What is an Induction of Labor?
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An induction of labor is the starting of the labor process before the body is doing so on its own. You may have a reason that your Obstetric Provider is recommending your labor to be induced. You may also be offered the option of an elective induction of labor.
Reasons induction of labor may be recommended by your Obstetric Provider:
You are getting close to 42 weeks pregnancy (the recommended cutoff for delivery due to increased stillbirth rate after 41 weeks of pregnancy)
Your water broke and you are not in labor
Your amniotic fluid level is low
High blood pressure orr preeclampsia
Your baby is growing small (growth restriction)
Your baby’s heart tracing or ultrasound monitoring are concerning enough to recommend delivery but not concerning enough that an urgent c section is indicated Your placenta is starting to separate from the wall of the uterus (called an abruption) but it is safe for you to try for a vaginal birth
Countless other maternal or fetal indications
Elective induction of labor:
A recent large multi-institutional study called the ARRIVE trial that was published in the New England Journal of Medicine demonstrated that of women who had a low bishop score (unfavorable or unripe cervix) who were randomized to either elective induction of labor at 39 weeks versus expectant management, c section rates were significantly lower in the induction group. There were also significantly lower rates of gestational hypertension, preeclampsia, and need for neonatal respiratory support and NICU stays in the induction group. Due to these findings the American College of OB/GYN (ACOG) now states it is reasonable for obstetricians and health-care facilities to offer elective induction of labor to low-risk nulliparous women at 39 weeks gestation. This study has caused a big shift in that institutions and providers who have the resources to allow for elective inductions of labor at 39 weeks are now offering this as a routine option for any patient who desires induction prior to late term.
Preparing for your Induction of Labor:
I have had many shifts on labor and delivery when a patient is admitted for induction of labor and is not prepared for the process or the amount of time to expect from the start of an induction of labor until the birth. They often arrive with their partner and multiple friends/family members anticipating we will start the process and within a few hours they will be having the baby. Unless you have had a few babies and your cervix is already very ripened (high bishop score) when you arrive, this is extremely unlikely to be the case.
Inductions of labor can take a long time. For your first baby once the induction process starts it is reasonable to anticipate approximately 24 hours until you deliver. Consider yourself lucky if the process moves along quicker than this, and do not consider it a failure if it takes longer. A failed induction means that you have been induced for 24 hours and are not yet in active labor or have been on pitocin and had your water broken for 12-18 hours and are not yet in active labor. Active labor starts at 6 cm of dilation. This means that some women are 6 cm at the 24 hour mark and from this point average dilation in the active stage is 1-2cm/hr followed by on average 2 hours of pushing for a first baby. None of these time frames are the outer limits- if you have a bigger baby, smaller pelvis, you are obese, or the baby is not in the best position to come down, active labor and pushing may take even longer. I am saying all of this to let you know that you should come prepared. Eat a good meal and take a nice shower before you come as depending on your hospital protocol you may not be allowed to eat regular food again until you deliver. Bring plenty of entertainment: books, music, shows or movies you have been too busy to watch, whatever will help you happily pass the time. You are in it for the long haul so please do not be frustrated or disappointed when things do not happen quickly.
Induction of labor methods
How you are induced will depend on your cervical exam. The softer, thinner, and more open your cervix is, as well as its position in the vagina and the position of your baby, all add up to a score called the bishop score. The higher the initial score the more ripe or favorable your cervix is and typically the easier it will be to get labor started.
Bishop Score, reproduced from the NCBI
If your cervix is not ripe, induction is typically started with prostaglandins such as cervidil or cytotec, both of which may be placed vaginally. Sometimes cytotec is placed in your cheek and then swallowed. Prostaglandins mimic the natural inflammatory factors that are released when your body goes into labor and help ripen the cervix to get labor started. This may be done alone or in combination with a cervical ripening balloon.
A cervical ripening balloon looks like the foley catheter that is placed in the bladder only it has two balloons. The catheter is threaded through your cervix and into the lower portion of the uterus and then the two balloons are filled, one above the cervix and one below, to put pressure on either side of the cervix which mechanically compresses and stretches open your cervix. If it sounds uncomfortable that’s because it is. This causes a lot of cramping and pressure. Many people request pain management either before or during the procedure. Typically the balloon is checked every few hours and when it comes out that means that your cervix has dilated to approximately 5cm. It does not, however, mean you will continue to progress rapidly into active labor. Often when the balloon falls out you are still not having strong regular contractions, your cervix has not thinned out, and the baby has not come down. This means your cervix has been stretched open but your body has not caught up yet with the physiologic progression to active labor. The time from a 5cm cervical ripening balloon cervix to a 6cm active labor cervix may be a long time.
Pitocin, the IV medication that mimics your natural oxytocin, is another medication that may be recommended after the prostaglandins once your cervix has started to dilate or even initially in conjunction with a cervical ripening balloon. Pitocin has been given a bad name over the years as it makes the contractions very strong and if used too aggressively (contractions become too frequent or too strong) can cause distress to the baby or even a rupture of the uterus. However, hospitals have protocols for how to safely start and increase or decrease/ stop the pitocin based on the baby’s heart rate and the contraction pattern. If used safely pitocin is a great medication that can help you progress in labor when natural contractions are not strong or frequent enough.
