Medical Interventions
There is a time and place for every medical intervention, none is inherently “bad”. The goal is to gain familiarity with all the options and terminology, understand the benefits and downsides, and proceed with an intervention at the right time for you.
Many people have strong - and sometimes judgmental - opinions on these issues, so try your best to tune it out and focus on what makes sense for you.
Saline Lock/Hep Lock
Upon being admitted to the hospital, you may opt to have an IV catheter inserted into your arm or hand and closed off to use if a future need arises (doesn’t restrict mobility at all until used)
Allows for immediate access for pitocin, antibiotics, fluids, and other meds in case of emergency
Some nurses are better than others at inserting the hep lock, missing or even worse puncturing a vein (this happened to me and was surprisingly painful). You can request that someone from the hematology department do this procedure, since they have more expertise.
Doulas and natural birth folks may recommend forgoing the hep lock, believing it makes use of medical intervention too easy and more likely; this seems misguided, as it just gives you more optionality
Induction
TLDR: might increase pain of contractions but otherwise safe; try nipple stimulation (and patience!) first
Why induce?
Induction has become increasingly common, at about 25% of pregnancies in the U.S.
Medically necessary if health risks to fetus/mother (e.g. not enough amniotic fluid) or pregnancy has gone beyond 41 weeks (induction reduces risk of stillbirth)
If bag of waters (i.e. amniotic sac) breaks before labor has begun, many providers recommend induction if labor hasn’t begun within a certain timeframe, to avoid infection
Trickier decision is whether to get elective induction, increasingly offered as early as 39 weeks based on new guidance from ACOG, or wait for “spontaneous labor” to happen on its own
Two main categories of induction methods: physical and pharmacological (using drugs); physical are generally gentler and lower risk but less effective or slower-acting than pharmacological
Benefits of elective induction:
Can reduce risk of complications that occur later in pregnancy like preeclampsia
Keeps the baby from getting too large, so vaginal delivery may be easier
Makes timing of birth more predictable for family support reasons
If final weeks of pregnancy have been brutal, you are done being pregnant sooner!
Downsides of elective induction (primarily risks of pharmacological only):
After induction begins, you stay at the hospital, so you won’t labor at home at all
Drugs can take a while to start working, which can lengthen overall time in hospital
Risk of hyperstimulation which can cause fetal distress (lowered heart rate) - but baby will be continuously monitored during induction process
Contractions come on faster and stronger than if you’d naturally started, so more likely to get an epidural
Beware a few unfounded claims from natural birth advocates:
Claim: Induction makes it more likely you’ll end up having a C-section
Truth: based on flawed studies- a recent randomized-control-trial found no difference between women who were induced vs went into labor naturally
Claim: lots of natural ways to induce labor, like sex, exercise, spicy food, raspberry leaf tea, pineapple, dates, acupuncture
Truth: while none of these methods is harmful, there is no solid evidence that they help
Nipple stimulation: the only “natural” method that is proven effective. While you could just massage by hand, works best if you use your breast pump on one breast at a time for about 15 minutes each a couple times a day (pairs well with Netflix!). Also a great way to familiarize yourself with your breast pump in advance! (meta-analysis)
Induction Methods:
Physical:
Sweeping/Stripping the Membranes: OB/midwife puts their finger in cervix and sweeps to detach membranes connecting the amniotic sac to the uterine wall. This can help your body release the chemicals needed to start up labor. Uncomfortable, but not very painful. After the procedure, you typically go home and labor hopefully starts in next couple days.
Foley Balloon/Bulb: a rubber catheter is inserted into your cervix and inflated with water, putting pressure on the cervix to dilate. Very low risk procedure, but may take many hours to work (usually you’ll wait at hospital but they may allow you to go home). Might need to be used in conjunction with other methods if cervix opens but contractions don’t begin.
