[Moonridden]

Hi, all

In the middle of trying to write my birth plan (for a hospital birth), and I'm working on what I would like to see happen if labor stalls or stops and needs augmentation. I'm opting for natural methods first, but I would like to have something down if further interventions are necessary. What's the major flaw with having membranes artificially ruptured? I see in a lot of sample birth plans that state that they do not want their waters artificially ruptured at all, but wouldn't that be preferable to being given pitocin if augmentation of labor becomes necessary? I understand that an AROM might not work, at which point I'd be given pitocin anyhow, but is there a reason why it wouldn't be preferable to try AROM first before going straight to drugs?

Hope this question makes sense. Thank you!

 

[hippy mum]

Are you planning an induction or waiting for labor to start and progress naturally first? An induction can fail if the bishop score isn't high enough.

 

[Katie8681]

AROM starts the clock in most providers' minds. Once your water breaks, they start to worry about chorioamnionitis, and it's pretty standard to want the baby to be born in 12 hours. (I am not saying I think that's good- just that it's the hospital norm.) And it's easier to get baby repositioned with intact membranes. AROM with an OP baby and it's more likely to stay OP.

 

[Moonridden]

hippy mum - I am not planning an induction, no. I intend to birth naturally and hopefully be in the hospital as little as possible. I'm just trying to plan for as many eventualities as possible and get my preferences written down. In this particular case, I'm just not sure what is better for augmentation, the AROM or pitocin.

Katie - that's good to know re: easier to reposition baby with intact membranes, thank you.

 

[JenVose]

Katie has made some great points on AROM. I'd also add that you might consider GBS status in any decision made on AROM (if you are planning on having the testing done), as your baby is not exposed to this at all until after the membranes are ruptured, but once they are, what my midwife explained to me is that it takes four hours for the IV antibiotics to be fully effective in preventing possible illness to the baby. So, in a way, if those membranes are still intact, that is also a natural line of defence for your little one.

Congrats for considering AROM and your position on it early, however, because I'm sure there are many women who do not even think of this in their birth plans!

I had a natural birth and no Pitocin, so I cannot compare in any way, but I can tell you about my own personal experience with AROM. I was GBS positive, and planning a completely natural birth in an out-of-hospital birthing center, therefore the long discussion with my midwife about the risks/what course of action we should take on treatment. I chose to only have the midwives/assistants use a topical antibiotic during checks (I could have opted for IV antibiotics), and in the end, with the way everything went, that choice was perfectly fine for us, as I delivered a healthy, happy little girl less than 15 minutes after AROM. I did not feel that the membranes being intact impeded the actual progress of my labor in any way (although it might have slightly slowed down dilation of my cervix), but rather that it slowed the labor just to the point that it should have, allowing my body to get ready for the delivery of my baby. When I began to feel the urge to push, I actually pushed through about two contractions with my membranes intact, and that was when I did feel as though the membranes were an impediment, as I felt like the baby was bobbing all the way back up to the original position after each push, so it felt as if I were making absolutely no progress (I can't tell you if this is the actual case or only in part). The midwives said I was making some progress, but I don't really know if they were just trying to be encouraging.

I have read many studies that say there is no conclusive evidence that the tendency for your water to break is passed down genetically, but I had really kind of guessed that I might have thicker membranes because my mother had AROM with all three of her deliveries (really, just because that was what I was most knowledgeable about, and had never really been with a laboring woman who had ever just had her water break spontaneously!). My mother's hospital AROM was always done shortly after she arrived, just as a matter of practice. When she delivered me (her first), the doctor went home after the AROM assuming it would be morning before she delivered, and she delivered me I believe within 2 hours of arriving, so it may have helped to speed things along (she had also been inducing at home with castor oil and walking). With my oldest brother, it was around 4 to 5 hours after AROM when he arrived, so it's hard to say whether or not it sped things in any way or would just have been the natural progression. With my youngest brother, AROM did not seem to help in any way, and my mother still received Pitocin as she had a lengthy labor with him even after her waters were broken.

