EBB 367: Early AROM and High-Dose Pitocin with all Inductions? Breaking Down the Latest Induction Trends with Jennifer Anderson, RN, Doula, and EBB Instructor

Dr. Rebecca Dekker – 00:00:00:

Hi everyone. On today’s podcast, we’re going to talk with registered nurse, experienced doula, and EBB instructor, Jennifer Anderson, about the trend of recommending high-dose Pitocin and early rupture of membranes during a labor induction. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to the Evidence Based Birth® podcast. Today, I’m so excited to talk with EBB team member, Jennifer Anderson, about current trends in labor induction. In the meantime, I hope you’ve been enjoying our special August series where we’re highlighting the voices of Team EBB. Today Jen is going to educate us about the trend of high-dose Pitocin and early ruptured membranes of labor inductions and then there is still more to come later this month. Next week, in Episode 368, you’ll hear a moving birth story from Rikki Jenkins, our EBB instructor program coordinator. Rikki is a doula and an IBCLC. And she and her husband Nova are going to share their journey through a planned home VBAC hospital transfer and ultimately a redemptive Cesarean birth. Then, on August 27, Dr. Morgan Richardson Cayama, a research team member at EBB will share her work on respectful care in preventing mistreatment in childbirth. We will also have a special brand new Evidence Based Birth® handout on respectful maternity care that you can download on that day as well. I am so thankful to be able to work alongside such a dedicated and compassionate team here at Evidence Based Birth®. Everyone’s commitment truly inspires me and keeps me going even when it’s hard, and I hope these upcoming episodes will educate and inspire you too. So don’t forget to listen every Wednesday in August on your favorite podcast app or you can watch our episodes in the Evidence Based Birth® YouTube channel. If you want to help us out, you can subscribe so you never miss an episode, leave us a review on your favorite podcast app, that helps us reach more people, and connect with us on Instagram @ebbirth for an inside look at Team EBB and all of the episodes we’re sharing this month. 

And now, I’d like to introduce today’s honored guest, Jennifer Anderson. Jen Anderson is a registered nurse, professional doula, and an Evidence Based Birth® instructor, as well as a proud member of Team EBB. Her work as a high-risk doula combines her knowledge base as an RN with a passionate dedication to shared decision-making and tapping into the values of her clients. As a doula with a focus on supporting people who are pregnant over the age of 35, those with IVF pregnancies, or those attempting a Trial of Labor After Cesarean, Jen supports her clients in labor through her a la carte approach to interventions, including inductions, while still maintaining a low Cesarean birth rate in her practice and healthy outcomes. Jen brings this focus to her Evidence Based Birth® Childbirth Classes by making the content applicable to those who know that interventions will probably be a part of their birth experience. Jen, I’m so excited to welcome you back to the Evidence Based Birth® podcast.

Jennifer Anderson – 00:01:43:

Hi, Rebecca. It’s so fun to be here. I’m happy to talk to you today.

Dr. Rebecca Dekker – 00:01:47:

Awesome. Okay. So last time you were here was episode 222, which seems like a very lucky number.

Jennifer Anderson – 00:01:55:

Easy to remember.

Dr. Rebecca Dekker – 00:01:56:

Easy to remember. And you talked with us about navigating the induction decision if you were giving birth at the age of 35 or greater. And this time, I asked if you wanted to come back and you said you wanted to talk about a new trend you’ve been seeing. So this trend you said is pressure to optimize labor inductions by making them move faster using a bundle of interventions that might be more invasive or just more in general than what your clients would prefer. So give us a scoop. What got you interested in this topic?

Jennifer Anderson – 00:02:30:

Yeah. So I was actually working with a client last year, the end of last year, who was having a normal spontaneous labor at home. Normal in that first time babies could take 10 minutes or they could take 20 hours. And this one was taking a while. We had actually labored at home. We headed into the hospital after the third night of prodromal labor. She was working hard. Contractions were not progressing. She had gone in for labor checks and she was still two to three centimeters and kept wanting to come home because she wanted to avoid induction. Eventually it got to the point after the third night of lost sleep that we needed some help. So we finally came to the group decision to head on into the hospital. This time stay, be admitted and get some help. She got an epidural. She desperately needed some sleep. And once the epidural, and at that time, once she had her epidural, they did an exam and she was actually five centimeters. We’re like, took us three days to get there, but she was there. And so she had her epidural and they had just settled everybody down. And they said they were going to start Pitocin, which we expected. And she was closing her eyes to go to sleep. And I stepped out to talk to my family after three days. And I come back in after about 30 minutes and I noticed that the Pitocin was on a really high rate. And I was like, I looked at my watch. I’m like, we just started this 30 minutes ago. How are we on eight of Pitocin already? And the nurse had come in and said, well, this is our new induction policy. We’re going up by four instead of two and starting at four instead of two, yada, yada. I’m like, but she’s been laboring for many days. She’s also not being induced. We’re augmenting her labor. And I kind of felt like she was a little spring loaded and that this was a really heavy pit dose to kind of hit her with. 

But I’m like, okay, well, let’s just see what happens. But I’m going to ask to turn it down if we start having too many contractions, 15 minutes later, she started banging out contractions one after the other, the baby started showing signs of distress and they turned the Pitocin down and then off. After that, I was like, all right, what about this policy? I’d stepped out to the bathroom for a little bit. And there was a big poster board that was by the nurses station that had talked about our new policy. So in that moment, they had scan codes on there. I scanned what their policy was that they made public to everybody who was walking in the hallways. And I started looking at this. And it really started to show what this hospital system is now kind of endorsing that I’m seeing at other hospitals. And it just brought to light a thought. It bears another conversation about how inductions can go slow or fast, as well as what some of the research is out there that is really kind of pushing providers and hospitals to move things along, sometimes a little faster than maybe our clients or birthing people might want. So that was kind of the what is good about this policy, what is not good about this policy, and what do patients actually need to know when making decisions about their induction based on this policy? What questions should they be asking?

Dr. Rebecca Dekker – 00:05:22:

It’s so interesting, because like you said, this was going in for an augmentation of labor, your client was already five centimeters dilated. So not an induction, but they were essentially following an induction policy for the Pitocin or the Oxytocin that they were giving. And you said, can you explain a little bit before we go any further about what is two by two and four by four mean with Pitocin with an induction?

