*sigh* I have cholestasis and will need to be induced.

[PeaG]

I'm so upset. I'm 25 weeks along with my first bebe (Miss B.) and it turns out the itchy legs I've been complaining about really *were* something. My liver function test just came back with elevated levels and my midwife has diagnosed me with obstetric cholestasis. She's prescribing me Actigall and says that I'll have to be induced around 36 weeks to hopefully avoid the risks involved with that last month.

Just two days prior we were discussing my plans for a completely drug-free waterbirth and everything looked great. I'm really anti-drugs in general, and particularly in pregnancy, and this is killing me that I'm going to have to take Actigall. It's even worse knowing that it's an off-label use and it's never been tested or even proven effective with pregnant women.

And the induction! Crap. I'm assuming pitocin will be the route, which will likely lead to other pain meds? Anybody have any experience being induced? Is it even possible to have a natural birth after being induced well before my "time?"

I'd love any stories or advice. I know that the goal is ultimately to get my healthy newborn out safe, but I can't help but mourn the birth I had envisioned.

[Xiaguan]

i was induced with my 4th child at 35.5 weeks due to leaking amnio fluid for 13 weeks prior~ I still had a quickish labor with no other drugs. It can be done~ It is not easy but it can be done~ The birth ball was my friend for that birth


Melissa

[beka1977]

Get a second, and possibly a third, opinion.

[bemommy]

I was induced with pitocin for both of my kids births. I used no pain meds and made sure that the protocol used was to turn off the pitocin once labor had been established. My labors went pretty quick and my saving grace was making sure to change posiyion/move around as much as possible.

[sarahmck]

Not in your DDC but saw this in New Posts. I was told I had cholestasis with my first child, and I'm sure I would have been with my second if I had had the tests.

What are your bile acid levels? Elevated liver function alone do not make cholestasis. My story is long and I'll be glad to share it if you're interested, but it basically came down to me being told that I had to take the urso (I didn't) and be induced at 34 or 35 or 36 weeks (I wasn't). My bile acids initially came back a tad high, but it turns out that my doctor didn't tell me that I had to fast for the test and I called the lab and asked and they said it was a fasting test. Since bile acids take a week to come back, my liver functions were always a week ahead and they were sky high and climbing every week. But my bile acids were never more than marginally high and then they went back to normal.

Long story short, I had an uneventful home birth (in California) after a hugely stressful pregnancy, worrying about my baby and whether my midwife would deliver me at home (she almost didn't). My second pregnancy was the same as the first except that I didn't get the tests done and thus didn't know about my "cholestasis."

I guess I'm trying to say that you should be really sure that you have a severe form of the disease before you resign yourself to medical treatment. There's lots of literature out there saying that the stillbirth risk doesn't go up until your bile acid levels are quite high. Other literature says that it doesn't go up at all.

Good luck.

[wanderinggypsy]

I had cholestasis with my third and am now expecting my fourth, not sure whether the cholestasis will return...

Here is the thing. In the last three weeks of pregnancy bile acids can spike, tripling overnight. That can take a moderately elevated level to one which is fatal to a baby in a period of hours.

Personally, that is way more of a risk than I was willing to take. I took early induction at 36.5 weeks. I had a wonderful birth experience with no pain meds required, and the docs and nurses were kind enough once active labour was established to leave the room and allow my midwives to see me through to delivery of my daughter.

This time around, I am doing what I can to prevent recurrence through diet, exercise, and herbal liver support. That having been said, if I get symptoms, I will request a consult with an OB immediately.

I wish you the best of luck with the rest of your pregnancy, and please don't despair. All is not lost. You can still have a beautiful birth and in my case my daughter's lungs were fine and we never had to be apart... she slept with my from the first moment and I brought her home the next morning.

Take care. And you may consider talking to a naturopath about diet/herbs.

[amandaleigh37]

Sorry that you have to deal with this It couldn't hurt to get another opinion?

I was induced with my son, but I was full term (40w4d). Pitocin was used, and I had a short (2 hr) but INTENSE labor, without any pain medication. So yes it is possible.

