Induction and the Membranes

Stripping the Membranes

Sweeping the Membranes

Stretch and Sweep

Most of us have heard the terms at one point or another because many moms are induced and this procedure often precedes an induction.  It is designed to stimulate prostaglandins prior to an induction and hopefuly start the dilation process to avoid pitocin or at least make a mom more "ripe" for induction success the following day.  A provider inserts their digits for a vaginal exam and separates the membranes/bag of waters/amniotic sac from the lower portion of the uterus which is known to stimulate prostaglandins.  During a vaginal exam you say?  Yes, they can do this without your consent - without you knowing.  In fact, I know moms that have been told "Oh, by the way, you might experience some bleeding tonight because I stripped your membranes."  Legal?  No...  but who's stopping them?

Prostaglandins, with high levels naturally in semen (in fact, some cervical ripening medications have been derived from the high levels in pig semen), make the cervix more pliable which aids during the dilation process. Moms body will typically make all that is needed - provided she lives a healthy and well balanced lifestyle that allows proper hormone production and body function.  Time, however, is needed during the gestational period as most first time moms birth closer to 42 weeks and most multips also birth after 40 weeks - with wide fluctuations on either side of these numbers.  It is indicated that a longer menstrual cycle is more indicative of a longer gestational length than conception date.

So, is stripping the membranes really necessary?

When moms are recommended for induction, they are often given what is called a Bishop score which looks at various factors such as gestational age, cervical dilation and effacement, number of vaginal births...etc.  A higher Bishop score is connected with higher success for induction... and it is also connected with spontaneous labor happening sooner anyway.  Makes sense, right?  A mom with signs of progression is likely closer to spontaneous birth.  Let's keep in mind a question as well... if mom is in *need* of an induction, is scheduling it for next week the best way to go?  Is the induction actually needed?  Do we know that in many cases the risks of induction are the same as the risks for the situation warranting the induction?  Weigh the pros and cons of waiting vs. the risks of all induction methods (herbal, "natural"...  are any inductions actually natural?, sweeping the membranes, oral/vaginal prostaglandins, breaking the water...etc.).

Also, take a look at Primal Health Research and the studies that indicate because of the risks immediately and long term from pitocin induced births, cesarean often carriers less risk for breastfeeding, bonding, depression, fetal/maternal distress...etc.

In addition to sweeping the membranes, moms are often given some sort of cervical ripening agent either orally or vaginally... or both.  In many cases, this is Cytotec - an ulcer medication which has off-label use for induction... it can also cause uterine rupture and death of the mom and/or baby.  Pitocin also carries these risks in similar rates - but pitocin can be turned down for strength if the uterus seems to be hyper-stimulating (which isn't always measured accurately).  Once Cytotec has been taken orally or given vaginally, that's it - there's no going back - and without proper studies of the medication for this use, we get a wide range of dosages and a wide range of efficacy and experience.  Cytotec is approved for post-birth hemorrhage, however.

While also sweeping the membranes, moms may experience AROM or PROM - Artificial/Premature Rupture of the Membranes.  While ROM may happen spontaneously at home in a low percentage of moms giving them time to monitor their health while waiting - when you're in the hospital and with most medical care providers, that's it - your labor clock has started.  There's no going home now or waiting things out.  You often receive an IV and antibiotics because of the now increased risks for infection.  And while home birthing women have experienced their water breaking and then sealing, this doesn't happen in a hospital birth.  You're either waiting a few hours for labor to begin on its own, or provided with augmentation to get labor contractions started.

Some moms say, "I don't have another option."

There are ALWAYS options.  Not feeling comfortable with one of your options is a different story altogether.  Explore that.  Why are you afraid of the alternative?  What can you do (especially if you're TTC or early in pregnancy) to prevent those fears from limiting the choices you're comfortable with?  What is available to provide you with the knowledge and skill needed to overcome those fears?

