Q: Any ideas, advice or recommendations on how to naturally induce labour? I am a midwife with a high percentage of first time mums overdue; they get fed up, and I have run out of tips.
-Anon.
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Choosing Your Style of Management
by Maryl Smith
1. Conservative (expectant) Management: Fetal assessment and evaluation without intervention unless there is an indication of compromised fetal status.
2. Active Management: Implies induced labor at a predetermined date (usually 42 weeks).
3. Combined Management: Conservative management is followed by a shift to active management before the referral deadline (usually 43 weeks).
Several studies over the past decade seem to indicate that fetal outcomes are comparable regardless of management style. Not even one study could provide enough empirical evidence to support routine induction for healthy postdate pregnancies. Two general areas of agreement exist for management of the postdate pregnancy:
1. Fetal assessment in the postdate period is appropriate with induction occurring if there is evidence of fetal compromise.
2. Post-date women with additional risk factors for uteroplacental insufficiency (e.g. hypertension, diabetes, fetal growth retardation) should be induced according to her status rather than dates. This may be before 40 weeks. It is generally agreed it should be no later than 42 weeks.
Most studies seem to show that the group of primary concern is women with correct dates who do not enter labor spontaneously and eventually must be induced. Only one study showed an increase in cesarean section rates (2.7%) in the expectant management group due to fetal distress. However, in several other studies the cesarean rate was higher in the actively managed groups due to failure to progress. In a third study the outcome for patients for whom conservative management was planned but induction became necessary was no different from that of patients who underwent planned inductions at term. Whether conservative or active management is used, the two groups show no difference in the length of first or second stage labor.
There is a trend toward an increased need for intervention for fetal distress in the active group. This may be due to the increased fetal stress that can accompany use of interventions such as oxytocin. In one study Apgar scores were similar, but in another study a greater proportion of the active group required intubation and ventilation and had a greater incidence of neonatal seizures, intracranial hemorrhage, and nerve injury (an increase of about 0.5%). Umbilical cord venous pH showed a significantly lower mean in the active group. There was no difference in birth weight. In all studies the outcome for post-date mothers and babies who were allowed to go into spontaneous labor was generally good and the mortality rate was similar to the actively managed group. Multiparas were shown to have no more obstetric complications due to post-dates than if they deliver at term. Primiparas, on the other hand, seem to be at greater risk for post-dates complications as is true for primips who deliver at term. In conclusion, patient satisfaction should be the most important indicator of management style.
Emotional Factors in Prolonged Pregnancy
Begin early in pregnancy to accustom the mother to the idea that a term pregnancy lasts anywhere from 37-42 weeks. Tell primips that many first time mothers go ten days past the due date. Only 40% of mothers will deliver within 5 days on either side of the due date and about two thirds deliver within ten days. Important attention to the following will help a mother cope with prolonged pregnancy:
1. Reassure her that her body is healthy and working perfectly. Remind her that 60% of women have their baby after the due date.
2. Reassure her that her baby is healthy and wonderful.
3. Help resolve any difficulties sleeping.
4. Ask about her social contacts and family relationships.
5. Turn on the telephone answering machine. Don't answer the phone.
6. Give her statements that can be repeated for self reassurance.
7. Examine worrisome statements by friends and relatives.
8. Include family and friends in a prenatal.
9. Check for overexertion or the inertia of depression.
10. Has she cried? Express empathy.
11. Leave a stethoscope, Pinard horn or Doppler with a mother if she finds it reassuring to hear her baby's heartbeat. Instruct her on proper use,inviting a phone call when she wants your input and is using a Doppler.
12. Discuss preparation, fears and husband's feelings to clear charged issues.
13. Discuss pressure coming from family members with impending airline departure dates. (one of my least favorite circumstances).
14. Discuss inducement of labor.
15. Plan moments of self indulgence and relaxation.
16. Encourage her to talk to her baby.
17. Provide gentle labor encouragements such as homeopathics or 5 week botanical formulas so that she feels she has some active control over her circumstances.
18. Draw her baby on her belly with a washable felt pen.
19. Rave about small cervix changes or any descent in station.
Reprinted from Midwifery Today E-News (Vol 1 Issue 51, Dec 17, 1999)
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