A Tale of Two Inductions
By Lisa Vanbuskirk, Expat Mom and Family BloggerI had both of my children at Reinier de Graaf hospital in Delft; Daniel (March 2010) and Melissa (January 2012). Both babies required scheduled inductions to be born. In 2010, the hospital let babies remain in the womb until 42 weeks, but by 2012 they had changed their policy to maximum of 41 weeks. Both induction processes ultimately are success stories as my children are healthy, which in the end was/is most important to me; they just are very different stories.
In 2010, my son was still in a "Frank Breach" position at week 34, so the midwife transferred me to the hospital obstetrics clinic for care. At week 36, the hospital was able to successfully perform an "external version" and turn my son head down. I also did some acupuncture to try to help facilitate the turn, which didn't work spontaneously on its own, but perhaps contributed to my own positive mental state of having him turn. The external version wasn't painful, other than the nurses' nails digging into my stomach to turn my son. The drug they give to relax the uteruses also makes your heart beat like crazy, which was a weird feeling as well.. I was then returned to the care of my midwife with the hope of labor beginning on its own.
After three attempts at "stripping the membranes" by my midwife and hospital clinic, with no resulting contractions, I entered the maternity ward at 7 am to begin fetal monitoring at week 41, 6 days. I was a mere 1 cm dilated (which is why stripping was unsuccessful), so the first step, since my son's heartbeat was normal, was to apply prostaglandin gel to the vagina to soften and open the cervix, with the goal of then progressing oxytocin drip. I was told it could take more than one application of the gel, so to be prepared for a long day. I remained on the fetal monitor during this time, which was important, as my son almost immediately went into fetal distress. His heart beat dropped quite dramatically relative to the lack of contractions my body was experiencing. Many hospital staff flew to my bed, closed the curtain, did some stuff, then relocated me to intervene in various ways to stabilize my son and begin preparations for an emergency Cesarean Section. When they closed the curtain around me, they told my husband and I they needed to work, and then would explain it all to me (since neither of us understand Dutch). And I was (and still am) fine with those priorities and the delayed explanation of what they were doing and why.
So off to the operating room we went! My husband met me there with scrubs to hold my hand, and my son was born at 9:30am. My husband accompanied my son through his checkups while I was stitched up, and I met them in a recovery room. My son then stopped breathing for a few moments, but was whisked away to NICU, where he spent the first night. I was wheeled up there twice to visit in the first day/evening. He was released to the maternity ward without them identifying any specific reason why he stopped breathing.
Subsequently I've read on the internet that C-Section babies are more likely to stop breathing, most likely just because of the sudden shock of their birth to them. I also read that something like ~50% of drug induced labor inductions lead to emergency C-Sections because the baby is not ready for the artificial hormonal start of labor and subsequently go into fetal distress. I am glad I didn't read those stories before we went to the hospital, but I could have just as easily been in the 50% that delivered just fine with the induction drugs. While not the delivery I anticipated at 7am when I checked into the maternity ward, my son is healthy, so I am happy with the end result.
I remained in the hospital for three evenings and was released the morning of the fourth day to return home with my son, and was met by the kraamzorg. At my follow-up appointment with the OB/GYN six weeks later, I was told that there was no physical reason preventing me from a natural delivery next time, if I so wished.
A Vaginal Birth After Cesarean (VBAC)? In my home country of the USA, I would have needed to really search for an OB/GYN who would be willing to let me attempt a VBAC. My perception is that American OB/GYNs prefers repeat C-sections, even if they are not otherwise medically necessary, because they are scheduled, efficient, and I suspect medical liability insurance plays a role as well. If I had our second child in the US, I probably would not have actively sought out a VBAC, but would have been accepting of a second Cesarean delivery.
The benefit of a VBAC over a repeat C-section for me (when pregnant with Melissa), had more to do with being able to chase after my 22 month old son post-delivery, then the "natural" experience per se. Sure, it would be convenient to know when Melissa would arrive from the perspective of arranging childcare for Daniel while we were in the hospital for a scheduled Cesarean, but it is still surgery, with associated risks and recovery time.
For my daughter's birth, I was able to see a midwife in town until week 36, but she would not be permitted to perform my delivery (even at the hospital) because of the previous Cesarean Section. I was transferred to the care of the midwives at the hospital for the last month of care and delivery (note that I did not need to see an OB/GYN). I was hoping that labor would start naturally, but alas, no such luck in the end. I had to be induced a second time.
