Advice needed on client being pressured to induce- UPDATE post 9

[Katielady]

hi all,

My client (my first) is due in about three weeks, Aug 31, with her second baby. She has had high blood pressure for much of the third trimester- not incredibly high, hovering around 129/79. She had the same thing happen with her last pregancy, and the baby was born healthy at 2 days before 40 weeks. (Vaginal birth w/ vacuum extraction when the baby's heart rate began to delerate during pushing stage). Her midwife has been carefully monitoring her blood pressure, and it has remained there without going up. She had a non-stress test and all was well. No protein in urine, edema, or other signs of pre-e.

But my client's very upset because MW is still telling her they're likely to induce her at around 38 weeks. Apparently they're concerned it could still develop into pre-eclampsia. Client disgarees and feels fine, doesnt' want induction, hates having to lie still at all during labor (doesn't everyone?), and is worried she'll get booted out of the hospital's Birth Center into Labor & Delivery if things get too interventive. She thought about acupuncture and castor oil, but just emailed me to say that she really doesn't feel like the baby is ready to come out and she doesn't want to force it, whether by castor oil or cervidil. She is very upset and I don't know what to tell her.

I asked on my local doula listserv, and apparently my client's midwife is known for being a medwife, always pushing her clients towards interventions like this at the slightest hint of anything "off." I haven't told my client this because I don't want to cause her more stress, but it does make me doubt the MW even more than I had been.

SO...here are my questions:

1) Is it common to induce for borderline hypertenion like this? Can my
client refuse and still give birth at the birth center?

2) What happens if she simply refuses to be induced? Can they refuse to take her at this hospital or something? We're in New York State, if that makes a difference legally.

3) If she is induced with cervidil and possibly pitocin, any tips on how I can best support her in having as natural a birth as possible?

Thanks all.

[Reha]

I'm so sorry that your client is having to go through this.

I don't consider 129/79 to be borderline hypertension. Especially as in the last month or so, there is often a physiological rise in bp to as the body's way of meeting our growing baby's needs. Totally normal, and a good sign, imo. It makes me so sad that she is being threatened with induction for a bp of 129/79.

I know that she is 37 weeks already, but is there any way for her to consult with another midwife, for at least a second opinion???

[Katielady]

Originally Posted by Lennon

I'm so sorry that your client is having to go through this.

I don't consider 129/79 to be borderline hypertension. Especially as in the last month or so, there is often a physiological rise in bp to as the body's way of meeting our growing baby's needs. Totally normal, and a good sign, imo. It makes me so sad that she is being threatened with induction for a bp of 129/79.

I know that she is 37 weeks already, but is there any way for her to consult with another midwife, for at least a second opinion???

Thanks! I don't have any medical training beyond my doula training, but I know that when I was pregnant my BP tended to be 120/60 and they said that was perfect, so I'm like how can this be that bad a number??

:

I was thinking a second opinion may be a good idea. Maybe she could do a last-minute transfer...midwives around here book up fast, but it's possible that someone had a late transfer to an OB's care, and would then have an opening. I guess all I can do is bring it up as a suggestion- my client will have to decide what she wants to do.

Ugh. This is so hard!

[momileigh]

At our birth center we don't consider anything under 140/90 to be hypertensive. We might be concerned about her bp if her baseline was very, very low... but for most women 130/80 is a perfectly fine bp.

[InaX5]

I'm in canada so I don't know about new york state But I agree her B/P doesn't sound that unusualy for end of pg.

2nd opinion would be good.

Personally I had one induced labour like what you are describing (last time I'll ever set foot in a hospital). It was horrendous but I made it with out pain meds, It wasn't easy, & it was long (47 hrs, 45 min from active labour on, just keeping them from cutting me open was hard enough)

If she ends up going this way, & ask for meds during contractions, tell her to ask for them after the contraction if she really wants it. Have her go over her list of birth partners, (can they handle supporting her if the birth is rough?) Big long talk with her DH about not being drawn into the science & machines that he may hear or see. And be prepared for more advocating then usual.

Make sure she will get food (while still wanted & drinks other then water)

Also i made this labour dress I invented that people love (including myself), I use light weight stretchy material so it clings to the body. It has pockets for holding heat & cold packs. These pockets go all around the middle section at various levels (to accomedate the pain as it moves down through the body) & one at the back of the neck (cold packs). This allows you to have heat packs where you need it even as you walk around etc. Feel free to copy my idea, just don't patent it & get rich off it, I'd rather people experience my idea for free.

[Charmie981]

I agree that the BP isn't high, and that a second opinion is a good idea, but I know that by 37 weeks, people are very unlikely to look elsewhere for a provider, so I'm going to answer your other questions.

She can refuse the induction. She can go ahead and schedule it and "flake out" and not show up. If they call, she can say she overslept and reschedule, then flake out again. She can also avoid their calls if she wants. The midwife she's seeing might "fire" her, but I kinda doubt she would. If she does, the client can't be refused care when she's in labor. It's illegal for them to refuse her, but she will have to take whose on call and she might not have the option of the birth center (I don't know the rules on whether they can refuse care or not).