[firewoman]

I know nothing of cholestasis but I am a doula and have been at induced births. If they are going to induce that early, they will *most likely* have to use a cervical ripener to soften your cervix before they can administer the pitocin. The cervical ripener I have seen used most often is cytotec which is not FDA approved for labor induction. They can't start a pitocin drip without a favorable cervix. I would ask your paractioner about all of this now so you fully understand the protocols and possible risks on all sides. If you do have a serious liver problem that may affect the health of the baby you have to do what needs to be done to protect him/her. These are you first big decisions as a mother and they won't be the last. In the end what matters most is that you have a healthy, happy baby and mama and you need to research to choose the best path to get you and your baby there. I know this is a lot to deal with so early but you can do it. Gather your strength and you will get it figured out. Good luck.

[sarahmck]

Originally Posted by wanderinggypsy

Here is the thing. In the last three weeks of pregnancy bile acids can spike, tripling overnight. That can take a moderately elevated level to one which is fatal to a baby in a period of hours.

This is what I read too, however I think other factors have to be considered as well. For example, all the early induced births that I personally know about (friends and acquaintances) failed because they were too early so they ended up in C-sections. C-sections also have risks and my experience in the cholestasis world was that the only risks that were considered were those related to bile acids, not those related to the drugs or the premature birth or the likely cesarean.

If the OPs bile acids are already high that's one thing, but she only mentioned her liver functions and those are not the diagnostic test for cholestasis. As I said, mine were sky high (800s instead of 50 or whatever is the top of normal) but my bile acids were either borderline high or high normal, depending on the week. I finally switched my care to a peri-natologist (the head of the department at a big medical center) who told me that "elevated liver enzymes, in and of themselves, are obstetrically insignificant."

[PeaG]

Sarah, could we possibly chat further? I am very interested in hearing more about your experiences.

I took my first pill today (because I was guilted into feeling like total crap for not having done so when I stopped by my doctor's today), and am still waiting on my bile tests. I asked the nurse practitioner there whether it could be anything else (knowing that, yes, in fact, it can), and she said "No, you definitely have cholestasis. Make sure you take the pills." :

[annekh23]

http://www.rcog.org.uk/resources/Pub...lestasis43.pdf

Have a read of this, it's a guideline for doctors, compiled by the Royal College of Obstetrics and Gynaecology - the UK equivalent to the ACOG. It's surprisingly readable and as far as I can tell a fair review of the literature up to the point it was written, January 2006, so not spanking brand new, but definitely a good baseline for what questions to ask etc.

According to this cholestasis is diagnosed based only on elevated liver function tests and itching, so elevated LFTs even in the absense of raised bile salts, but it's very clear that other causes for these must be excluded and I'm unclear as to whether your midwife has done this thoroughly enough, your description sounds rather like pregnant, itchy, elevated LFTs so immediately jump to diagnosis of cholestasis. Honestly, I think this situation is one that goes beyond the remit of a midwife.

The guideline seems pretty strong on making sure the correct reference ranges are used for the tests, it's an easy lab error to make, test the blood correctly, but not see that the pregnant box has been checked and just print out the standard reference ranges.

I had to google the drug you mentioned and it's the one covered in section 10.3, seems like it's commonly used but there isn't all that much evidence for it, with only small studies having been published, so the nurses attitude that you must take it, seems a bit strong. Taking of any drug should be up for discussion, let alone something with only limited evidence.

I've often thought when this subject has come up in the past, that though all the potential complications of early induction should be considered and on a population basis may well balance with the stillbirth stats, that on an individual basis, nothing is going to balance with a stillbirth, because even if those complications may ultimately cause death, they still win for me because of the time and the potential for treatment, whereas the kind of sudden interuterine demise that occurs with cholestasis, may well be rare, but is too unpredictable to mess with.

[sarahmck]

Originally Posted by PeaG

Sarah, could we possibly chat further? I am very interested in hearing more about your experiences.

I'm PM you my e-mail address.

Originally Posted by annekh23

I've often thought when this subject has come up in the past, that though all the potential complications of early induction should be considered and on a population basis may well balance with the stillbirth stats, that on an individual basis, nothing is going to balance with a stillbirth, because even if those complications may ultimately cause death, they still win for me because of the time and the potential for treatment, whereas the kind of sudden interuterine demise that occurs with cholestasis, may well be rare, but is too unpredictable to mess with.