Jennifer Anderson – 00:05:47:

So you always talk about in your articles on the podcast, what we always talk about low dose Pitocin, like I want low dose Pit. And I always kind of joked in my area, I’m like, I don’t, there’s no such thing as high dose Pit anymore. I really didn’t see it that often. So low dose Pit, really the general definition of it is that when we do start Pitocin, we start at one or two milli units per minute. Pitocin is an infusion, so it has to go continuously because it has a very fast half-life. If it’s not just going in continuously, it’s going to disappear out of our bodies. So it’s a Pitocin infusion, and that’s, I always explain that to my clients so that they understand, like the dose of Pitocin is constantly changing based on what your body needs. But in the very beginning, we don’t know what your body is going to need. So we usually start out at two and then solid research for many, many years. We really kind of adhere to after 30 minutes, if the contractions are not where we want them to be, let’s go up by another two. And so we’ll start at two and then 30 minutes later, we go up to four and then six and then eight and then so on. Sometimes we’re close, but not quite there. We may just go up by one. And then sometimes we start contracting too frequently and the nurse can go down by two, by four. We can half it if you’re at 10, turn it down to five. But we really kind of look at the fetal monitor, the contraction pattern, and how are all those playing together to ensure that the baby is doing okay, that the birthing person is coping with the contractions okay, and that we are getting the contractions where they need to be to continue to move that dilation forward.

Dr. Rebecca Dekker – 00:07:18:

Okay. So a low dose regimen of Pitocin is usually starting at two milliunits per minute and increasing it how often by another two?

Jennifer Anderson – 00:07:28:

Every 30 minutes.

Dr. Rebecca Dekker – 00:07:29:

Every 30 minutes.

Jennifer Anderson – 00:07:30:

And it should never be anything less than that. That research and knowledge is pretty well out there. We used to increase it by 15 or every 15 to 20 minutes. We figured out that 30 minutes is really that happy place.

Dr. Rebecca Dekker – 00:07:41:

Okay.

Jennifer Anderson – 00:07:42:

But the range of how much it can go up is really kind of a lot of the onus is given to the nurse. How is things looking? Can I go up by one or two? Or with these higher dose regimens, now we’re starting at four and going up by four every 30 minutes. So it’s the same 30 minutes, but it’s a bigger jump and a bigger starting point.

Dr. Rebecca Dekker – 00:08:01:

Okay. So that’d be a four by four regimen, sometimes called the high dose Pitocin regimen. So our listeners can understand a lot of institutions, a lot of hospitals have standard protocols written so that the nurse doesn’t need to call the doctor or the midwife every 30 minutes. Instead, they just follow the protocol. As long as the client is meeting certain criteria, then they go ahead and keep increasing it until they decide to stop increasing it. Correct?

Jennifer Anderson – 00:08:25:

Correct. And also as an RN, I kind of know what these protocols are. I know what the fetal monitoring requirements are. I’ve looked through that part of their policy that was stated there. And there really is nothing I can argue about. They list all the reasons why we should not go up, which are all very appropriate. Fetal heart rate distress, too many decels, contractions too close together. They give really good guidelines on all these. When should we pit off? When should we have it? How long can it be off before we restart it? All of those things were quite in line. Not a whole lot had changed there. And there’s really nothing that I disagree with as far as their decisions to start Pitocin, turn it up or turn it off. All of that-

Dr. Rebecca Dekker – 00:09:05:

It’s just the starting dose and the increasing.

Jennifer Anderson – 00:09:08:

It’s the rate that we start and how fast we’re increasing is kind of more the new thing that seems to be supported in the research. But I don’t know how often our clients are being informed on what we’re starting at and how frequently we’re going up.

Dr. Rebecca Dekker – 00:09:20:

Okay. And yeah, and that’s another discussion in terms of like, we talk about this in our labor induction Pocket Guide that the low dose versus high dose is controversial in the literature and among practitioners. And you see different recommendations depending on which organization is making the recommendations. So in general, obstetricians, their organization in the U.S., ACOG recommends that low or high dose pitocins are appropriate. Whereas AWHONN, which is the Association for Women’s Health Obstetric and Neonatal Nurses, they recommend starting with the low-dose regimen. So the research is not completely clear. It’s open to interpretation. There’s probably some risks and benefits to both approach. And as a result, you can see differing opinions. But this hospital in particular you’re talking about is not just a single community hospital. So it’s a very large system from what I understand.

Jennifer Anderson – 00:10:15:

Yeah. And, you know, this is not the first I’ve heard of inductions like this. We could talk about this hospital or this system. But in all honesty, other people in other states and other regions all around the country are probably seeing this too. It was just kind of a wake-up call for us in this region. But I’m highly confident that other people are seeing this or have never even heard of the low-dose first, potentially.

Dr. Rebecca Dekker – 00:10:38:

Yeah. But in general, in California, where you’ve been practicing, you’ve mostly just been seeing the low-dose, the two-by-two. And so you were kind of shocked.

Jennifer Anderson – 00:10:45:

Correct.

Dr. Rebecca Dekker – 00:10:45:

When they started using the four-by-four. And then you discovered, oh, like this entire healthcare system in California is going to be using this because they have a new induction protocol. So tell us, walk us through what else is in this new labor induction policy that you discovered.

Jennifer Anderson – 00:11:02:

Yeah. So there’s a lot of good things about this, about their new policy. And when I say good things, because who thinks an induction is good? None of us are like, yay, I can’t wait. Right. But a lot of good things in this policy and their approach based on the literature. So there’s kind of like, I would say probably sum it up in like three big chunks of what they really are trying to make uniform across all hospitals in this system, which is one, got to start with cervical ripening. And that part we all agree with. So they are very kind of descriptive in what cervical ripening needs to be. The Bishop score, what Bishop score this person has, is this an elective induction or is it a medical induction? The Bishop score is a numeric score based on your cervical exam. This is also really well explained in the pocket, the induction Pocket Guide for folks that who have that. And the Bishop score pretty much gives a numeric number to your cervix that will tell us, do we think this induction is going to be successful or not? And that has been well-researched. And I do educate all my clients about, hey, let’s really think about this elective induction if your Bishop score is really low. And so this policy actually includes that. They talk about how we should be inducing and using cervical ripening if the Bishop score is. So that part I think is really useful and helpful. Another part of this policy is in the cervical ripening mode, which can include membrane sweeps, using the balloon catheter or the Foley catheter, as some people might call it, the cervical balloon and prostaglandins for cervical ripening. 

