we're trying to sleep in a hospital with an induction and we just need the shh and the visceral can help you do that So, Vistral on the night, the first night of an induction, when our goal is to help you sleep, might be that saving grace to help you guys get through that first induction, or at least that first night.

20:29After that, wheels are off. And if labor hits really fast as soon as we're out of that, there is no problem with coping with labor. You're up, you're working, you might be a little tired, but you get through it. It's not like we're in this narcotic haze and we don't remember our births. Vistral isn't that kind of medication. So as for Vistral, if you have to spend the first night in the hospital with an induction, that's my timing hack. Any other kind of thoughts, Shante, on that? Like as you think about it with your own clients or your own births yourself? With the timing, I did have one thought.

21:04If it's not like urgent, like you were saying, like high blood pressure, like it's not urgent. We can wait. You have a big baby. That's not urgent. it. You can wait, right? I do like the 6am inductions. Because one, yes, you are sleeping in your bed, or you're trying to sleep because your excitement, your adrenaline, all the things, but you're still at home. And so you're comfortable and maybe you get to doze off just a little bit. And then I've also shared with clients is that those 10pm inductions, people aren't thinking about it but you're being charged for a full day at the hospital for two hours and most of the time you're just sitting there so just go the next morning so yeah and i've i've had it where i've had families just show up that morning instead of that night they showed up at like two o 'clock in the afternoon they're like i'm here and they're like well your induction is until not oh really i I thought you said 10 a.m.

22:04So I showed up at 10 a.m. instead of p.m. And while I'm here, do you have space? And it could sometimes work out. You know, I don't recommend that, but I've had clients do it. So sometimes the schedule isn't as such where it can work out well. Is there some hidden motivation behind bringing us in early in order to get that, you know, that one day charge? Who knows? Quite possible. I do believe there's a lot of motivations that don't have anything to do with us or our human body being induced and helping us have our baby. 100%. No, but I've had a lot of support persons be like, thank you for that tip.

22:42I've got a great story at the end that kind of works this little skill into play as another way that you can manage a nighttime induction if that's what they're kind of pushing on you. All right. So number three is to ask for the Monica fetal monitor. So, inductions involve fetal monitoring. They almost always do. At very least, we need to monitor your contractions and baby's status when we're giving you induction medications, whether that's misoprostol or pitosa. We cannot give those to you without monitoring you at the same time. It would be dangerous. So monitors are involved because of that.

23:20But if we're not using medicinal ways to get your body into labor, then what is the diagnosis that we're inducing you for? If it's post-dates and we've got a great looking baby, then we may not need to monitor the entire time. We just need to monitor long enough to get you into labor and then maybe your body will take it from there. And you're healthy otherwise, so you're just post-dates. But we can be healthy and be post-dates. We can be healthy and be fat. We can be healthy and be a lot of things. and the monitors can sometimes come off. But in the beginning, when we are giving you medications that require monitoring, the Monica is a different kind of technology that allows, especially at nighttime, for that nurse to leave you alone.

23:59We don't have to come in and adjust those monitors every five minutes. The electronic fetal monitors that strap on our bodies are very subject to our positions. As soon as you stand up, sit down, roll over in bed, the nurse has got to come in and change it. But the Monica fetal monitor works on Bluetooth technology and it picks up the electrical signals from the uterine muscle on the heart, the fetal heart muscle. So it's picking up things that the monitor is going to find no matter what position the birthing person is in. And that is a lifesaver, especially when we're inducing at night. If I got to take misoprostol every four hours, you got to monitor me.

24:35But I'm going to be able to sleep because all you're doing is give me a pill every four hours and I'm not in labor yet. yet. So with the monica on, that nurse can literally leave you alone until four hours later when it's time to give you the next dose. She doesn't have to come in and adjust your monitor every single time you roll over in bed, which probably is the thing that would come in and wake you up. So the monica is a lifesaver in inductions. And I will also kind of loop in. Some people are very difficult to monitor. I will bring in my high BMI clients as a part of this, where depending on where we kind of carry our subcutaneous fat in our bellies, the upper monitor or the lower monitor might have a hard time seeing what's inside with the traditional external monitors.