I totally understand this point of view, and it does seem to be the one shared by just about everyone. When I declined medical treatment for my cholestasis (and it's up for argument whether mine was really cholestasis), everyone thought I was insane and irresponsible. But from my perspective it appeared that the risks were probably even greater on the mega-intervention side (especially if you count softer risks like having a baby who ends up in the NICU for a while and is fine in the end but misses the window to breastfeed, for example) and if my baby was going to die or have big problems, I wanted them to be those inflicted by nature and not by me trying to mess with nature. I realize that this point of view isn't for everyone.

[wanderinggypsy]

Just wanted to add that while the numbers are not clear (there's been kind of a lack of research into cholestasis), the full term still birth rate has been estimated as high as one in four. Now, those aren't "my" numbers, but they are drastic enough that in the absence of clearer research, I wasn't willing to allow myself and my baby to be guinea pigs. I went for early induction. What we did was for three days running my midwife did vigorous stretch and sweeps and I took black and blue cohosh tinctures as per her instructions. On the third day she ruptured my membranes. The following day we went to hospital where I was administered prostin tablets orally. Within an hour labor was well established and no furthur intervention was required.

Another point to consider is that those much coveted bile acid levels are tricky to obtain and the lab work generally takes at least a week, sometimes two weeks, depending where you live. That window of time can be most crucial in proper treatment for cholestasis.

I am absolutely the last person in the world who would generally advocate for premature induction of labor. However, for every rule there are rare exceptions. Cholestasis is one for me.

[BethSLP]

I don't know anything about cholestatis, but I had an induction with my DD (first birth). I was 41 weeks, and had pre-eclampsia.

The OB actually told me that he thought I had very little chance of a vaginal delivery because I had such crummy factors (cervix totally hard and closed, cervadil did nothing etc.). I got to the second highest dose of pitocin before I started contracting. They almost cut off the pitocin to prep for a C-section, when it finally started slowing working. So while technically "overdue," my body really did not feel ready to go into labor yet.

It was a tough road and I had pain meds when I got stuck at 5cm. I went from 5cm to 10cm in an hour after my epidural. My MW (who is a homebirth MW and totally against drugs) admitted that the epidural may have "saved me" from a C-section. Sometimes pitocin can be so intense, that its hard for women to dilate, or so I was told.

I don't say any of this to scare you, but just to let you know that I gave up my homebirth because I needed to. Most in the natural birth community agree that hospitals are there for medical issues. Sometimes, like it or not, our plans don't work out the way we want them to.

I feel GREAT about my birth. I really do. I learned SO much about myself and I came out of that birth feeling like a super hero because I ended up with a vaginal delivery (which many felt was a long shot).

I have utmost respect from mamas who have natural births, but I've also heard some birth stories where I can promise you that I could have done that too! My birth was insane. I'm not embarrassed I used pain meds. In fact, like I mentioned earlier, they may well have helped my labor in this case.

So I guess my advice is to take one day at a time and make your decisions based on your comfort level and the risk/benefit. Its super dissapointing to have to think about all the unknowns of induction (and even that daunting possibility of C-section). I know that the whole "at least you have a healthy baby" arguement makes mamas who end up with a c-section cringe. Its possible to mourn your birth but still appreciate your healthy baby. But honestly, I think we all agree we want to do whats best and safest for the baby in the end. I'd just keep an open mind, research, etc.

My lama says if you don't have expectations, you can't be dissapointed. This is where I'm at with birth. I know my rights as a mama and I want to be respected, etc. but I also know that certain things are beyond my control (i.e. health conditions) and am grateful the hospital was there for me when I needed it. I feel because I didn't get too wrapped up in mourning the loss of my ideal birth experience, I was able to fully embrace and learn from the birth I did get. It felt completely empowered by what I was able to get through in the end. I felt like I could do anything if I could make it through that difficulty. Taking a newborn home seemed like a piece of cake. It was a complete rite of passage for me. I am sad for mamas who are so hung up on their expectations for their birth, that if something doesn't work out the way they wanted, they lose sight of the lessons of the birth they did get, if that makes sense.

Best wishes to you on this journey!
XOXO
B

[sarahmck]

Originally Posted by wanderinggypsy

Just wanted to add that while the numbers are not clear (there's been kind of a lack of research into cholestasis), the full term still birth rate has been estimated as high as one in four.