So Cytotec or Cervidil are the two most common ones that people will see kind of nationally. They’re really kind of encouraging dual method cervical ripening. So that’s the part that gets a little aggressive. Dual method cervical ripening involves placing the balloon catheter, which for some people can be extremely uncomfortable. I always say for the balloon catheter is a catheter that will go into the vagina through the cervix. And basically there’s a balloon on the inside and the outside of the cervix that we blow up. And I like to say, it’s kind of like pinching your cervix together. We’re mechanically thinning your cervix. Some people, and this is a rather large catheter and a bigger balloon that’s going in that space. So some people have a very, very hard reaction to it. I don’t want to use kind of trigger words, but people don’t cope with it. Well, it’s extremely uncomfortable. And then I have other clients that are like, I don’t, I don’t see any difference, but for clients who are birthing people who have a history of sexual trauma, painful intercourse. I like to say, if you do the butt walk, every time someone wants to do a cervical exam, balloon catheters are not necessarily the thing that is going to help you or be a positive experience in your induction. I like to give my clients the choice to decline that. This policy is very heavy on doing the dual method, which includes putting that balloon in and then giving medications, either Cytotec or Pitocin at the same time. That’s a lot more aggressive type of cervical ripening than what we’re usually used to. Although not new, we do see this not uncommonly.

Dr. Rebecca Dekker – 00:14:07:

Okay. Yeah. And we do talk about combination induction methods in the EBB Labor Induction Pocket Guide. I think one of the reasons you might be seeing this is there was a meta-analysis published recently. They compared giving Misoprostol, which is also known as Cytotec, with the Foley versus just the Misoprostol alone. And they found that the time to giving birth was three to four hours shorter. There were lower rates of NICU admissions, lower rates of negative fetal heart rate changes. And they think the reason the combination method works better is because then they can use lower doses of the Misoprostol. So the Foley combining with the Misoprostol means you can use smaller doses of the medication, which then creates a safer cervical ripening method.

Jennifer Anderson – 00:14:53:

In my experience, it does work. It does allow the ripening to happen much more quickly.

Dr. Rebecca Dekker – 00:14:59:

More quickly and then hopefully at a lower risk to baby, because you can use a lower dose, which it looks like in their protocol, they’re recommending that kind of. The misoprostol or the Cytotec is the brand name to be at a lower dose.

Jennifer Anderson – 00:15:11:

They’re very conservative in their dosing. Yes. Have no problem with the dosing.

Dr. Rebecca Dekker – 00:15:14:

With the cervical ripening part. Yeah.

Jennifer Anderson – 00:15:18:

And they also talk about within the cervical ripening kind of model, either the two hour dosing or the four hour dosing for Misoprostol. So Misoprostol, we usually will give, typically most hospitals will do every four hours. But the half-life is one that’s significantly shorter than that. I don’t know that I kind of understand where the four hour dose comes from, because when we do the two hour, where we give Misoprostol every two hours, we don’t see these big kind of like, I’ll see my clients like really peak at the two hour mark. And then they come back down the other side. And then we give another dose two hours later. So every four hours, they peak again and they come down the other side. Eventually somewhere they peak at that two hour mark and they keep going in a normal induction, an efficient one, where every two hours, we’re just staying there at that peak. And I have personally seen that we are doing the two hour dosing. We give less meds overall and get past that cervical ripening phase a little bit more efficiently. But again, clients should be given kind of the option to, do I want to do every two hours or four hours? And I don’t feel that that’s getting offered either.

Dr. Rebecca Dekker – 00:16:22:

Okay, so typically they’re just doing the every two hours now? Okay, what else is in the protocol?

Jennifer Anderson – 00:16:28:

The one thing that, and I don’t know if you’ve come across any research on this one, but it shocked me when I had another hospital, not in the system, ask this question. And then I read this policy. I’m like, Oh, this is where it came from, which is doing a digital exam, a cervical exam with our fingers about six hours into when the balloon has been placed. Now, if you don’t know what a balloon is or what it looks like, like we’ve got a catheter in the vagina, we’ve got something that’s about three centimeters blown up in the vagina and the whole point-

Dr. Rebecca Dekker – 00:16:57:

It’s up in the uterus.

Jennifer Anderson – 00:16:59:

Or in the well-

Dr. Rebecca Dekker – 00:17:00:

Yeah.

Jennifer Anderson – 00:17:00:

Half in the cervix, like half in the cervix, half in the vagina, like the double balloon.

Dr. Rebecca Dekker – 00:17:06:

Oh. With the double balloon. Okay. Okay.

Jennifer Anderson – 00:17:07:

And what they want to do is check the cervix around it to see whether the balloon can come out. So we’re putting fingers in, in around in a balloon to see whether the cervix is actually dilating. And I kind of laughed at the resident. I’m like, pull on the balloon. If it doesn’t come out, then we’re still there. But then it was in this policy too, different hospital. And so I was like, what is the purpose behind this? And I think it’s that either patients when we ask you to pull or nurses when they’re encouraged to pull and the patient then kind of goes, ow. We stop. Basically, we’re not pulling hard enough. Could that balloon come out sooner than what it is by just our tugging? And I think the point of checking is to go, oh, it’s right there. If we give just a slightly harder tug, it’ll come through. But I don’t necessarily know that there is a solid reason or evidence as to do we get the balloon out faster when we do these exams. To me, it feels like a pretty heavy assault on somebody with all those things going on all at the same time. So that part bothers me a little bit. But at least now I understood why. I really do think that either nurses or patients, the hospital system feels we’re not pulling hard enough.

Dr. Rebecca Dekker – 00:18:17:

And are they recommending the double balloon in this policy then?

Jennifer Anderson – 00:18:21:

I don’t know about the double balloon. I would have to go back and look on that. I will say that I do the double balloon a lot.

Dr. Rebecca Dekker – 00:18:28:

Are you seeing it a lot?

Jennifer Anderson – 00:18:29:

In our range, we never see a Foley catheter. It’s always the cervical balloon that goes in with the double balloon.

Dr. Rebecca Dekker – 00:18:35:

Oh, okay.

Jennifer Anderson – 00:18:36:

And usually we’re blowing up both ends, but not necessarily all the way to the max. I think you go up to 80 milliliters. And I think these, we blow them up to like 40 to 60. I’ve heard midwives talking about things like that. So there’s a lot of research going on about how to best manage a double balloon. Blow it inside, blow both of them up, but not as full, blow them up really full. I know that there’s studies out there, but I still think we’re figuring that part out. So, but that is the difference. Maybe on the East coast, we might only see the Foley balloon with just the single balloon that is on the inside of the cervix. That is another method that is perfectly appropriate and still kind of fits under this guise of balloon induction. And then the last thing that they talked about with the cervical ripening that I also don’t disagree with. And I think this one is a good one for your listeners to understand is that membrane sweeping, when we do a digital exam and we’re really kind of, I like to say, making your cervix very angry. It’s more than just a check. We’re actually trying to separate the internal os of the cervix from the amniotic membrane. 

