Ripening the Cervix, and Induction of Labor; a discussion for patients  by Martina Nicholson, MD, FACOG, 2009
WITH MANY THANKS to Dr. Aaron Caughey, MD, MPP, MPH, PhD,  at UCSF, for the expert review of the data and nuances of this topic.  When we wonder about the “best” time for delivery of a pregnant woman, there is now sufficient data about how long the cookies should stay in the oven, so they will come out golden brown, not underdone or overdone. And the answer is 39-40 weeks. There is the lowest chance of morbidity at that time. So now we are trying to get as many babies as possible to deliver within that window of opportunity.After the edge of “term” there is more risk of the baby being surrounded by inadequate water, so the cord can become squeezed in labor, as the contractions intensify. The cord brings oxygen to the baby, and if it is too “vulnerable” it will not deliver enough, so that the baby gets stressed, and then distressed”. This makes it important to try to get through labor when there is still enough fluid around the baby so that the cord can float freely, and pass oxygen in and carbon dioxide out. The placenta is “breathing” for the baby, until delivery.Also, the baby can go poop in the water, which is called meconium. If the baby takes deep gasping movements, the fluid in the baby’s lungs can be so noxious, covering the insides of the lung surface, that the baby can not breathe air when it comes out. The baby has to make a transition from being in a watery world, to being in air, and learning to breathe, rather than get all its oxygen from the placenta, through the umbilical cord. So it is very important for the baby not to gasp and inhale deeply the meconium. We now know that babies gasp as a reflex, when they are inside and there is not enough oxygen. So we want them not to have long or deep fetal heart beat decelerations, which cause them to feel less oxygen, and gasp. Babies can tolerate some stress, some low-oxygen, for awhile. But labor can be long and hard, and if it is getting harder and harder to get enough oxygen, the baby will become “distressed”– and need to be bailed out.So a big part of the work of doctors, in watching labor, is to gauge how much stress the baby is under, and whether the baby is bearing up under it. In a fast, easy labor the water is abundant, the cord is not compressed with contractions, and mother’s pushing allows a natural squeezing which may help the lungs be less full of water, and more ready to take in air when the baby first breathes.In a long hard labor, there is also the risk of infection, which can rise from bacteria which naturally live in the vagina, up into the uterus. So it is really important for the mother to be delivered as promptly as possible, to reduce the risk of infection passing to the baby. The mother also can get a deep infection in the walls of the uterus, which is called “chorioamnionitis” (infection in the bag of waters) and later, “endometritis”(infection in the lining of the uterus)–and this causes the walls of the womb to be less capable of contracting efficiently, both in labor, and afterward, to keep from bleeding from the raw site where the placenta was attached.When a baby is post-dates, and has meconium, and has infection, it is like 3 strikes against them. For this reason, we want to get them delivered when they are ripe but not at risk.Some women look askance at us, for trying to talk them into being induced at term. They need to understand that this is the underlying reason. For most moms and babies, it is safer, and there is more chance of a successful vaginal delivery, if we don’t wait till two weeks overdue.In general, I try to “let the river flow, rather than trying to push the river”. But sometimes we need to nudge someone into labor to get them to deliver in the best window of opportunity for safety.What stops us? The last process of pregnancy before labor is cervical ripening. If the cervix is like a green apple, it is much harder to get it to open. It needs to be like a ripe peach. The soft, squishy, mushy tissue will more easily begin to open up. So what we now use, to get the “ripeness” we need, is prostaglandins. The medicine Cytotec, or misoprostol, was invented for ulcers, but it was found to be exactly what is needed to make the cervix ripen. This is what does it naturally, in most women. But some women don’t make enough. So we can give them this medicine, vaginally or orally, and the cervix will respond by ripening.After the cervix is ripened, which may take around 24 hours, the uterus can begin to open up the cervix, by contracting. The contractions are like a castle opening a heavy drawbridge. The drawbridge is drawn up and into the castle walls. We sometimes have to use pitocin, a medicine which is dripped into mom through the iv, to help this process of lifting open the cervix.Another thing that has to happen is the baby has to come down deeper into the pelvis, and make it through the outlet of the bones. Some babies are just too big for the bones of their moms. Others are lying in a position which makes it harder to get through the pelvis. And some have a tight loop of umbilical cord holding them up. Sometimes we can change the mom’s position to help get the baby to turn and come through the pelvis. Sometimes we can actually reach in and turn the baby’s head a little, to get it to do this.When the baby is distressed, or there is thick meconium, or the baby has a body which is too big for the mom’s bones, we do a Cesarean Section. This surgery has helped millions of babies to be safely born, with lungs which can breathe, and not having severe infections, and so they can stay with their moms and breastfeed, and not need to go to the nursery in exhaustion and need tubes, iv’s and oxygen to help them get out of trouble. A lot of people think doctors are making unnecessary interventions, because they do not understand these facts. All our monitoring is to make sure the baby and the mom are both safe through the process of labor. We want to help babies be born safely, and in optimum health, like golden brown cookies!

