​As I near the end of the prenatal visits with patients, I often hear “Whatever you do, I hope I don’t need pitocin,” but when I ask why, there’s never really a clear answer.  It’s usually that they heard from someone who had a friend who had a cousin, or they read online that someone said it was bad.  With this blog, I hope to help sort some of the fact from fiction.
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What is pitocin?  Here’s the fancy answer:  “it’s a nonapeptide protein.”  That’s the one you can use to sound smart.  Here’s the simple answer:  it’s the synthetic form of oxytocin, which is a hormone released by your very own pituitary gland.  Oxytocin is produced in response to labor and helps stimulate contractions, and it also is released during breastfeeding.  Those cramps you have while breastfeeding?  You can thank pitocin.

Why does your ob/gyn use this medication?  There are 2 main reasons:  it can be used to increase the strength of contractions, and it can also be given after delivery to help prevent bleeding (it helps the uterus contract and squeeze blood vessels closed).  During labor, you might think, “My contractions are plenty strong on their own, thank you very much,” but occasionally they aren’t.  Generally, the ideal strength of contractions that are strong enough to change the cervix in a timely manner without being so strong as to stress out your baby is 200-300 MVUs.  The strength of the contractions can be measured with an internal monitor placed beside the baby called an IUPC, and this monitor helps the nurse adjust the medication into the appropriate range to achieve the contraction strength noted above.  This can help the labor progress in the optimal timeframe to help minimize the chance of intrauterine infection and decrease the  chance of cesarean section once your labor has started or your water has broken.  Pitocin can also be used to stimulate contractions in order to initiate labor when medically indicated.  During inductions when the cervix is unfavorable (ie closed and not thinned), this is the time when we may  see an increase in the need for cesarean delivery with pitocin.  However, sometimes deliveries are medically indicated in patients with an unfavorable cervix, such as in patients with certain blood pressure issues, diabetes or other situations where to continue pregnancy has greater risk to mom/baby than ending it.  Without pitocin, though, medically indicated deliveries in patients with an unfavorable cervix would almost certainly have to be via cesarean delivery.

Is it safe?  Oxytocin is unavoidable during labor and breastfeeding, and your body has been designed to utilize this hormone in both cases.  When used at doses to obtain appropriate strength of contractions, both mom and baby tend to tolerate this medication well.  Even if the baby shows some element of stress, the half life of pitocin is only 3-5 minutes, so the effects end shortly after the medication is stopped.  Additionally, medications such as terbutaline can also be used to relax the uterus if needed.  Lastly, oxytocin used immediately after delivery decreases the chance of hemorrhage.  Postpartum hemorrhage is the leading cause of maternal death worldwide and the main reason that the maternal mortality rate is 239 per 100,000 in developing countries vs only 12 per 100,000 in developed countries.

Are there any other options?  At this time, pitocin tends to be the most effective and safest option that we have.  Some researchers have looked into the use of nipple stimulation to release natural oxytocin to stimulate labor, but at this time, there has been limited success, probably due to the fact the nurses’ hands must have gotten really tired ;)  Besides, there’s really only so much that lanolin can do for the breasts after a long labor like that!

So, while not all pregnancies require pitocin, it may be required during labor or after delivery.  When dosage is titrated to the optimal contraction strength, pitocin is often the most effective method to help obtain a safe outcome for mom and baby (not to mention decrease the odds of a cesarean section!).  And for us, this helps us to reach our ultimate goal, which is to conclude the pregnancy with a healthy, happy mom and baby :)

Nick

​I get this question all the time:  'My due date is here- is there anything I can do to help get this process started?'  Let’s take a quick look at some of the popular ways of trying to serve that eviction notice…

1. Exercise: Being active and getting the heart rate up is a great way to get your body ready for labor.  Even something as simple as going on walks can help bring that baby into the pelvis and place some pressure on your cervix making it more favorable for the labor process.  While there is no good evidence supporting this option, it may help you prepare for labor itself which is a physically intense ordeal. 
2. Intercourse: Sex can help through multiple different mechanisms.  First, semen contains prostaglandins which can help dilate and thin out the cervix.  Second, sex can help release a hormone called oxytocin which can cause contractions.
3. Evening Primrose Oil: This oil comes from the evening primrose plant and contains linolenic acid which is thought to trigger a prostaglandin response in the body.  This can be taken orally or placed vaginally.  However, while it is easily accessible, there are very few studies to show any benefit on the cervical ripening process.  One study even found that women who took the supplement were in labor for longer that those who had not taken it.  While it likely has no effect on breastfeeding, it can act as a blood thinner (possibly predisposing to heavier bleeding with delivery) and can have side effects like headaches and GI distress.  I would probably stay away from this one until more research is done. 
4. Red Raspberry Leaf Tea: The mechanism of action here is not clear.  However, some feel this tea “helps tone up the muscles of the uterus thereby preparing it for labor”.  However, there are no studies showing that red raspberry leaf tea can induce labor.  Since there aren’t any significant side effects, I guess if nothing else it can help you relax.
5. Castor Oil: Castor Oil is a laxative and stimulates your bowels by causing spasms.  The idea is this intestinal irritation can cause uterine contractions.  However, if you are not already in labor, this is likely only going to give you diarrhea and lots of GI distress.   I would definitely skip this one unless you want to be sick to your stomach. 
6. Nipple Stimulation: Nipple stimulation causes the release of oxytocin which can cause contractions.  This would be somewhat similar to being in the hospital and being given Pitocin.  However, in the hospital your baby’s heart rate would be continuously monitored while on medication, ensuring that contractions were not causing any distress for your baby.  Please do not do this if your baby is not being monitored because we would have no way to ensure that the baby is not being stressed by those contraction.  Plus, it sounds pretty painful!!!
7. Membrane Stripping: Membranes stripping is done while checking your cervix.  Your provider will separate the amniotic sac from the cervix causing the release of prostaglandins.  This really only helps induce labor if your cervix is already favorable.  Stripping membranes on an unfavorable cervix is very difficult (and painful) to do and not likely going to cause any cervical change or thinning.  Membrane stripping can cause some cramping and spotting and can also increase the chance of your water breaking.  If your water breaks or if you are bleeding and not just spotting, you should go to labor and delivery and be evaluated immediately.
8. Acupuncture, acupressure and massage: No proof that any of this helps induce labor.  However, it may provide a little bit of relaxation.  And your partner probably owes you some massage at this point ;)