So it’s a more assertive exam, a little bit more uncomfortable. It’s frequently done in the office and it’s frequently offered anywhere from, I hate to say it, 37 weeks on. While I’m not a big fan of doing that ahead of no idea when we’re going to go into labor, the research, and you actually mentioned this also in the Pocket Guide of doing a membrane sweep immediately ahead of starting an induction. When we get admitted to the hospital for an induction, a cervical exam is part of that process. We need to know what your cervix is so we can have an idea what meds and what processes are we going to try to induce you with. During that exam, they can sweep your membranes. I’m all in on that one because I really do believe that that can help move things along without some of the downsides of cramping, uncomfortable nights of sleep that can really wreak havoc when we’re still at home waiting for labor to begin.

Dr. Rebecca Dekker – 00:20:30:

Okay, so in general, the cervical ripening part of it, it’s called their algorithm for induction of labor. If you need the cervical ripening, it looks like they recommend sweeping the membranes right away, placing a cervical ripening balloon, which has the trademark symbol. So I assume that’s the double balloon you’re talking about. And if eligible, initiating Misoprostol, checking the balloon with the digital exam every six hours if you’re hospitalized while this is happening. And then they say the cervix does not need to be fully ripe before moving on to the next step. So why don’t you talk about what the next step is?

Jennifer Anderson – 00:21:03:

The next step is one that I really struggle with because personally, this is one of my big soapboxes, but they call it timely AROM. So AROM stands for artificial rupture of membranes. You may be when you’re sitting in your birthing room hearing your providers or your nurses talking back and forth. So we’re going to AROM. So I always want my clients to know like this is what AROM means, Artificial Rupture Membranes. Basically, the provider is going in with an amnihook to break your bag of water manually. The alternative to that is what we call SROM, S-R-O-M, or spontaneous rupture of membranes. So that’s when your water breaks on its own. So we’re talking about timely AROM. For me, I like to call it in what it really is defined as is early AROM. We’re basically breaking this bag of water earlier in your labor than your bag of water wanted to break on its own. Or basically before active labor, which is really their definition. Breaking the bag of water before active labor, that’s defined as early AROM or early rupture of membranes.

Dr. Rebecca Dekker – 00:22:03:

Okay, we’ll come back to this step in a minute. In the algorithm that they wrote for this hospital system, they wrote, this is the pivotal step. Do as soon as feasible with the head engaged, does not need to be a certain station. And they want this to happen ASAP within zero to four hours of the balloon being removed as soon as the patient is at least three centimeters dilated or their Bishop score is five or greater. We’ll come back to that and then tell us about the Pitocin or the synthetic oxytocin protocol.

Jennifer Anderson – 00:22:36:

Yeah. And then this is where the Pitocin protocol starts to come in where… The way I teach in the Evidence Based Birth® Childbirth Class is I use like three centimeters as the fulcrum between cervical ripening medications and Pitocin or synthetic oxytocin. So it’s not as simple as that, but it’s a good kind of rule of thumb. If we’re before three centimeters or less, your cervix needs some ripening. The membrane, the balloon, all those kinds of things, the Misoprostol. If we’re four centimeters or more, your cervix is already ripe. Cervical ripening is done. A balloon would have come out by then. The really the only thing left to do is break the bag of water or start Pitocin. So their discussion is to start Pitocin immediately after the balloon comes out, I think. So once the cervical ripening is done, we’re four centimeters or more, this policy says, okay, we’re inducing, let’s start Pitocin. We’re going to start it at four million units per minute, and we’re going to increase it by four million units every 30 minutes. What this policy doesn’t kind of identify, or at least in this, like kind of the way it’s described, is what is the birthing person doing already? What is their contraction pattern already? 

I will very frequently see in these scenarios where the balloon came out, or we broke the bag of water, we’re past cervical ripening, and the birthing person is contracting. Like, okay, we’ve run out the course of Misoprostol, no more, and she’s contracting on her own. So why would we want to start Pitocin without evaluating whether maybe these contractions are going to be the thing that takes it the rest of the way? And so I have an argument with, and I see this all the time, and I advocate for my clients all the time. Okay, no more Misoprostol, let’s start Pitocin. And we’re sitting in the shower laboring. I’m like, why are we starting Pitocin when she’s working? So I think the question, and clients need to kind of know and understand, is that an induction doesn’t have to include Pitocin after. Cervical ripening methods can very frequently get us into labor, where our body will continue the process and labor organically on its own after that. But if patients don’t know that, and they assume an induction also includes Pitocin, because it usually does, and the stories will usually do, then our patients are saying, yes, okay, well, it’s part of the induction policy. And I’d say, let’s go outside of your room and walk around for a little bit. You know, let’s, you know, order in some food and try to sit down and eat before we get going. Let’s pay attention to the human being who is going through this process and give them a little bit of a say as to what happens next and when.

Dr. Rebecca Dekker – 00:25:13:

Yeah, that might be a good point for a break because the cervical ripening process can take a while or a long time. You might be tired and have gone through some interventions that you’re trying to recover from, such as repeated vaginal exams, placement of the balloon, tugging of the balloon, all those things-

Jennifer Anderson – 00:25:30:

All the fetal monitoring that goes along with that?

Dr. Rebecca Dekker – 00:25:32:

Yeah, so this is a chance you could have to kind of take a little bit of a breather instead of just diving headfirst into the rest of the induction. And as you said, some people, their bodies go into labor on their own at that point, and they don’t need the Pitocin, if you’re lucky enough.

Jennifer Anderson – 00:25:49:

Yeah. It depends on the kind of induction. If you’re having a 41 week induction post dates, plain and simple, that’s not a body that needs a whole lot of pushing unless our dates are really wrong. But in general, those are smoother inductions. If we’re inducing at 37 weeks, because someone has severe range blood pressures, that’s the kind of induction that’s going to go longer. It’s going to take more cervical ripening. And there’s also a lot of stress in the mind of that person that is holding back a lot of their own hormones. So we kind of have to be a lot more gentle with that person and try to get their bodies and their minds to wrap their head around this. If the mind is not involved in this, we can throw all the medical stuff at it. We can, it’s going to be a harder experience and it may not be the experience that she wants. So I feel like a lot of this is leaving out, even though they say it here, and I’ll give this system credit, bedside labor support and shared decision-making are critical to the patient’s experience and success. So I give them credit for acknowledging that labor support and shared decision-making should be a part of that. I don’t know that I’m necessarily seeing that come out in the actions and the conversations, still a little too early to kind of see that, but I at least will give them credit for that. But I still feel like we’re not listening to what the patient really needs and what really truly needs to happen.