AKA “The Baal Shem Tov and the Bishop”

The book “The Spirituality of Imperfection” by Ernest Kurtz and Katherine Ketcham, has been a favorite source of reflections for me for about 15 years.  One of the stories I love best is from Jewish lore.  I call this the story of The Baal Shem Tov and the Bishop.   The Baal Shem Tov before he died, asked a disciple to carry on his work, going far and wide to tell stories about the master.  In a far country, a wealthy nobleman was very happy to receive the disciple, and eagerly waited to hear the stories.  But his mind went blank.  Finally, after a few days, he started to leave, and then he remembered one story.  He was with the Master when they came to a Christian town, just before Easter.  The usual thing there was to kill a Jew, in the fervor around the crucifixion of Jesus.  So the disciple was very afraid.  But the Baal Shem Tov went to a big house, along the square, and threw open the upper window to look at the procession of people coming into the square.  The bishop in his robes was very imposing.  The Baal Shem Tov told his disciple to go down and tell the bishop that the Baal Shem Tov wanted to see him.  The disciple was trembling with fear, but went to the bishop, and was amazed that the bishop listened, and after his sermon, went with the disciple, to see the Master.  They went to an inner room, spoke for a long while.  Then the Baal Shem Tov came out, and said now they could go away.  The disciple was very sorry this was such a fragment of a story, but he did tell the nobleman about it.  The effect in the nobleman was immense.  He recognized the disciple, and he said, that the bishop in the story was he himself.  He was descended from a line of distinguished rabbis.  He had converted to Christianity in a time of persecution, out of fear, and had been praised, and raised to being a bishop.  He had had a dream, in which he recognized that his soul was in peril.  The Baal Shem Tov had told him that he should return to a simple life of holiness and prayer,  and give up his money and titles.   He should have hope, and  “When a man comes and tells you your own story, you will know that your sins are forgiven.”   When a man comes to tell you your own story, you KNOW that your sins are forgiven.  And (what is always true), is that when you are forgiven, you are healed.

I love this story, because although I am a Christian, I understand that there are people who are and must be, true to their own faith, their own understanding of God.  I do not think we should try to convert or change people’s faith.  What I do think we should work to change, is our own behavior, and especially that part of us which is conscious, which has that “still small voice” of conscience.   Expanding our ability to love, to forgive, and to have patience and forbearance, is what we are being invited to DO.  God calls to each of us, and God forgives us, and we need to hear that voice of forgiveness.  We never hear the voice of God when we are self-satisfied, but only when we are trying to live with peace, with serenity and courage, and to do the will of God.  Putting aside our own egos, trying to help meet the needs of others around us, is what most heals.  When we reach out in love, in solidarity, and forgive each other, we are most like the God we want to be close to, and with whom we want to be in relationship.