As a result of the previous Cesarean, the hospital could not use the prostaglandin gel to begin labor. The risk of rupturing my Cesarean scar was too great with the gel, as well as my own concern about my daughter going into distress like my son did. Instead, the induction was begun using a Foley Catheter balloon. Basically a balloon is inserted into the vagina and filled with a saline solution, via a tube that they tape to your leg. The goal is to apply pressure to the cervix and force it open enough (approximately 3cm) to break the waters. At 3-4cm, the balloon should/could fall out on its own.
I entered the maternity ward at 8am at week 41. I was put on the fetal monitoring and the balloon was eventually inserted at 10:30am. We were told that it could take 24-48 hours to work. Yikes, longer than we anticipated! When we had looked it up on the internet, the articles mentioned 6 hours of use of the balloon, not up to two days. So, not expecting instantaneous results, my husband went home to look after our son (and free our friend to come back later when we really needed her to watch him). I would call this a cultural difference in managing expectations between the Dutch staff and their non-Dutch patients, not a language translation issue.
I spent the day reading a book, listing to my Ipod, and taking short walks around the ward to break up the monotony. I felt some mild cramping, but no contractions. The balloon itself was not painful and except for the rubber tube attached to my leg and inability to leave the hospital, I could kind of ignore it. That evening they placed me on the monitor again to confirm my lack of contractions and again the following morning. After the morning monitoring, they added some more saline to the balloon, and we went back to waiting. About 30 minutes later, the balloon burst, which they told me could happen with the addition of more saline in the balloon.
After an internal exam, the midwife recommended breaking the waters and moving on to oxytocin drip. I was not quite 3cm dilated (but more dilated than I thought I would be at least) and the cervix was still long, but a new balloon would not be more effective or quicker at that point. At 10am they broke my waters (really more of a puncture, no dramatic gushing at that point) and started the oxytocin drip half an hour later, increasing the strength every 30 minutes. I applied my TENS machine patches and turned on the machine in the hope of avoiding an epidural. The midwife reminded me several times I could have an epidural, I just needed to ask and to ask early in the process. By 1pm, the contractions were registering on the monitor (and more importantly, felt to me) like a continuous earthquake seismograph, with no down time between contractions, so I asked for an epidural, knowing I had a long day ahead of me. Thankfully, they stopped the oxytocin, I got the epidural within a relatively short time frame, and we started all over again. I was still only at 3 cm dilation at this point, but the cervix had flattened. After about a two hour break in feeling any contractions, as they slowly re-increased the strength of the oxytocin, I began progressing at 1cm dilation per hour. The contractions were manageable through just breathing, thanks to the epidural and they were now rhythmic. I achieved 10cm dilation at midnight and they turned off the epidural to allow me to be able to focus and feel the need to push. I began pushing (on my hands and knees, much to the frustration of the Dutch midwife who wanted me on my back) at 0145, and Melissa was born at 0208. For the last contraction/push effort, the midwife had me flip to my back so she could cut an episiotomy. By then I knew what I needed to do pushing wise, so I was ok pushing the last bit on my back. My pushing efforts also earned me a few hemorrhoids, so my bum was sore for a few days afterwards. But, more importantly, I had the natural delivery I wanted. I was released from the hospital 7 hours after delivery (50 hours after I initially entered), and was again met by the kraamzorg at home.
I was/am quite pleased with the use of the Foley Catheter balloon to begin my second induction. There is less risk to the baby for initial fetal distress (a major concern of mine) and was probably the only way I could have attempted an induced natural delivery, given the previous Cesarean Section. Again, I don't think in the USA, I would have been given the opportunity to use the Foley Catheter balloon to begin an induction. So even if initially it took longer than my short American patience wanted, it did work.
I'm also pleased I pushed on my hands and knees, even if the midwife didn't agree with the position. My British midwife (who unfortunately couldn't do my delivery because of the C-section), told me later that Dutch women are more accepting of midwife advice to deliver on their backs with feet up in the air, unlike British/American women. Even though I was tethered to the bed electronically and by IVs, it was still possible to lower the foot of the bed and turn around to face the pillows/mattresses to push the way I wanted to do so.
Yes, every baby and delivery is different, but if the end results is a healthy baby, I think that is more important than the delivery path to get there.
Tuesday 10 July 2012 at 09:31 am.
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