Dr. Rebecca Dekker – 00:27:06:

So when they talk about shared decision making, you know, it’s interesting because they have a patient facing resource page, which I went to and I read in preparation for this podcast. And most of the information is good. But one of the interesting things is they never say that you have the right to refuse or decline anything, which I think, is important we talk about that in our Pocket Guide to Labor Induction and in the EBB Childbirth Class that you have the right to refuse dose increases. You have the right to ask to have it turned off or turned down. And you have the right to refuse certain aspects of an induction, such as the earlier, they call it timely, artificial rupture of membranes. But one of the things that was interesting is there was some misinformation on that page. Their paragraph on amniotomy or artificial rupture of membranes, which we’re going to talk more about the research on this in a minute, was inaccurate. They write, quote, amniotomy is a safe way to induce labor. If the bag of waters isn’t open, labor usually won’t start during an induction, which both you and I know is not necessarily true. Yeah. Labor can start and you could break your waters later or have them break on their own. It says amniotomy allows your baby’s head to put pressure on your cervix, which triggers hormones that promote labor, which there is truth to that. And then it says postponing opening the bag of waters can increase the chances of getting an infection during an induction. It’s not harmful for your baby if your bag of water is open for more than 24 hours. And so that is what is not correct because we pulled all the research studies they cite. For this protocol. And there was not a single study that they referenced that showed that later AROM or letting your waters break on your own increases the chance of infection. In fact, the research that they cited found no differences in infection with early AROM or late AROM. And that’s, I think what we need to dive into next. So Jen, what were your questions for me? You sent me a bunch of studies. Like what were your questions about the early or quote unquote, timely AROM or Artificial Rupture Membranes?

Jennifer Anderson – 00:29:14:

My big question is, and kind of compare and contrast to the ARRIVE trial where the end result is, hey, induce the 39 weeks, we can reduce your chance of having a Cesarean birth by 16%. That sounds great. That’s kind of what I always like to say, like that great used cars sales banner on the board. Like, oh my gosh, that sounds awesome. So here it’s, hey, let’s break your bag of water early and we can increase your time from induction to delivery. I saw, depending on the study we looked at, three to five hours. And for a lot of people, they go, okay, that sounds great too. Sign me up. But what I want to find out is we know for a fact that the rates of infection will increase with the number of cervical exams a person has during labor. Upwards of eight exams, we can have a 500% increased chance of having chorio or that infection of the uterus, chorioamnionitis. So my question was, how are these studies played out with cervical exams after AROM? Was there a protocol that they had to follow with regards to the frequency of exams or indications for exams that were able to, after we broke this person’s bag of water, they were still able to be in the hospital for 24 hours without a fever. That’s-

Dr. Rebecca Dekker – 00:30:27:

Okay. I will give you the bottom line first, and then I’ll dive into the research and then I’ll reaffirm that. So from reviewing the research on early versus late rupturing of the membranes with the labor induction. There seems to be no difference in Cesareans or infections, but labor is shorter by anywhere from two to five hours, depending on the study, if you rupture the bag of waters earlier. But the Cesarean rates and all those other outcomes that they looked at for babies and birthing people don’t differ. And I think the reason why, because you do mention, we do have research on premature rupture of membranes where your waters break before labor begins. And I think those are the statistics you were citing that the more vaginal exams you have after your membranes have ruptured, the higher the risk of infection. And I think that’s true. I think what happens is there is a benefit to early AROM in that it does shorten the labor process. And it’s probably more related to the fact that the labor is shorter is the reason we’re not seeing an increase in infections. So I only found one randomized trial where they actually specifically measured the vaginal exams that each group had. And that was the largest single randomized trial that’s ever been done on this subject. It was by an author named Macones et al.. And it’s called the efficacy of early amniotomy and nulliparous labor induction, a randomized controlled trial. So this was a study all with first time moms. It was done in the United States, in St. Louis and in Pennsylvania. So you could be included if you’re a first time giving birth with a single baby at term. And in the early amniotomy group during the induction, amniotomy or AROM was performed as early as could be done safely. There was no specific instructions for the other group that was left up to the treating physicians and as well as all the other decisions about how to do the labor and how to manage the medications and everything. And so they were primarily interested in how long it took to give birth and the proportion of women who give birth within 24 hours of the induction starting. And I think there was about 290 people in each group. So a decent sized study, although it’s interesting that this is the largest study on this topic. So it’s still somewhat small compared to some of the other studies published. And most people got Misoprostol during cervical ripening. The one group had their membranes ruptured as soon as possible, which tended to be at three centimeters or earlier, or sometimes four centimeters. And on average, when you looked at the two groups, the early group got their membranes ruptured at around three centimeters. And the standard or control group got theirs ruptured around seven to eight, around seven and a half centimeters. And they both had equivalent numbers of vaginal exams. So they both had six. So, but labor was shorter in the early group. It was on average about 19 hours long for the whole induction in the early group versus 21 hours in the standard group. So that might have been a little protective and that’s why the vaginal exams weren’t hurting them as much. But the end results were the same in terms of Cesarean rates, infection rates. But one thing, and I think it’s really interesting that if a hospital is trying to copy this study, they didn’t really have that great of outcomes. Their Cesarean rate in both groups was 40%.

Jennifer Anderson – 00:34:05:

Yeah, see, that’s not good. For new parents, right?

Dr. Rebecca Dekker – 00:34:09:

These are all first-time moms having inductions of 40% Cesarean rate, which is twice as high as around the ARRIVE trial, as you know. And really the only benefit to the early AROM was it shortened labor by two hours, which for some people that sounds great. For other people, they’re like, well, maybe it’s not worth it. So I think that was an interesting study. There was one other that took place in Egypt that was also sort of large. This one had a total of 320 people. So it was smaller than the other one. And this one took place in Egypt. It had a mix of people giving birth could be their first baby or could be a subsequent baby. And they did not measure the number of times people receive vaginal exams. And they had no cases of chorioamnionitis, which seems strange to me. Makes me wonder if they were not measuring it. The rates of maternal fever were 7% in both groups. There was no significant difference in Cesarean rates, about around 30%-ish total in the whole study, which includes a lot of people who’d given birth before. So it seems also kind of high. So again, it kind of raises the question, like, are we really wanting to? You know, use the same protocols that were done in these studies when they weren’t having like incredible outcomes. I also think that these studies were a little bit small and maybe underpowered to detect the infection rates that we were discussing. In the one I mentioned earlier that took place in the U.S., the total numbers of infection were numerically higher in the early AROM group, but it was not statistically significant. There were 11.5% chorioamnionitis rate in the early AROM group and 8.5% in the standard or late group. And it was not statistically significant, but I wonder if they’d had more people in the study, if they would have seen a difference. To me, this is kind of like still somewhat small, even though it’s a nice number, it’s still like could be a bit larger to really tease out some of these less common outcomes.