25:20The monica, again, picking up electrical singles, it can see through all sorts of extra tissue and still give that birthing person a fantastic looking strip that we can at least utilize for the first part of our labor until. And then there's the until part. So monocas tend to piece out on us somewhere around four or five, usually around six centimeters dilated. These monitors are not really good for picking up more frequent contractions or more finite kind of changes in the fetal heart rate tracing. So once we're working harder, the monica tends to become less reliable. I've had it where the nurse was suspecting that herpitocin was too high, but looking at the contractions, the monica wasn't picking up very many.

26:06Once we put the electronic monitor on, she was banging them out. So the nurse was right. There was way too many contractions going on. Mom wasn't feeling it, but she turned down the Pitocin and got it. So your nurses are usually really savvy on when that switchover needs to happen, when the picture isn't matching what's happening with your body. But it is a lifesaver. You can wear a moniker for 12 to 24 hours sometimes in an induction where we're starting you at 39 weeks. So that 24 hours of wearing that type of moniker can be a lifesaver. Do you ever see these monitors in your hospitals in your region too?

26:46Yeah. Yeah. Well, one hospital used to have them, but then switched to a different brand name. So that's something else to consider, especially like if we have parents listening in. Yeah. But that's a great question. again to ask prenatally like do we have the wireless monitors at this hospital and i would qualify do we have the bluetooth wireless monitors every hospital is going to say they have wireless monitors because whether the monitors have wires or not we can plug it into another machine that makes it wireless so wireless monitors they may think that you're asking about the the ones that strap around your belly ask about the bluetooth monitor or the sticker because that's what the monitor looks like it's a sticker on your belly which is so nice no big straps and that's also i say very humane for my bigger moms that really could you know those straps for after wearing those for a long time so um yeah so it's good to know that you're seeing them there and fascinating because i have not seen anything other than a monica but it makes perfect sense that different companies are going to come out with this technology.

27:56Monica started it. They finally got it to a point where the monitors are working pretty well and the nurses know how to use them. But it's definitely I can definitely see another vendor coming on the market anytime now. So, yeah, it might not be known as a Monica, but it's known as a Bluetooth fetal monitor that definitely allows for more freedom of movement, especially in the early parts of your labor. That's number three. Number four is very close. Number four is right on top of that, which is that these monitors can get wet. Your IVs can get wet. Monitors and IVs almost always go with inductions.

28:30Hospitals usually want you to have IV access in the form of saline lock, at least. We might not need to use that IV in your induction, but they're going to want to have it. And a lot of us think because we have an IV, whether it's running fluids or not, or because I'm wearing this monitor, that my plans for laboring in the shower or in the tub, if my hospital has one went off the table. Nope, no, they didn't. Those things can both get wet. Now, with the monica, different hospitals have different policies about whether you can get into the tub with a monica or into the shower. In my mind, if you really want the shower, it's worth it to switch over to the monitors that they say can let you get into the shower because you're at a point where you're hurting if you're asking for the shower.

29:11So let's go with that comfort measure, the comfort of having an easy monitor that doesn't hurt. Now we're beyond that. The contractions are going to bug you more than the monitor will. So let's switch it over and let's get you into the shower. So families need to know that just because I'm being induced, I am not a sick patient who has to sit in bed. Rebecca's, I love her first story where she shows the two pictures of her standing in her driveway with her cute little perfect pregnant belly. And then her sitting in the hospital bed with the hospital gown on with the IVs and all the things. and she was told she was not allowed to leave bed for the entire thing of her labor when her waters broke first a lot has changed since then that child is now in college but at the same time some things haven't changed and a lot of families have that vision in your head like every time i see a picture on the internet it's mother or birthing person sitting in a hospital bed screaming and holding on to their partner really hard nope that's not what labor tends to look like So we need to kind of pull back the curtains a little bit and look at more normal labor.

30:16Normal labor, you're up and moving around and you're using showers. And don't let those monitoring things that kind of have to go with an induction keep you away from those tools. Because water is one of the strongest comfort measures we all have in labor. Waters and doulas and walking. Those three things, you got those three things. I always say I can get anybody through an induction as long as I got water and as long as I can keep you moving. Many people decide to not do it that way, but we all can do it, but we need some help if we're not going to use medicinal pain relief. So that water is a must.