Some moms say, "My provider is forcing me."  In some shape or form, they're being coerced and often in a negative/controlling/fear-tactic sort of way.

Woah!  This is a CLEAR indication that your provider doesn't understand birth at all.  We'll get to this more in a minute... but how on earth can you TRUST a provider that has to use fear tactics to make you submit to their will?  If the provider is recommending the best for you and wants you to have the best experience, why are they incapable of providing the evidence and the love that makes you comfortable with their choice?

One thing to remember is that you have rights and can refuse any recommendation. In most cases (not saying it hasn't happened before) - they're not going to hold your arm down, stick an IV in it, and give her pit without her consent... whether forced or coerced - she still gives consent.  Why, yes, they can strip your membranes without your knowledge - if you're not accepting vaginal exams, this is not possible. This leads us to another question.  Are vaginal exams necessary?  Well, for thousands of years babies came without vaginal exams.  Babies, with some providers, are still coming out without vaginal exams.  Ask "why do you need to do that?"  Ask "what information might you learn that would change how we approach labor and birth?"

If you're not comfortable with your alternatives for care and location, you could take a lawyer to an appointment with you and a copy of A Guide to Effective Care in Pregnancy and Childbirth (not saying that's 100% accurate as studies have flaws... but you can at least look up the studies that your provider is *supposed* to be following as you're in your appointment). Unfortunately the fear that surrounds women is often the "I can't switch" reason vs. the actual inability to switch providers. They fear home birth more than they fear pitocin. They fear unassisted birth more than they fear the years of unknown ahead from what an induced birth can cause. They are not educated on unassisted birth from their provider or birth class, so they're still assuming the worst and thinking their situation - regardless of induction method - is still the saf"ER" route.

Let's look at this for just a moment.

Home Birth

Stripping the Membranes

Natural level of prostaglandins

Little to no vaginal exams

Bacterial presence from the home

ROM typically occurs during birthing stage or shortly after

Patience

Higher - in comparison to hospital birth - level of spontaneous and non-augmented birth

Higher - in comparison to hospital birth - level of vaginal birth

Increased Prostaglandins

Increased Vaginal Exams

Increased risk for infection (albeit, studies show negligible)

Increased risk for Premature Rupture of the Membranes (now studies show the risk of infection is no longer negligible)

Decreased "labor clock"

Increased risk for Pitocin & decreased level of spontaneous birth

Increased risk for cesarean

Now, let's think about home birth vs. induction.  Induction doubles the risks of cesarean, increases pain significantly, increases epidurals (and those risks), increases uterine rupture and mother/baby death, increases PPH.... and home birth increases spontaneous vaginal birth, breastfeeding rates, decreases postpartum mood disorders, and reduces all interventions.  This doesn't even cover the comparison to unassisted birth.

There are a variety of risks with stripping and all that goes with it (like moms getting cytotec slipped in without consent - not to mention the risks of infection... which I would think a provider would be more cautious about if a mom were GBS+... but that's another reason antibiotics are given to all GBS+ moms because they can practice invasive without a second thought... or so they think and now new generations believe).

So what is a mother to do?  What about those moms that really have been encouraged so much by our culture to believe intervention is safer than the alternatives?

I focus on WHY moms might not be moving into spontaneous labor ON TOP OF the fact that most 1st time moms birth closer to 42 weeks. Additionally, moms with longer menstrual cycles tend to gestate longer as well.  These are averages that we know IN ADDITION TO every mom and baby needing different things... like time...

What I also remind moms is they need to get their head out of the game.  Relax, de-stress, unwind, and stop thinking about a birth date.  Stop thinking about what someone is going to recommend to you.  Stop thinking about the birth.  Stop thinking about work.  Stop thinking about that misinformed person that keeps asking you "if they're going to let you go past ____ weeks."  Stop thinking and just ENJOY.

Stripping the membranes might increase prostaglandins and a Bishop score, but this is letting the tail wag the dog!  Dilation... rather, labor progression is much more about an efficient uterus than it is about a ripe cervix - and we all know what causes an efficient uterus, don't we?