Jennifer Anderson – 00:36:15:

Yeah. Well, I find those results interesting because that’s important for our clients to know, for our patients and birthing families to know is that this can, the early AROM, the early amniotomy can be done safely.

Dr. Rebecca Dekker – 00:36:28:

Right.

Jennifer Anderson – 00:36:29:

And the studies certainly prove that. And I actually don’t disagree with that. And where I kind of come in is one statement and then one thought process, which is in their Q&A that they gave out to the staff. One of the things that he said in there with regards to the early AROM, I think it’s that, or maybe all of it, but there is room for individualization. Yay. Yes. We have to individualize to me. It was in my bio. Like I’m an a la carte kind of person. We are here now. Let’s do one thing at a time and let’s see if it works. And then let’s choose the next thing. And the a la carte is what matches your values better. Are you somebody who can handle the intra vaginal kind of approaches, or do you need something that’s medicinal? Do you want medicated versus non-medicated. Monitored versus not monitored. When there’s choices, these kinds of things matter to birthing families. And so I love there’s room for individualization and they point to shared decision-making and they offer several resources for patients to learn more about the induction process. And for me, that kind of says like, okay, here we’re going to give you all the literature that supports our induction process. Here you go. What studies don’t tend to study, and none of these are talking about it, and it’s hard to measure, is patient satisfaction, the birthing experience. And I have a saying because I do induction so often that induction is more than just a word. It’s a nice little rectangular word, fits in a nice little box, but induction is more than just a word. We don’t blink and the baby shows up. It’s we’re going in, we’re doing this, we’re doing that. It is your birthing experience. We may need an induction, but there’s a lot of moving parts to an induction that can also be honored in a birthing experience. 

And that shared decision making or the individualization is something that I haven’t tested the waters yet, but I really, really hope that they will follow through with that and honestly be okay with declining the early AROM. And what they talk about is rupturing the bag of membranes no more than four hours after the balloon comes out. Odds are really good that I couldn’t say odds are good. Who knows? But you may or may not be in active labor by then. But that four hour window does give your body time to see whether it’s going to work out. But at four hours, it shouldn’t be like, okay, four hours, we’re done. Because a lot of patients will go, okay, hospital policy says I have to do it. But the patients don’t have to abide by hospital policy. The nurses do. The providers do. We have a choice. And it could be four hours. You know what? I’m not ready to break my bag of water yet. Because here’s the thing. When we do break the bag of water, the providers, I will say this all the time, providers pop. Okay, great. See when it’s time to push and they walk out and they leave. Who gets left with that birthing person? The partner, the family, the doula, the nurse. And in an instant, this person was managing their contractions. Okay. And when our waters break, it can be, especially when our body’s being pushed into labor, our waters breaking can be a zero to 60 scenario. And that’s where I feel like a lot of the choice might be taken away from people who are really committed to an unmedicated birth. And when all of a sudden I’m coping with contractions and the next one, like you said, fetal head on the cervix, it hurts more. We’re working harder. And for some folks may not be ready for that. It hits them like a ton of bricks and we get an epidural earlier than we had planned, or we get an epidural when we had never planned it. And so we may have a faster time to delivery, but was that their goal? Was that their goal?

Dr. Rebecca Dekker – 00:40:00:

Yeah. That was interesting reading the background or introduction section of all of the research studies that they cited that I was able to pull. You know, they talk about how it’s amniotomy or AROM is low tech. It’s inexpensive. It’s relatively safe. Yeah, it’s non-medicinal and there are some potential clinical concerns. If like the head is not applied well to the cervix, then you could have the umbilical cord prolapse, that sort of thing, which is rare. But it was also interesting to read, you know, that they talked about efficiency of the hospital is one of the reasons for this. You know, shortening an induction by two to five hours, you know, let’s say you have an epidural and you’re just hanging out. It’s not a big deal to have a labor that’s two hours or four hours longer. But for a hospital that is backed up or short-staffed or has people waiting for all their elective inductions or their medically indicated inductions, it’s kind of like working in a restaurant. For those of you listening who’ve worked in a restaurant, I have. That table turnover is a real thing, right? The restaurant can’t make as much money the longer people sit there unless they’re ordering a lot of food and drinks. But in general, the goal is to as soon as a table is empty and cleaned, you fill it. And it’s the same thing with hospital beds.

Jennifer Anderson – 00:41:19:

It feels like the patient is being put on a, well, the clock now exists, but even though nobody’s talking about the clock, but it does really feel like, hey, you done yet? Can we have that room yet? Like, when are you gonna have the baby? And fast is not necessarily what every birthing person dreams of, especially folks that really want to have this birthing experience. I have many clients that say, I want to feel all of it. And there are probably listeners out there to go, you’re crazy. But it’s the beautiful thing that makes the world go round. Like, you’re allowed to want to feel it. You’re allowed to not want to feel it. You’re allowed to do all of those things. And I feel like this policy, if you don’t know how assertive it’s going to be, I don’t like to use the word aggressive, because to me, that sounds faulty. Like, there’s not a whole lot of fault evidence wise in their policy. But if patients don’t know that they could say no, or ask for more time, or just do a timeout, let’s take a break, whatever that might be, or they don’t have a doula that is kind of saying, you know, you can ask for time, then they’re just going to keep saying yes to every next step. And by the end of it, you’re sitting there with an epidural and you’re looking over your shirt. How did I get from 41 week induction to here? Maybe they still have a vaginal birth, but was that the story that they wanted to tell? I want people to choose an epidural because that was always my goal or, Hey, this got harder and I wasn’t ready for it. I don’t want them to choose an epidural because if I would have not let them break my bag of water, then maybe-

Dr. Rebecca Dekker – 00:42:47:

That they felt railroaded into everything. Yeah, and I think it’s interesting because if you look at their algorithm, when it talks about the quote-unquote timely AROM, it says, again, this is the pivotal step and they literally bold pivotal step. But the interesting thing is the research they cite, it doesn’t improve outcomes. It does shorten labor. And I think that is pretty consistent. So if that’s something you’re interested in or is important to you, then I think that is a good reason to have the early AROM. But if you don’t want to or you want to let your waters break on your own, the research shows that that has just as good of health outcomes. Right. So if we’re talking about health or birth outcomes, they’re equivalent pretty much. And also the length, there are things you can do to shorten labor that don’t involve rupturing the membranes. So there are other options.