30:51Don't let the hospital say, well, you can't get in because you have an IV. I'd be like, well, then let's pull the IV so I can get in. That's my answer, which is not right. But sorry, that's the punchy gin that comes out sometimes. anyway um do you see that families are limited in their ability to use comfort measures like that when they're being induced i know you don't you do more home birth so you probably haven't done a ton of inductions but you hear i was gonna say it depends on the facility yeah depends on the provider yeah i mean literally you can go to one hospital and you know you know this like one policy is here and go down the street and it's like completely different world.

31:30So it just depends. So one way that all of us can also flashlight in and know whether what our hospital will allow us or potentially not allow us to do, and I hate using that word, but sometimes they literally put down hard rules, is to look at your hospital birth plan. So every hospital spits out a birth plan that is put in your third trimester packet that you fill out and you give to the doctor or the nurse when you show up in labor. What is on that birth plan? What did they list on there? Does under comfort measures, do they offer showers or tubs in labor? And if that isn't there, especially the shower, because every hospital has a shower, almost every client can labor in the shower.

32:13Not every client or every patient is tub compatible for birth and not every hospital has one, but there isn't a shower, a hospital room out there now that doesn't have a shower. So do they provide for that? Do they allow that? Is that on the birth plan? If it's not, you better darn well believe I'm asking. And that might also impact whether I might decide to do an induction or not if you're not going to let me use some of my favorite comfort tools. And this induction really is not aligning with my values. So there's a number of things that can go into it that can help us make this decision. But knowing that you guys can get wet that's the one part i do want you to know is that every single thing that we have wireless monitors can get wet monica's can get wet ivs we just have to put a plastic bag or tape over them and those can get wet too whether they're running fluids or not all right yeah i think that's a really good tip to know especially for first-time parents it's a whole new reality like whole new experience all together and just knowing these small tidbits of information really adds tools and nuggets to like your advocacy bag and what to ask for.

33:22And I would say don't feel bad that you're like, I didn't know that. Like, I didn't know I could have gotten the shower. When we were talking about making this, when I made this in a webinar last spring, I was mentioning some of these things to our group, our programs team, and we all do birth. And Ricky was like, I didn't know you could like you can get monitors wet, or I didn't know you could get into the shower than I mean like people who do this for a living don't know this so families like this is why we're putting this out here is even birth workers don't always know your doula might not know so yeah if you've got a newer doula you might be able to teach her something or have her listen to the ebb podcast and brush up on some good stuff so number five um and this one really does kind of it gets into the weeds a little bit but I just want you guys to know that it's out there, which is a failed induction protocol.

34:12So, EBB has a number of articles on things around the lines of failure to progress or failure to descend, which is our labor starts on the way from zero to 10 centimeters, or our labor stalls somewhere between pushing when we start pushing. But a failed induction is a different scenario altogether. I always say there's three ways that our laborers can just stop. Failure to progress or a labor rest after six centimeters, a labor arrest when we're pushing, or a failed induction. So the failed induction has a couple more things into play, and this is where advocacy skills and knowledge of what my diagnosis is and should I be consenting to an induction right now is super important.

34:54One of the things that we are looking at when we are doing an induction is known as your Bishop score. We've talked about this in a number of other podcasts, and it's in the class, but it's a five-point assessment on your cervix. So when your provider does a cervical exam, there's five pieces of information they have when they pull their hands out. We usually only hear the first one or maybe the second one, which is dilation and effacement. How thick or thin your cervix is, is that effacement? But there's three more numbers. How high or how low is your baby in your pelvis? Where is your cervix?

35:27Is it pointing towards your tailbone? Is it in the middle or in the front? or is, and then how firm or soft is it? So those are all things that your provider gets by feel and those numbers all get put into a little chart that develops your Bishop score. And in general, when we are considering inducing electively, meaning we don't have a diagnosis that says we need to do this today. When we're looking at a post-AIDS induction, for example, a classic example, for a repeat mom, for a repeat birthing person, we would want that bishop score to be around six or higher. For a first-time birthing person, we want that bishop score to be eight or higher.