OYTOCIN

Let's think about how to increase oxytocin.  Let's think about how to create uterine efficiency.  You have all the makings, you just need to put it together.

"Oops, I'm so sorry, I can't make it to my appointment today - I'm out of town. I need to reschedule." (Yes, even when you're 41+ weeks).  Call after hours when you can leave a message even, then turn off your phone.  I am not encouraging a relationship with your provider that doesn't involve complete trust, but I do want you to think about what your body actually needs and how you can be a decision making factor in this process.  Then, book a cabin in the woods (semi close to the birth place so driving doesn't hinder you should labor begin) and stay there until your oxytocin levels are now able to rise because adrenaline decreased. Take all the spa treatments, bubble baths, walks on the trails with a camera....etc.  Can't get away?  No problem - do it at home in your back yard, in the park... anywhere that feels relaxing to you.  All these things increase oxytocin and decrease adrenaline. 

While adrenaline is a handy dandy survival hormone that tells us "Nope, not safe to have a baby here/now" - it does so because it is also antagonistic to oxytocin.  So, if you want labor to increase, you need to think happy thoughts and fly away to labor labor land.  Need a little pixie dust to give you a boost during pregnancy/labor?  Ask the oxytocin fairy (i.e. doula).  All these factors work just the same in labor as they do prior to labor.. as the last weeks of pregnancy are really a continuum and not a separation of here is pregnancy, and here is labor.  It's a circle that completes with breastfeeding and starts the process over again.

 

Additionally, work with posture, stretching (the hamstrings and abdomen especially), and abdominal tone all throughout pregnancy.  It is never too late to start.  Tight hamstrings cause a tight back which causes discomfort (decreased oxytocin) and also less ability for the pelvis to flex and allow room for baby. Yoga, Pilates, walking, hiking, swimming, pelvic rocks, tailor sitting, stand up desks, birth balls... all these things that strengthen the body, especially the muscles that support the uterus and pelvis, and support baby's position.  A baby in a funky position with a poorly supported uterus might need some hands on techniques - like spinning babies - to get them into a position where labor will progress further.  Stress and position are a key factor in prodromal labor.  These are all techniques that support the body's natural ability - not "what can I do to self-induce."  Belly dancing is AMAZING for pregnancy/birth. It gets baby into position, it stretches the ligaments, and it just feels amazing. This is what belly dancing's original purpose was - and now there are even birth classes surrounding the idea... but really just some big swirls of the hips and figure 8s with the pelvis are great.

Last, but not least, are you receiving proper nourishment?  Are you getting all your B vitamins, all your minerals like calcium and magnesium, enough sunlight (i.e. natural Vitamin D) for dopamine production which supports oxytocin?  If you're not sleeping well, I'd say you might need to get up and exercise a bit in the sunshine.  All of the necessary nutrients for proper body function can be found in a healthy balanced diet of colorful vegetables (lightly steamed, of course), and healthy food choices.  Dark greens are often a big factor for the modern to THRIVE and work at its optimal level.  A glass of equal parts nettles and Red Raspberry Leaf (a few pinches of each steeped for 3-5 minutes) is a great daily tonic tea that provides nourishment throughout the body.  It is great warm, it is great iced, it is great unsweetened.  If you want it sweetened, though, add a *pinch* of whole leaf stevia - or at most use a smidge of honey.  This is not an encouragement for using these as induction agents!  This isn't even a medicinal dose anyway, just a regular tonic (toning, nourishing) dose in addition to all your tonic foods.  This is encouraging you to make sure you and your baby are receiving adequate nourishment for proper body function.

Your body is amazing.  It was MADE to birth.  When interventions are recommend, only you can decide if this is something you want for your baby and yourself.  Looking at it from a logical perspective, however, often helps us to move the fear tactics aside and get down to the root and not put the cart before the horse.

Blessings on your journey!