If she opts to be induced, she'll have an IV and will have to be on the monitor the whole time. This situation is a good candidate for an internal monitor : because mom can move around and baby will still be heard/traced. Be prepared as a doula to deal with transition-like contractions for the duration of her labor if she's induced with pit. It's very hard and the contractions can be really unpredictable (easy one time, terrible the next). If she decides on an epidural (a lot of pitocin induced moms do), try to put it off until she's 5cm, as this really reduces the risk of c-section.

[danotoyou2]

Not a professional, but just poking around and saw this. I had pre-e with my son, and have done a lot of research for this second pregnancy. If she just had high BP with her first child, but it didn't develop into pre-e, it is HIGHLY unlikely that it will develop into pre-eclampsia.

Even if you've had it before, your odds of getting it again are lowered (10-30% depending on the point it struck with the first pregnancy). It is typically a first-pregnancy illness (although it can and does happen in second pregnancies, it's not nearly as common).

I would be VERY skeptical of anyone that thought that a BP of 129/79 was reason to conclude that she has pre-e in a second pregnancy. It just doesn't make sense AT ALL.

If you were my doula and were aware of this, I know that I would appreciate a gentle discussion about what you've heard 'through the grapevine.' You're an advocate for her, after all.

[Romana]

http://sagefemme.blogspot.com/2007/03/hypertension.html

Read this blog entry. Great info, great approach. While I don't think your client's BP is really elevated, the fact is that moderately elevated BP in late pregnancy is not associated with any increase in complications or poor outcomes (unless, of course, you induce unnecessarily). That is moderately elevated BP in the absence of other signs of pre-e, such as proteinuria or edema, which you stated your client does not have.

HTH. It is from pamamidwife's blog.

ETA: I am not a pro. Obviously pamamidwife is.

[Katielady]

Hi all,

Just wanted to post an update. My client continued to have blood pressure readings that her midwife considered high, and I presented her with all kinds of info about hypertension (the blog link above was EXCELLENT, btw) and about her options. I put the idea out there about getting a second opinion or possibly switching providers, but as many of us suspected she didn't want to think abotu switching so late in her pregnancy. I can't really blame her- that would be a very hard thing to do.

Anyway, she was induced Friday morning at exactly 38 weeks, first via breaking her water and a few hours later via pitocin. She progressed quickly with pitocin and we helped her manage the labor naturally. At one point she decided she wanted an epidural, but very soon after that she went into transition and started pushing- the anesthesiologist came in as she was well into 2nd stage. She had a beautiful vaginal birth with one small 1st degree tear. Baby boy is pink, healthy, and nursing like a champ. Woo!

The midwife was great during the whole process. Ultimately I don't feel like I know enough to say whether or not my client and baby would have done fine without the induction. My gut says she didn't need it, but maybe the midwife has seen a lot of cases like this turn sour. But as far as how we were all treated during the labor and birth, I couldn't ask for more. The midwife was warm, calm, caring, and smart.

Mostly I'm just so proud of mom for dealing with all the procedures and being on labor with all these wires coming out of her, and yet still having an unmedicated vaginal birth. I think I was really able to help her, too, and I feel great about the whole thing.

thanks for the advice and support, all!

xoxo,
a very blissed out katie

[Rockies5]

Originally Posted by Katielady

Hi all,

Just wanted to post an update. My client continued to have blood pressure readings that her midwife considered high, and I presented her with all kinds of info about hypertension (the blog link above was EXCELLENT, btw) and about her options. I put the idea out there about getting a second opinion or possibly switching providers, but as many of us suspected she didn't want to think abotu switching so late in her pregnancy. I can't really blame her- that would be a very hard thing to do.

Anyway, she was induced Friday morning at exactly 38 weeks, first via breaking her water and a few hours later via pitocin. She progressed quickly with pitocin and we helped her manage the labor naturally. At one point she decided she wanted an epidural, but very soon after that she went into transition and started pushing- the anesthesiologist came in as she was well into 2nd stage. She had a beautiful vaginal birth with one small 1st degree tear. Baby boy is pink, healthy, and nursing like a champ. Woo!

The midwife was great during the whole process. Ultimately I don't feel like I know enough to say whether or not my client and baby would have done fine without the induction. My gut says she didn't need it, but maybe the midwife has seen a lot of cases like this turn sour. But as far as how we were all treated during the labor and birth, I couldn't ask for more. The midwife was warm, calm, caring, and smart.

Mostly I'm just so proud of mom for dealing with all the procedures and being on labor with all these wires coming out of her, and yet still having an unmedicated vaginal birth. I think I was really able to help her, too, and I feel great about the whole thing.

thanks for the advice and support, all!

xoxo,
a very blissed out katie

: glad it worked out well! Thanks for the update.

[momileigh]

Thanks for the update Katie! Glad everything went well!