36:07A perfect bishop score is 10. I'm going to tell you I've actually never seen a first-time parent ever walk in with a bishop score of eight ready to go. So I kind of don't hold that high, high standard because that's somebody who's walking around at four centimeters dilated just waiting for contractions. Repeat, parents do this, but first-time parents do not so a bishop score of zero and i'm 41 weeks uh or better yet and i'm 39 weeks and my doctor really wants to induce because hey nothing great ever happens after 39 weeks that's a strong no because that bishop score is telling you you might not get through this induction our our methods might not get you into labor if we are having a more elective induction where that score is a four or a five, I feel much better about saying, yes, today's the day.

36:57But if the day shows up and my Bishop score is two and we can wait another day or two, or maybe ask about outpatient cervical ripening in that scenario so that we can improve that score before we start hitting you with the medications. So that Bishop score is important to know for yourself, ask your provider when they do their exam, what is my Bishop score? And that number can be predictive of whether you're going to have a vaginal birth or not. I've had plenty of people with a bishop score to zero have a vaginal birth the next day. I've also had a lot of people with a bishop score of five who ended up in a cesarean three days later.

37:32So it is not conclusive by any means. The numbers correlate, but they do not conclude. So the field induction protocol, that's number one. If we're doing this elective, we should be starting with a bishop score of six or above. I just say that for all general population. and we should be saying no to that elective induction if we're not there but let's say my induct my bishop score is three and i preeclampsia okay we're not waiting we're gonna go ahead and do this but now we have we're gonna be put on a clock where we're gonna do all the cervical ripening things and then we're gonna move on to things that are gonna bring on contractions once we start pitocin and your waters are broke and your waters are broken so both of those things the moment that both of those things exist in your body pitocin is running and my waters are broken that's when a clock starts and i hate talking about clocks this is the only clock i ever acknowledge is the failure is the failed induction clock because the moment if my waters are broken already and we were doing this and now i start a pit okay that's when the clock started if i was already on pitocin and nothing was happening so they decided to break my bag of water that's when the clock started.

38:44And with that, we have about 12, the evidence supports about 12 to 18 hours of Pitocin plus water is breaking to get you into labor, okay? Where you're contracting, you're working hard, we're making our way towards active labor, six centimeters dilated. If we hit that 12 to 18 hour mark, there is evidence to support saying we have a failed induction. However, ACOG is very clear that they prefer a full 24 hours of Pitocin plus water's breaking as long as the maternal and fetal status permit. So if you're healthy and your baby's healthy and this induction's just taking its sweet old time, once we broke your bag of water and you're on Pitocin, then we're going to give you 24 hours.

39:27And I do see hospitals in my region literally being religious about this, which is good. The point is, I don't want to say I'm going going to start somebody at two centimeters on, you know, with an induction for preeclampsia in 38 weeks, and I'm going to give her 12 hours and that's it, you're done. No, we got to give that body longer as long as the status permits. So this failed induction protocol is really important to understand. I go into this in a little greater detail in my childbirth class with EBB simply because I have so many people planning an induction. But another great resource that we can put in the show notes is the California Maternity Quality Care Collaborative, CMQCC.

40:08They've got a great toolkit on their website and there is an algorithm in there for you engineers out there and you data hounds that want to look at the algorithm for a failed induction protocol. as long as we're allowed to put that on there. If not, we'll put a link. As long as we can put that PDF on there, I would love to have that there for you guys to take a look at it. If not, going to the CMQCC website is a very great website. Their toolkit there is downloadable for anybody and just look for Appendix R, which is that failed induction protocol. Yes, that website is amazing. So many. Great.

40:42So I like to say like an early AROM, early breaking of the bag over water, artificial rupture membranes, AROM, can often seal that fate. Once your waters are broken, usually we're not going to go home after that. And once your waters are broken and we start Pitocin, that's it. That's the track that we're on until we either make progress or don't. And that's the hard part about inductions is they don't always work. All the best medicine in the world can sometimes not get a person into labor. I've done this. I've had a number of failed inductions where that person is on way high doses of Pitocin, but the water's broken and she's sitting there in the rocking chair at five centimeters feeling nothing and the contractions aren't happening.