So, that’s the scoop on starting labor.  For many women, the body will probably go into labor when it is ready, no matter what you do or don’t try at home.  For others, the body may need a little help to get things going, particularly if you are past your due date.  Ultimately, regardless of how your labor starts, the most important thing is a healthy baby and mommy at the end of your labor 😊

​Dr. Pam

It seems like there a few longer weeks in a woman’s life than those during the last month of pregnancy. Back pain, swelling of hands and feet, difficulty sleeping, and indigestion are just a few of the complaints I hear near the end of pregnancy. There is also often fatigue and Braxton-Hicks can be regular occurrences.  By this point, women are often uncomfortable and are generally counting down the days (perhaps seconds) until delivery.  “Can I have this baby now?” is nearly a daily question.  So, here is a quick review of the what, when, why and how of labor induction.

How do we induce labor? Any means used to stimulate contractions that result in cervical dilation and ultimately delivery of a baby is considered an induction of labor.  Other than “stripping” or “sweeping” membranes (a cervical exam separating the amniotic sac from the inner portion of the cervix to release prostaglandins), more definitive means of labor induction include synthetic prostaglandins (generally vaginal suppositories), amniotomy (breaking the bag of water), and Pitocin (synthetic oxytocin, the hormone released via breastfeeding and other sources of stimulation).  These last 3 methods are done in the hospital, although stripping of membranes can be done in the office.

When and why do we induce labor?  The answer to when largely depends on the reason for induction, so we can cover both the when and the why here.  As a general rule, elective inductions (ie, I’m tired of being pregnant, get this thing out of me NOW!) occur at 39-40 weeks.  Many insurance companies and Medicaid don’t pay for elective deliveries prior to 39 weeks, and with the lowest risk of injury/death to the baby between 39 weeks 0 days until 40 weeks 6 days, this generally makes sense. Elective deliveries prior to this time may also violate hospital policy, so even if your provider wanted to schedule you sooner, he/she probably wouldn’t be able to do so.

Of course, there are exceptions to the rule.  Catastrophic findings may require immediate delivery regardless of gestational age, and certain medical conditions such as some twins, preeclampsia or high blood pressure due to pregnancy diabetes, and fetal growth troubles can also be an indication for delivering your baby sooner.  Also, if your pregnancy nears the 41 week mark, we generally advise for labor induction due to the slight increase in stillbirth risk that begins at 41 weeks gestation and increases until time of delivery.

Bonus question: If I am being induced, does that mean I will have a cesarean delivery?  The answer to that question is that it depends.  Certainly, if the cervix is favorable (depends on dilation, position, thinning and softness of the cervix), particularly for someone who has had a previous successful vaginal delivery, then the chance would be very low.  However, for a first time mother with an unfavorable cervix, then her chance of cesarean delivery is higher.  The chance of primary cesarean delivery in Idaho is roughly 14%, and this may increase up to between 25-33% depending on the circumstances.  For instance, even though the size of the baby is the same (either it will fit or it won’t), the cervical exam does change over time.  These exam findings may be an indication of how well the cervix will respond to labor induction, which in turn is an indicator of the likelihood of successful induction as well as how long the process is likely to take.  A mother with several previous deliveries may require only an amniotomy and her baby will follow in a few hours, but a first time mother may require a day or more of medical induction depending on her exam findings. 

Rarely does the induction process cause significant enough stress to the baby that intervention is required, but even if contractions begin to come too frequently, there is often a medical treatment to reduce their frequency and decrease the stress on the baby.  For instance, terbutaline can be administered in some cases, particularly with prostaglandin induction.  With Pitocin, the half-life is only about 3-5 minutes, meaning that the effects of either too strong or too frequent contractions usually resolves within that time after stopping the medication.

In summary, labor induction is a complex decision.  Even now, there is continuing research on this topic, and recommendations change frequently, but it remains a reasonable option in many pregnancies.  There are many variables, but if you are interested in labor induction, be sure to discuss your specific medical history with your provider to see if “you are there yet!”

Nick