 

[cyclamen]

AROM vs pitocin also depends where you are in labor and what is happening. Ideally, you will have found a health care provide that you can trust, and who you feel treats you with respect, and that you feel you can be honest with about your feelings. Ideally they will recognize that your feelings are a part of wellness, too. As you get closer to labor, this is one of those questions to ask your HCP - when do they decide to do what, and why? What are your options? What are your values and worries and how would you like to see them addressed? How do their answers make you feel? If you don't like the way they treat you before labor, a birth plan will probably not improve anything for you during labor, kwim? Screen you doctor or midwife - even if you have medicaid, you are hiring them. They work for you. That's something I wish I'd known during my first pregnancy.

The goal is not to be the doctor or midwife yourself, and decide ahead of time, AROM or pictocin, but to communicate what is important to you so that your HCP can give you the information you need to make the best choices for yourself.

Then if something happens during labor you can get an expert opinion from someone you trust who has seen hundreds or thousands of births, who is also observing your birth, and they can explain what they think is the best course of action and why. And then you can make your decision that way. It's kind of difficult to anticipate everything that can happen during a birth.

FWIW, I had AROM with my first because my contractions were strong, regular, and very painful. I was fully dilated for over an hour, without any descent. I was starting to get exhausted, so they asked me if I wanted my water broken and I said yes. So they broke my water and she came right down, and I still had to push probably another hour and a half or three hours (can't really remember... it was a long time!) because she had a nuchal hand, but out she came. I did used to wonder if maybe I'd spent a few contractions in some kind of head down position before AROM, she might have been able to move her hand, and so that is a question I would ask if I found myself in the same position again. (I didn't with my second birth - she came quick.) But ultimately, I don't know if that would have changed anything. I do know that she was born without too much trouble for her or to me, so in retrospect it was a "good-enough" decision.

 

[Moonridden]

JenVose - thanks for taking the time to make a thoughtful comment. It was very helpful!

Cyclamen, you said If you don't like the way they treat you before labor, a birth plan will probably not improve anything for you during labor, kwim?

and

Screen you doctor or midwife - even if you have medicaid, you are hiring them.

Understood, but I have tricare insurance and will be giving birth in a very large army hospital in the south. That might give you a rough idea what I'm up against. =) I can't have a legal home birth in this state - or else I certainly would! - and I have a history of very short labors and am somewhat high risk, so the birthing center 2 hours away is not an option. I like my CNM okay, but I have no guarantee that she will be one of the dozens of midwives and OBs on call when I deliver. My options are pretty limited, and that's one of the biggest reasons I put out the cash to hire a doula … so that I had someone who would read and acknowledge my birth plan and advocate for it.

 

[cyclamen]

I grew up with tricare, so I totally understand that there are not a lot of options and that army hospitals are not known for being at the leading edge of evidence based medicine, and that really sucks. During my last pregnancy, I also went to a practice with over a dozen hospital midwives, and no guarantee of who I'd get, or what OB (that I'd never met!) would be working. So I can sympathize with wondering if it's even worth the effort to try to develop a relationship.

As you write your birth plan, it would then be even more important for you than for a woman who has a guarantee of their choice of doctor to have open lines of communication with your OB or midwife- "Under what circumstances would you recommend AROM? Pitocin? Ideally, I'd like to avoid [blah blah] so what would you need to see?" So at least you have an idea of what your doctor's logic is, whether or not you agree with it, and what you are facing.

A birth plan is a good thing, and a doula is great, but it's ultimately only as good as the person who is in charge of making the ultimate decisions in the hospital. That's the unfortunate reality. Sometimes you will get lucky with that person and sometimes you won't, but one thing you can do to improve (not guarantee) your odds of being respected is to have open lines of communication with as many of your potential caregivers as possible.

Finally, it doesn't make sense ahead of time to decide you want AROM vs pitocin. Every birth is different, and you want the solution tailored to your exact birth situation. You do want to know why a doctor or CNM recommends one over the other..

 

[scottishmommy]

I think it depends on how far you are in labor. If your are 10 centimeters and the baby isn't descending then go AROM. If you are earlier you may want to wait. I find that the contractions hurt a lot more after your water breaks, so for that reason alone, I say wait. Of course pitocin is painful too so maybe it's a toss up? The best thing you can do to avoid augmentation is to stay home as long as possible( within reason of course). My OB told me not to come in until I couldn't talk through contractions/ or if I wanted to yell at anyone else who was talking through my contractions!!