41:25So it's just the body going, nope, not ready yet. And fortunately, if we needed to do this, we have to have a cesarean. The frustrating part is if we didn't need to do this induction and the body said, I'm not ready, we're still going to a cesarean once we've been, our waters have been broken and we've been on ketosis for 24 hours so i really do try to protect that breaking in the bag of water and always discuss going home if this thing does not look like it's taking off on day one if my medical status permits and that's where sometimes it doesn't we got to just keep going so those are my five big hacks of how like common things that i am always kind of preparing my clients for when we're going in for an induction so i have a question.

42:08Yeah, go for it. In some instances, you know, our clients might know that, yes, I'm going in for an induction and they have that time to prepare. But for those where it's like, you know, you might be getting scheduled for an induction, like in the next two, three, four days, what are your tips for going in to that conversation with their provider? like let's think along the lines like i'm planning on going completely natural no medicine no induction you know because sometimes we have clients who are like that's their mindset which is nothing wrong with that but then you know something might happen and it's like let's monitor this yeah yeah so you know when we're when we have i would say induction changes our birth fans it's it's this cute little rectangular word that just goes okay let's just induce your baby and i always say like a lot of times we kind of magically think like blink and the baby's just going to show up in our hands and we don't realize how much goes into that rectangular little word and part of that is just the decision to say yes and then it's the death by a thousand decisions entirely throughout the entire labor do you want to start driving now i want to do later we're gonna check now we're gonna check later no i don't want to be checked i want to start this meta and we're constantly saying yes or no to things so when we have that time when we kind of like have a lead time where we're scheduling this and this isn't oh by the way right now labor nudges are your best friend let's try and i call these labor nudges not natural induction techniques because i always say nature doesn't induce nature lines up all the things in the body so that when the baby says i'm ready the body knows exactly what to do these labor nudges can kind of sometimes accelerate that process but they're not going to put you into labor at least not full labor except for one my favorite one is acupuncture because acupuncture does have some very strong evidence that it can work and if i know i got a few days i'm hitting my local acupuncturist if i possibly can if i have someone around to do that now not all of us have access to acupuncturists or ones that will do induction procedures so what else is out there pregnancy prenatal massages just relax get the oxytocin flowing that massage and relaxation and just that loving hands on your body are some of the things that allow our brain to release that oxytocin if you've got a toddler snuggle with that kiddo as much as you possibly can and you know what if they've stopped breastfeeding try to get them to start again and if we just got off of it you know have a play around anyway nipple stimulation can also get the oxytocin flowing in our body and maybe do some thinning while that toddler is maybe nursing on you.

44:53So don't be afraid at this point in time of breastfeeding because it's an induction technique. Other things that are just a lot more nice is don't spend these last days doing things that are not trying to get yourself into labor. Like, ah, I got this induction on Thursday. It's Monday. Okay, today I'm going to do this. Tomorrow I'm going to do this. Don't schedule your week to go into labor. Schedule your week to do everything else but. The watch pot is such a beautiful analogy here and I use it all the time. That watch pot will not boil. If you're looking at that induction date on Thursday, you're going to drive right into it.

45:29There's a great analogy I use with my clients, which is I hated mountain biking with my former husband. He did it with me all the time. And I couldn't stand it because I didn't want to fall. I didn't want to hit a tree. I didn't want to hit a rock. And he was just like, you know what? When you're going down the hill, just look at the trail. Look at where you want your bike to go and the bike will follow. Well, I flip it around because I'm broken. And so I'm going down the hill. I'm like, oh, there's a tree. Don't hit the tree. Oh, there's a rock. I don't want to hit the rock. So I'm looking at the thing that I don't want to hit and boom, I go straight into it.

45:58And inductions are exactly that same way. Don't look at the thing that you don't want to hit. If you got an induction on Thursday, have lunch with friends and family. Do things that you would not have done, like eat a turkey sandwich. You know, just have some sushi, gosh darn it. Do things that are telling your body, I don't care anymore. Because what the body's going to do is go, oh, hey, you know what? I'm over here. You were paying attention to me this whole time. You're not paying. Okay, I'm going to make you pay attention to me now. And boom, contractions hit. So I think magical things happen when we give up trying to avoid that induction and recognizing that the days will pass and we can't make it happen mentally or physically.