Amniotomy/Artificial Rupture of Membranes (AROM): this is when a doctor “breaks your waters” by essentially poking a hole in the membrane sac. This may be done to induce labor or speed it along if stalled (called “augmentation”). Chances of infection rise once the sac is no longer protecting the baby, so if AROM is done too early or labor fails to progress within 24+ hours, it may increase chances of C-section to ensure baby’s safety.
Pharmacological:
Cytotec (brand name of Misoprostol): synthetic form of “prostaglandins” - the hormones released by your uterus to soften and dilate the cervix (weirdly called “ripening”) and bring on contractions. This drug can be taken orally or vaginally.
Pitocin: synthetic form of oxytocin, the hormone that stimulates contractions. It is administered through an IV and the amount can be increased or dialed back as needed.
Pitocin is also offered after delivery to help uterus contract and stop bleeding- unequivocally recommend this use!
How do these two drugs compare?
Both drugs may cause contractions to come on faster and stronger than they would have naturally, so women are more likely to ask for pain medication
Benefit of Pitocin is the amount can be increased or decreased, which can help avoid sudden painful contractions or hyperstimulation (vs Cytotec is a pill so dosage cannot be controlled later)
Benefit of Cytotec is it works faster than Pitocin and allows for more mobility (vs. Pitocin you are hooked up to the IV)
Castor Oil: “natural” over-the-counter substance that some doulas/midwives will recommend to induce labor. Research shows it is effective - but keep in mind that it also causes intense diarrhea (and thus potentially dehydration too) which is a major downside.
Medical Pain Management
Epidural:
TLDR: Extremely effective pain relief, poses no risk to the baby and doesn’t increase risk of C-section. May lengthen pushing phase and increase risk of complications for mom (e.g. vaginal tearing, rare headache). Impacts mom’s mobility during labor and postpartum.
Epidurals are a form of anesthesia that block feeling in bottom half of the body; you are also given local anesthesia when epidural catheter is placed in back
Available at any point in labor, but you’ll need to be able to remain still for 5-10 minutes which may be difficult as you get closer to delivery (e.g. 9 cm dilated)
People used to think that there was a risk of getting an epidural too early, but research has shown there is no difference in C-section rate, instrument use (vacuum/forceps) or length of pushing for early epidurals compared to later epidurals
Benefits:
Immediate & glorious pain relief (within 10-15 mins)!!!!
You may feel more relaxed and rested when the baby arrives
No negative impact on baby (review of research), which isn’t true of other medical pain relief options. Also, no negative impact on breastfeeding
Can decide to have more or less
Downsides:
Can’t walk around (you’ll use a catheter to pee) so fewer options for pushing positions, and takes a few hours to wear off after delivery
May slightly lengthen the pushing stage of labor (but only by 25 mins on average according to this study). No effect on first stage of labor on average- but for some women (including me!) it can speed labor because helps you relax
Small but significant increase in likelihood of requiring vacuum or forceps to aid delivery but does not increase likelihood of C-section (study)
May increase risk of tearing but not great data on this (link between epidurals and tearing may be correlational because first-time moms are more likely to tear and get epidurals)
Very small risk (1-3%) of post-dural headache: needle accidentally punctures the dura layer and causes spinal fluid to leak (also called a “wet tap”). Can cause migraine-like headache in the weeks after birth (recent study suggests might last even longer)
Nitrous Oxide (Laughing Gas):
Mix of nitrous oxide and oxygen inhaled through a mask at beginning of contraction
Benefits:
Zero negative impacts on mother, baby or labor progress
You can decide whether or not to use it for each contraction simply by taking mask off
Can be used in birthing tub
Downsides:
Only “takes the edge off” the pain temporarily, might not be enough for hardest parts
Can cause nausea
Opioids (morphine, fentanyl):
Injected or administered through an IV, best used early in labor
Benefits:
Provide pain relief and rest very quickly without causing immobility as an epidural does
Downsides:
Crosses the placental barrier, so can affect baby’s heart rate and breathing; might make baby drowsy when born, which can affect initiation of breastfeeding
Can cause nausea and vomiting
Pain relief doesn’t last long, so unlikely to help with later stages of labor and delivery
There are also many powerful non-medical methods to deal with labor pain such as breathing, visualization, massage. Worth experimenting with these before receiving pain medicine as you might surprise yourself by your ability to labor unmedicated for a while.