Jennifer Anderson – 00:43:39:

Yeah, like having that doula that I wouldn’t say that necessarily my labors are my inductions are some of the shortest ones. But I do help our inductions keep moving forward while still helping my clients grab those breaks or make alternative decisions when they need to. So the speed of the induction is usually not what somebody is sitting there worrying about. And one of my bigger concerns with the early AROM, and I, like I said, I see this not uncommonly. I don’t know if it’s in the research, but… If we break the bag of water before, and here they say that cervix does not need to be fully ripe before moving on to the next step, which is timely AROM, and they also say that the station doesn’t matter. In my world and in doula’s world, station absolutely does matter. And when we talk about the station, it’s how high or how low baby is in the pelvis. How well applied are they to the cervix?

Dr. Rebecca Dekker – 00:44:33:

And also considering the position of the baby too, right?

Jennifer Anderson – 00:44:35:

And the position, like are they facing mom’s spine? I always like to say, is the birthing person and the baby giving each other a hug? That’s the ideal position for baby. If they’re facing the same way that the birthing person is facing or sideways, then that can lead to back labor. Back labor is a deal breaker. We can still have a vaginal birth from it, but it changes birth plans. And an induction is a deal breaker. We can still have a vaginal birth from it, but it can change our plans. Once we start piling these things onto each other, we have an induction. Now we have back labor. That’s a person who’s really probably going to fall completely away from their birth plan. And healthy baby, healthy mom is only part of the equation. Health has to happen here too. And that’s what Doulas are really, really focused on.

Dr. Rebecca Dekker – 00:45:19:

Yeah. In your head. In your heart.

Jennifer Anderson – 00:45:22:

Yeah. We have to really be happy with this induction. Did you go over the other side and go, well, that stunk, but I’d have done anything different? Then we nailed it. If it stunk and I didn’t know that I had options that weren’t given to me and I chose wrong, that’s a person that really struggles to reconcile that birth, especially when we find out afterwards.

Dr. Rebecca Dekker – 00:45:43:

I also want to, before I ask for some final advice, we have the Evidence Based Birth® Pocket Guide to Interventions. There’s page 42 talks about time limits in labor. And we made a list of the evidence-based options for when labor is taking a long time or you’re wanting to move things along. So I wanted to make sure I mentioned some of the other options that can shorten labor include getting an epidural for pain relief and sleep if you’re exhausted, addressing fetal positioning, which we were just talking about, hands-on labor support from a doula or other birth support person, using a birth ball or a peanut ball, walking and using upright positions, laboring in a tub, which may or may not be permitted with an induction depending on your institution. We talk about Pitocin, hydrating with fluids, so actually making sure that you either have an IV running with hydrating fluids or you’re drinking plenty of liquids, maintaining your nutrition with food, and then also, you know, one option we didn’t really discuss but I think is in their protocol is if you might need internal monitoring to assess the strength of your contractions, that’s always an option as well. So I just wanted to kind of lay out that there are ways that have been shown by the evidence to help with the process of moving labor along. And it doesn’t just have to be AROM, although AROM is also an option.

Jennifer Anderson – 00:47:02:

Yeah. Yeah. And to me, in my mind, doula is at the top of the list. And I will give this system credit that they are working on helping doulas become available to patients, whether they’re able to pay for it or not. And there are many hospital systems around our region that are developing volunteer doula programs. Some hospital systems are now reimbursing doulas, getting them on their insurance plan, all sorts of different things look that way. But I will always say like, because of the demographic that I work with, which is rather high-risk, sometimes we do walk smack dab into an induction. I do these all the time. And honestly, the thing that is the most important is that we take a pit stop after every single step to really sit there and evaluate, is this the next step we want to do? Do we want to give?

Dr. Rebecca Dekker – 00:47:47:

You mean like a pit stop in terms of a travel stop, not a Pitocin.

Jennifer Anderson – 00:47:51:

Exactly. Not Pitocin stop. Sorry. Take a break.

Dr. Rebecca Dekker – 00:47:55:

Take a break after every step.

Jennifer Anderson – 00:47:57:

Yeah. Yeah. Take a break after every step. Really kind of evaluate, give it a little bit of time, talk about it. What do you need? Let’s put food and water ahead of starting Pitocin. I do that all the time. Like once you’re working hard, you’re not going to want to eat. So let’s plan on doing this after lunch. If we’ve agreed to do it, making sure that we can get, you know, that we’re paying attention to not only what it needs to happen right now, but I can see four hours from now we might need this. Do we need to put anything in place here to go there? Doulas have that ability to kind of think ahead and also know the clients better than the nursing staff will because we’ve been with you longer. So that part is a super important aspect of it, but the Pocket Guide is a fantastic thing to have along with you. And even this doula right here is breaking out the Pocket Guide all of the time. One last thing I wanted to mention about this policy and it could be put in elsewhere if need be, but they’ve also mentioned a failed induction protocol in this policy. And I think that’s really important that it is in place and it is cited correctly as per the failed induction protocol that is encouraged by CMQCC, which writes policies for hospitals. They’re a really great organization based out of Stanford. I know these policies well. And the failed induction policy is in there. 

What that means is we’re not going to say, oh, induction didn’t work on some arbitrary guide or measurement. They actually state that policy in there. And that has a huge impact on reducing Cesarean rates. And we’ve seen that start to happen in certain regions and across the country where we shouldn’t be giving up on inductions as early as we have been. So there are very strict protocol for if we do this, okay, this is this person that is going in for the induction. And then we did the cervical ripening and then we broke the bag of water and then we started Pitocin. There are time limits for how long the water should be broken. How long should we be on Pitocin? What is our contraction pattern? And is it adequate? The Pocket Guide spells all that out, which is probably easier to read than to listen to. But suffice to say, this hospital system does work that into play. And that is very important wherever we are. You don’t have to be within the system. Understanding what a failed induction protocol requires, meaning we got to give you a lot of time, at least 24 hours, as long as mom and baby’s condition are stable. And people who are being induced should understand that and know that just to make sure that they don’t get pushed into a Cesarean earlier with the didn’t work. Sorry, got to go back to the OR. And we go.

Dr. Rebecca Dekker – 00:50:24:

Right. Yeah. And you can learn more about that at ebbirth.com/failuretoprogress. We talk a little bit about the failed induction issue there. So Jen, thank you so much for coming on the podcast and sharing with us about this protocol, which it seems like as we’ve reviewed it, it has like pros and cons. And the important thing to remember is that you do have choices and options, even if it’s not presented to you as an option. Don’t forget that you do have choices. Do you have any final tips for maybe Doulas or help with educators or midwives or nurses who are facing these newer hospital policies, these trends towards starting the Pitocin at four by four, doing early AROM designed to kind of optimize labor induction in the name of making the inductions go faster. Any final tips for those birth workers out there?