46:39The way it happens is when we're not looking. We met the person of our dreams, usually not on Match.com. We did it when we were looking the other way and their shopping cart gave us a flat tire in the food store. So those are the ways that things happen in our lives. And I always think that birth is going to happen that way too. So when we know that an induction is coming, do lots of fun things that you can't do when a baby gets here like really fine dining or going to a three-hour movie that you know a kid won't sit through going for a hike and that can help you go into labor too so lots of fun ways to kind of normalize this process as we're waiting for the other shoe to drop and maybe try to have the shoe drop earlier and not avoid it so um do you want to hear a birth story want to put some of this in all right let's do it so i have two birth stories here but we'll go through one of them we'll see if we have time for another one.

47:30I picked these two stories out because they kind of touch on a number of the tips that we used here today. So this first one was what I call a surprise gestational hypertension induction. And Rebecca actually talks about gestational hypertension in podcast 359. It's one of her mini podcasts. So it's one of three topics. But for those of you who want to learn more, that podcast is out there for you. So this client was 42 years old. This was her second baby. She was 38 in one weeks that day and she went in for her 38-week visit to her prenatal provider. And at that visit, her blood pressures started to climb.

48:07She had two or three high readings in the office and high readings for a pregnancy are considered anything over 140 over 90. Either number over 140 over 90 gets kind of a flag and hey, let's look longer. So she was sent over to the birthing center or to her hospital for further monitoring. And usually we're going to do serial blood pressures during that time and also draw labs to potentially see whether preeclampsia is developing. So during that time that she was in triage, she threw out a couple more high blood pressures. Her labs came back borderline. She did not have preeclampsia. She did have gestational hypertension and they were recommending an induction.

48:45Now with this kind of induction, it wasn't critical, critical that we had to induce right then and there. Her blood pressures were high but they were some of them were normal but the preeclampsia wasn't there so as we were kind of talking about things i'm like well so what are you feeling i'm like you could go home and come back at 6 a.m for an induction like i'm all about like because it was five o 'clock on a friday afternoon her husband wasn't with her at that moment because she just went to this appointment herself and the baby uh her toddler they didn't have any child care for this kiddo.

49:14They weren't expecting this today. So we kind of went through like we could go home and come back. They might not like it, but you're stable enough. We can kind of, you know, make it make the judgment for yourself. She said she wasn't comfortable with that. She's like, I don't know that I would sleep because I'd be too worried that something's going to happen to the baby. I'm like, okay. All right. So that's where her values were. And that made perfect sense. I want you to go home and sleep. If you're not going to sleep, then why are we sending you home? So, okay, we're going to stay. But then I'm thinking, all right, here we go.

49:45After a long work week, because she wasn't on maternity leave yet, we're going into a Friday night induction at 39 weeks. This is, or 38. This might take a while. And so I said, well, you know what? You've been stable. Your baby looks amazing. Your blood pressures are a little high, but they didn't treat them with meds. So I was like, let's ask whether you can sleep overnight tonight where they can monitor baby, monitor your blood pressure, and then we can, you're right there, and we can start induction at 6 a.m. So she asked them those three things and they were like, yeah, yeah, we could do that.

50:15Sure, that sounds reasonable. Like, you know, she gave him her sob story. My husband's not here. I don't want her to talk. It was enough. And you know what? Providers do have a heart. Most of them do. And they can kind of understand. And our request was quite reasonable. And they were able to monitor and keep her safe. So that is what they decided to do. Her partner made it there later on in the evening after the kid was batting down with child care. and I suggested to her to ask for some Vistral that she did take and we all shut down and she went to sleep. She texted me at 6 a.m. in the morning.

50:46She said she slept phenomenally well because she had the Monica on and so she was able to just kind of, the nurses literally left her alone all night long with the exception of coming in to take her blood pressure a couple of times. At 6 a.m. they put the balloon catheter in place. That was the decision that they chose to make starting with the balloon only no misoprostol that balloon came out around 10 a.m and she was then three centimeters dilated and we talked about this in this webinar when i did this uh live which is that she was what we call mechanical three so balloon catheters because they don't have medications because the balloon isn't really talking to the brain yeah i can stretch open your cervix but the cervix might not tell the brain it's time to release oxytocin so she was what we call a mechanical three.