But if you decide you need more relief, there is zero shame in also utilizing the wonders of modern medicine! You don’t win a prize for going unmedicated!
Medical Delivery Assistance
Vacuum and Forceps:
Helps guide the baby out, working alongside your contractions and pushes (not just yanking out!)
Vacuum is like suction cup on baby’s head and is more common; forceps are like big salad tongs
Benefits:
Can help get baby out if you’ve been pushing for hours and are exhausted
Can reposition baby’s head so it’s coming out at a better angle
Alternative to needing a C-section, which is much bigger procedure and recovery
Downsides:
Could cause increased tearing and blood loss
May mark or bruise baby’s head, but it’ll go away within a couple days. Bruising could increase risk of jaundice, which is very treatable but important to monitor for.
Might not work and you’d need a C-section after all
Episiotomy:
This is when an incision is made between the vagina and anus to widen the opening so baby can come out more easily
Local anesthesia is used, unless there is already an epidural in place
Used to be more common but now is very rare and only used in emergencies (i.e. baby is in distress and needs to be delivered quickly)
It was once thought that an episiotomy is better than a natural tear, but now our understanding is the reverse (review of studies)
Benefits
Can speed up delivery if baby is in distress
Easier recovery than C-section
Downsides:
More bleeding/pain during recovery
Risk of infection
Pain during sex
C-Section:
About 30% of babies are delivered via C-section - safe, but major procedure that requires significant recovery
Possible medical reasons: twins/multiples, labor has stalled after many hours, baby in distress (e.g. heart rate dropping), baby’s position (breech or transverse)
Increase in C-section rates in recent years may be due in part to new “continuous” fetal monitoring which picks up on more dips in baby’s heart rate. Sometimes these dips aren’t actually a concern and would resolve normally, but staff may leap to action too quickly. Some women opt for intermittent monitoring, rather than continuous, to avoid this.
Natural birth advocates often claim that hospitals perform too many unnecessary C-sections because they are more profitable. IMHO this is very cynical and unlikely, but there may be some “if you have a hammer, everything looks like a nail” going on.
Around 3% of women chose to have elective C-sections for various personal reasons, but this is not recommended, especially if you hope to have more children as it increases risk of miscarriage or complications later
If urgent emergency, may require general anesthesia because it’s faster to administer, but otherwise you can use epidural for anesthesia and thus remain awake
Exposure to videos of C-sections might help you get more comfortable with them – I recommend the IG account empoweredbirthproject (best videos are labeled as “sensitive content”) and expectingandempowered
Benefits
Can save mom and/or baby’s life!!!
You can request a clear drape that allows you to see baby coming out
You can still do skin-to-skin after birth if awake (but you may feel numb on your chest), otherwise your partner can do it
Downsides
Risk of blot clots, risk of infection in the uterus or at incision site
Longer recovery on average than vaginal birth, could make first weeks with baby more challenging; certain breastfeeding positions are recommended while healing - check out my C-section recovery page
More likely to miscarry future pregnancies or have complications (meta-analysis)
A new area of research suggests that the microbiomes of babies born via C-section lack some of the healthy bacteria that vaginally-born babies are exposed to via the birth canal. This is likely only a short-term difference - breastfeeding can help build up the microbiome within a few months (source)
Concerned mothers can consider a process called “vaginal seeding” where babies are swabbed with vaginal fluid after C-section delivery, but know that this process hasn’t yet been well studied and isn’t yet recommended by any official orgs.
Some women feel a stigma around C-sections, like they’ve taken the “easy way out” or missed out on a core part of the experience; but a strong countervailing force rightfully celebrates the strength and beauty of C-section mamas. More fun language to describe it: “baby came out the sunroof!”