I've never heard a figure even close to that high. Do you have a reference for that? I'm always curious to read more about cholestasis in that I'm pretty confident that I will get it, or at least my variant of it, in every pregnancy.

Check out section 6 from this paper that I found rather comforting last time around.

[candynut]

Hugs!

I just had a baby and was induced thanks to cholestasis. I was 36 weeks when the itching suddenly appeared and was induced less than a week later after we all figured out what it was.

Once I found out I was going to be induced, I pretty much gave up on my epidural-free birth, but you don't have to! In fact, my doctor tried to make everything as natural as possible, given the situation. Once I saw that he wasn't giving up, I made a bigger effort, but ultimately got an epidural.

But, I got an epidural and then delivered the baby about 30 minutes later. (I went from 4cm to delivered in about an hour!!) So I could have done it, but when they checked me and I was only 4cm (after 6 hours of Pitocin and 1.5 hours after they broke my water), I was discouraged.

[Dahlea]

I was induced because of PUPPPS (thought it might have been cholestasis at the time) I can't remember the name but it wasn't pitocin used. It was a small pill placed behind my uterus. My OB hates pitocin, in fact!
I stil had a natural birth other than that, and though it was fast, and I hate that I missed out on my natural labor progression, it wasn't as bad as I thought an induced labor would be.

[Llyra]

Originally Posted by wanderinggypsy

Another point to consider is that those much coveted bile acid levels are tricky to obtain and the lab work generally takes at least a week, sometimes two weeks, depending where you live. That window of time can be most crucial in proper treatment for cholestasis.

I am absolutely the last person in the world who would generally advocate for premature induction of labor. However, for every rule there are rare exceptions. Cholestasis is one for me.

This was my decision, as well. I was diagnosed early, at about 30 weeks, so I had lots of time to read up on it and make a decision. We wound up waiting until almost 37 weeks, which was a week later than what the docs thought was ideal, but we did opt for early delivery. I dunno-- I guess this one is a call you make as an individual, but the hard data on stillbirth rates in cholestasis isn't very good, the potential risks seemed real, especially in view of how fast it can happen, and how long the test takes to come back, and the subjective idea of stillborn twins was horrifying to me.

[CookAMH]

I'm wondering how the OP is doing? This was a really interesting thread with good info.

[smeep]

I agree with Sarah about making sure it's the severe form. And I would google it and research it yourself, particularly the best methods of testing. Many caregivers don't know cholestasis exists, and many who do don't know how to test for it. You could also request testing every x often and see how it goes if that makes you feel better. I've read scary and not-so-scary things about it. I read (and it may've been here?) about a woman who drank a crapload of water and exercised and I think took herbs. I know dandelion root is great for the liver.

Some time after my son was born I decided to research my itchiness (mostly palms of my hands and soles of my feet, but occasionally in the second trimester on my legs). I am pretty sure it was cholestasis but mild. We had a wonderful birth at 41.5 weeks and he was quite healthy. That said, in my first trimester I told my midwife about the itching and she wasn't too concerned since it was rarely bad. She just recommended dandelion root and since I started taking that so early on I think it's the reason why my symptoms calmed (and only showed up randomly nasty on my legs occasionally in the second trimester) and never popped up in my third. I also started taking dandelion root as soon as I found out I was pregnant with my last but lost him at 8.5 weeks. However, I had NO itching with him at all and the itching with DS had long occurred by 8.5 weeks. I'm now maybe a handul of weeks along, if that, but so far no itching, though it could be too early. I think I was 6 weeks when I started experiencing the itching with my first.

All that said, do your own research. Induction may or may not be best. That's your call ultimately. Perhaps talking to those who do automatic inductions and questioning them on their reasoning as well as talking to those who do not and do other methods to control it, looking at both ends of the spectrum, would be helpful.

And always, always research the risks of the cholestasis (per your situation, health, etc.) vs. the risks of induction (per your health, history, family history, etc.). I always research risks vs. risks, never risks vs. benefits because when you throw in benefits it gets muddled and easy to miss the important things.

Good luck mama!

ETA: And I would recommend questioning mamas and caregivers who have both lost babes from cholestasis (or had other "poor" outcomes believed to be result of the cholestasis) and mamas and caregivers who had babes come on their own full term and perfectly healthy. And ask about their methods of treatment during pregnancy, if any.