51:33And that is a dangerous place to be in a hospital because they're like, okay, you're three centimeters, no contractions, but you're too far along from esoprostol. Let's hit you with Pitocin. And so that's exactly what they did. They started her on Pitocin. We started with low dose and we were going up and up and up. She started with that and nothing was happening. So a number of hours later, after about four hours, the Pitocin was getting higher and she was doing nothing. They're like, you know what? Let's back this out. They stopped the Pitocin and gave her a couple doses of misoprostol instead.

52:03That did the trick. That worked great. And she was now in labor. So now she was contracting and they knew they couldn't give any more misoprostol. She was like, they were like, okay, let's go ahead and restart the Pitocin. And I looked at him and I'm like, but she's contracting. So isn't Pitocin supposed to make it contract and we're contracting. So what? And they're like, oh, well, I guess we can wait. I'm like, let's wait. So we did. And I'm like, can I get her in their shower instead? She had the bluetooth monitor on still that was working great for she had her ib going or she had an ib but there was nothing going through it we got her in the shower she labored in that shower for the rest of the day probably she was in there for about five hours doctors came in wanted to do a check to see whether how far you know how she was progressing and we're like give us some time to think about it so they walked down i'm like well how do you feel and i'm like i'm gonna tell you why i'm watching you and she was having all the right different sensations of a baby moving down under her pelvis.

52:59I told her, I'm like, I have no doubt that you're more than three centimeters now. We can do an exam or we can hold off a little bit because if we do the exam, you're going to have to get out of the shower. And she's like, I'm not ready to get out of the shower yet. So we said, you know what? We'll let you know when we get out of the shower and you can go ahead and do a check then. They reluctantly said, okay, because they don't have a choice and everybody needs to remember that they do not have a choice. The mom has all the choices. So she said no. And about 45 minutes later, her water broke while she was in the shower.

53:27Great place for it to break. And immediately with the next contraction, she was pushing. So we called a man. We're like, okay, she was 10 centimeters. She started pushing 40 minutes later, she had a baby. And the second that that baby landed on her chest, the first thing she said was, oh my God, I would have never thought to sleep overnight and not start this until the morning. But that made all of the difference. And it just made my heart sing because honestly, she had the stamina for this unmedicated labor and that was kind of a goal for her and i'm like you're not going to get through an unmedicated labor if you're exhausted we can't do it we gotta have sleep in the labor process somewhere or fast labor because the body can only do so much and that allowed for it to happen she gave birth about 24 hours after she was there so she was probably in labor delivered about 24 hours but only about seven hours of that was actual true labor the rest of it was helping her stay safe, helping her rest, finding ways that we can work with hospital policy in order to make her birth experience super special.

54:32So it's always one of my favorite ones. And this was also her last baby too. So it was kind of nice to end on such a really good note and have a healthy baby all around and healthy parent who both of them went home the next day. And are doing great. Love it. Yeah, it's awesome. It's awesome. So things that we did in this induction, were talking about options, delaying things. You know what? The doctors are not like this brick wall. They do have some negotiation in there. And sometimes it helps if we know what to negotiate for, but the other part of it, we can just kind of ask the right questions.

55:09Or I'm like, this sounds like a crazy question, but I'm just going to ask it. Can we just sleep tonight and start at 6 a.m.? You don't know what they're going to say. And most providers, if they're going to say no, they're going to say it kindly. And if they don't, then that might be one of your red flags as well. But I am always surprised at how much providers will sit down and agree to kind of talk about different options, even if it's ones they would have never come up with before. Give them the option to go, I can't really think of why we couldn't do that. So sure, you can stand on your head and see if you can go into labor.

55:42You know, like, why not ask the stupidest, craziest things? Because I am always surprised when they do say yes sometimes. So, yeah, that is kind of how we can put some of these advocacy skills into place. I've got another great story where high BMI mom went through four days of an induction and even pulled her IV at the point in time where they wanted to break her bag of water because she had Pitocin running. And she knew if they break the bag of water, then we're committed. But the Pitocin wasn't working. So she pulled the IV and well, she pull it, but she's like, I'm going to go home. And they're like, well, you have an IV.