Jennifer Anderson – 00:51:13:

Yeah. The first one I would say is if you haven’t kind of read into the Signature Article on failure to progress or the podcasts that are available on the EBB podcast on it, that is super important because inductions and failure to progress go hand in hand together. The failure to progress scenario is frequently what is going to be the reason for Cesarean. Now, while we had equal Cesarean rates in both with an induction, the failure to progress can become even.

Dr. Rebecca Dekker – 00:51:39:

And some of these studies, they showed like 30 to 40% Cesarean rates. So yeah.

Jennifer Anderson – 00:51:44:

So understanding and knowing that I would also say, take a childbirth class for our parents out there. Take a childbirth class, please not affiliated with a hospital. The hospital may offer a free class and that is fantastic. Take it, but try to get some other information elsewhere. Even if it’s just going to YouTube and watching all of the crash course on childbirth from EBB, that’s free. There’s, you can piece-meal together all sorts of things. There’s lots of free ways to get education. If not taking a childbirth class, such as the EBB one, but hearing from people out in the community that are teaching and working at your hospitals. Hospital classes are going to teach you about hospital policy and how to be a good patient. And I’m going to be willing to guess that this hospital is not going to teach their clients that they can decline breaking the bag of water at four hours. They can decline having a cervical exam when the balloon is in. So understanding and getting that information from somewhere other than the hospital. And if you’re going to do that, compare and contrast with other information out there. Probably one of my biggest points so that you get the full skinny on what the hospital might be offering. And Doulas are the ones that are in their boots on the ground. They know what these policies look like when they’re being enacted. So even if you don’t have an opportunity to work with a doula, for example, I do a support group in my hometown. It’s free. It’s open to anybody. And I say, bring in all your questions. And we talk about this induction policy in my group all the time. So finding those community birth workers who are familiar with the hospital you’re about deliver at or birth, give birth at, I think is a really important tip. And also finding classes that are outside of that hospital system. And finding somebody who might know a little bit about the hospital system and policy, like what we’re talking about here. You ask me about the hospitals I frequent, I can tell you every single thing that is in their policy. And we can talk about it and be prepared about it ahead of time. I would say.

Dr. Rebecca Dekker – 00:53:38:

Yeah. So one last question I have for you, Jen. Let’s say, you know, you’re the partner of someone who is just finished cervical ripening and they’re about to start Pitocin. And you ask, what are they starting the Pitocin at? And the nurse says, we’re starting it at four. And how could you ask for the lower dose? Like, how would you say that as a partner? Or is the birthing person if you feel like speaking at that time?

Jennifer Anderson – 00:54:03:

Yes, either one of them. So I understand that that is your policy. And thank you for sharing that with me. I would like the opportunity to start off a little bit slower. My wife, my partner would like the opportunity to start off a little bit slower. And I would say throw in some kind of white language that certainly, and I mean like white lie language that is certainly not harmful. Like we’re really afraid of Pitocin. Most of us are, so that’s probably not a white lie. But we’re really concerned about Pitocin and how fast this might ramp up. Could we start it slow first? And if it’s taking a long time, then we might be open to bigger increases later on. My experience with my client at the beginning, we were already in labor. It reacted way too quickly. I’m not saying that 4×4 Pitocin might not work pretty well with somebody who is at 38 weeks getting the induction pretty early. But why not test the waters first? Let’s see what my body does with this lower dose. You know, I don’t necessarily need to stay here. We are open to having further discussions about it. So I would say kind of like dive in with your first request, but I always kind of end it with, and then we can talk about differences later. Or I don’t want to have an exam right now-

Dr. Rebecca Dekker – 00:55:14:

And just see how it goes and reevaluate. Yeah.

Jennifer Anderson – 00:55:17:

Yeah. Demonstrate your willingness to have ongoing discussions. And, pleases and thank yous and first names and smiles and all of those things. You know, our providers really are in this for.

Dr. Rebecca Dekker – 00:55:31:

Yeah.

Jennifer Anderson – 00:55:32:

And as they got in there for that, sometimes the policy takes control.

Dr. Rebecca Dekker – 00:55:35:

And if they push back and say, I can’t do that. It’s hospital policy. I have to start at four. What would you say?

Jennifer Anderson – 00:55:40:

I appreciate you for stating that. We are going to kindly decline that. We’re either going to start at two or we don’t want to start at all. I always say the word decline. Use the word decline versus refuse because refuse gives the petulant child. I refuse. I’m digging in my heels where we say I’m going to decline starting at four. I would like to start at two. You’re stating your no, but the word decline offers up a little bit more thoughtfulness. Like I know what I’m talking about. I know what I want. I’ve thought about it and I’m going to decline that intervention right now. This is what I’m willing to do.

Dr. Rebecca Dekker – 00:56:13:

It’s like a more respectful. Thank you so much.

Jennifer Anderson – 00:56:16:

Absolutely. Yes. And it keeps the communication open and going back and forth. I’ve always seen that soften the no, the word decline, stick it in there. And I always tell my couples play around with it at home. Like, would you like some more peas, dear? Nope. I’m going to decline my peas tonight. Like joke around and say decline with every single word. I tell my kids, I’m going to decline making your lunches today. It’s funny how it just, everyone’s like, Oh, okay.

Dr. Rebecca Dekker – 00:56:41:

It sounds a little bit nicer. Yeah. I refuse. To make your lunch. Well, Jen, it’s always lovely to talk with you. Thank you so much for coming back on the podcast to share your wisdom with us.

Jennifer Anderson – 00:56:53:

Thank you so much. And best of luck to everybody navigating inductions out there. EBB’s got lots of resources. Take advantage of them.

Dr. Rebecca Dekker – 00:57:01:

Today’s podcast episode was brought to you by the online workshops for birth professionals taught by Evidence Based Birth® instructors. We have an amazing group of EBB instructors from around the world who can provide you with live, interactive, continuing education workshops that are fully online. We designed Savvy Birth Pro workshops to help birth professionals who are feeling stressed by the limitations of the healthcare system. Our instructors also teach the popular Comfort Measures for Birth Professionals and labor and Delivery Nurses workshop. If you are a nurse or birth professional who wants instruction in massage, upright birthing positions, acupressure for pain relief, and more, you will love the Comfort Measures workshop. Visit ebbirth.com/events to find a list of upcoming online workshops.