56:18She goes, oh, yeah. I was like, watch this. And you pull the IV out. And she's like, I don't have an IV anymore. I can go home. And there was nothing they could do. She was healthy. It was 39 weeks. They were inducing her because she was overweight. And her baby was perfect all day long. We just had a 12-hour NST. Tell us we can't go home. And that's pretty much what she said. And in the end, she ended up giving every single thing that she wanted. She did come back the next day. She was on with a better provider that was a little bit more liberal with her options. let her labor off the monitor for a while let her get in the shower things that the doctor before wasn't letting her do and she had an incredibly empowering birth as well without a provider in the room because the provider was saying well because you're so big it's going to take you a while to push so i'll be in the break lounge and you let us know when the baby's you know the head's on the perineum well she went and the baby came out and we were they were all spinning around trying to get him he wasn't in the break lounge nobody was there the nurse caught the baby like we nurses do, not uncommonly.

57:20And then he walked in and he started lambasting the nurse for not calling him in time. I was right there and I saw that she called him at the exact time when he told her to. What happened? I said nothing. My client went full on at this doc and said, they were calling you. The charge nurse was walking around going, is he in here? Is he anywhere else? She was running up and down the hallway trying to find you. Everybody did it. And I don't know that this client would have done that had these nurses not really kind of rallied around us to really try to help us get what she wanted. You know, everybody really just became very endeared to her after three or four days and making decisions that most strong people wouldn't make.

57:59And she doesn't come across as somebody who's really, you know, strong, gets everything that she wants, you know. And I was like, where's that person in labor? Because I was like, you go girl. It, I think, taught her how strong she really can be. And I think that birth made her such a stronger woman and such a stronger mother in that moment. I get goosebumps every single time I think about her birth because I watched a mother be born that day and it was really truly beautiful and a strong one at that. So, you know, we can ask for things that we don't think we can ask for. If it's on your mind, say it.

58:35The worst they can say is no, is always my kind of takeaway there. And then my last takeaway is please, if you know that you've got some risk factor is in play and doctors are never shy about letting you know that then take a childbirth class and be prepared for inductions i wasn't when i was pregnant with my first i went to 42 weeks when my water broke there was very thick meconium and there was no going home waiting for labor to begin and in my birth experience i did not plan for the for the interventions because i was planning a fully unmedicated water birth and i got nothing of that and that lesson taught me that i needed to be prepared for all options because sometimes the body or the baby is going to take us on a journey that we'd hadn't planned for.

59:21We can make a lot of mental decisions, but when the body and the baby need medicinal help, that's where medicine has its place. And now we got to shift gears and work within that system. And there are ways to do that. Doulas, childbirth class options, and asking questions that you think are stupid are all really great ways of getting what you want out of this birth experience and turning that little square word into a beautiful birth experience instead of the one that the provider decided for you. So that's my little Sunday with the cherry on top. Well, thank you, Jen. We love when you come on and share your expertise with us.

1:00:00Thank you. It was my pleasure and I wish everybody the best of luck. And if you're looking for a childbirth class, just head on over to the EBB site and click on parents and childbirth class and the whole directory there lists people in every single time zone. If you see virtual classes, if the time zone works for you, then don't be shy about signing up. So we've got amazing instructors that will help mentor you through this experience. And I love doing it as well, but there's many of us out there. So I hope you guys all find what you're looking for. And in the end, I hope that we all go into labor on our own, but we know that that's not possible.

1:00:35So we here at EBV will be here to help you out when that doesn't happen. So So thanks, everybody. All right. Well, thanks for joining us on the podcast today. And we'll see you next week. See you next time. This podcast episode was brought to you by the book, Babies Are Not Pizzas, They're Born Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care. in this book you'll learn about the history of childbirth and midwifery the evidence on a variety of birth topics and how we can prevent preventable trauma in childbirth babies are not pizzas is available on amazon as a kindle paperback hardcover and audible book get your copy today and make sure to email me after you read it to let me know your thoughts