During the induction process your provider may also recommend breaking your water, a process called artificial rupture of membranes. It may be recommended at any point in the labor course and there is also a lot of variation in practice between providers and hospitals. I always tell my patients that unless labor has really stalled we do not have to break the water. I never recommend breaking the water until the head is well applied to the cervix- if the baby’s head is too high then there is a risk of what is called cord prolapse: the baby’s umbilical cord can slip down below the head with the gush fluid when the water is broken. This is cause for an emergency cesarean section as once the cord is past the head as the head comes down it will press on the umbilical cord and the baby can not get oxygen. The benefits to breaking the water is that it can decrease the time to delivery and also help labor progress if it has stalled. The risks, besides cord prolapse, are that contractions become much stronger, once the cushion of fluid is gone there is more risk of cord compression with contractions, and an increased risk for infection (especially if you have multiple cervical exams after the water is broken).
Another method of induction that may be done even in the doctor’s office is called membrane stripping, or sweeping the membranes. This separates the amniotic membranes from the cervix which causes prostaglandins to be released. When your body is ready to go into labor it may initiate the process. If your body is not ready then you may just have cramping, contractions, and spotting that stop and do not progress to labor. If your cervix is not dilated already this can not be done as your provider must be able to get a finger inside of the cervix to separate the cervix from the bag of water.
Nipple stimulation may also be recommended as a more natural means of induction as this releases oxytocin, the hormone of which pitocin is the synthetic version, which can start contractions. This may be done manually or with a breast pump.
When you are being induced, there are a few other things you should expect:
You will need an IV and will often be on IV fluids
You will need to stay on the fetal monitor as your providers must be able to see the baby’s heartbeat and your contraction pattern when you are being induced.
Your mobility will be decreased from doing early labor at home or even in the hospital when you have spontaneous labor and an uncomplicated pregnancy when you may be able to have intermittent monitoring and have more freedom.
There are different pain management options depending on where you give birth. The most common pain management, especially when you are in active labor, is an epidural. There are many rumors about epidurals, such as that they slow down your labor or will wear off so you should wait to get it. Your labor may progress slower not directly due to the epidural but indirectly as when you can not feel the pain and move freely you will be less able to innately move and shift your body with labor to rotate the baby into the best position to come down. This means that you may need help from the nurses and other support people to change positions or use birth props if your active stage of labor is moving slowly or your provider says the baby is not in the best position to come down through the birth canal. Sometimes when you are fully dilated with an epidural you can not feel anything which can make it hard to push so you have to wait for the baby to come down more or decrease/ stop the epidural to have enough sensation to push effectively. Some women actually progress more quickly once they get an epidural because they were so tense from pain prior their bodies needed to be relaxed to allow the cervix to dilate and the baby to come down. You do not have to worry about the epidural running out as additional medication can be added if you begin to feel the pain again so there is no need to delay getting the epidural if your concern is that it will wear of before you give birth. Like any procedure there are risks with an epidural and the anesthesiologist should always discuss all risks (most extremely rare, some such as spinal headaches a little more common) and answer any questions before doing the procedure.
Many hospitals also have narcotic sedation available in early labor. This involves a dose of medication through the IV and sometimes in your muscle as well to help with pain relief. Narcotics are only offered in early labor as it can make the baby come out sedated if given too close to delivery. Some facilities also offer inhaled gas such as nitrous. This is not as common in the United States as in other countries but there is momentum growing to start making it more widely available in the United States.
Patient Centered Care
When you are scheduled for an induction, always talk to your care team before beginning the process and make sure you are a part of the discussion every step of the way. Often there are many options for next steps and you can discuss the thought process behind your provider’s recommendations and let them know if you are comfortable with their plan. Sometimes recommendations are made for safety reasons, sometimes to expedite the labor process, and sometimes based on provider preference or what they have found works best throughout their time in practice. However, patient centered care remains important and if you do not feel comfortable asking questions and voicing your concerns and preferences please make sure there is someone in the room with you- whether a partner, friend, family member, or doula, who can be your advocate. Nurses and other support staff in the hospital are also good team members to help you along the process and if you ever feel uncomfortable make someone aware as it is always important that you understand what is going on and why your provider is recommending certain plans of management.
Often women come with very specific birth plans and this can be difficult to reconcile during an induction process and inductions are innately more active management and tend to involve more medications. It can be hard to reconcile when you have planned for a certain labor and birth experience and situations that lead to the recommendation for induction may make it difficult or impossible to have your birth experience measure up to what you expected. Please try to think of birth plans more as birth preferences or wishes and know that some interventions are recommended for your safety or that of your baby.
I often tell patients when recommending an induction that this is our first lesson in parenting- we can plan and prepare and envision a certain experience- when and how we will give birth and exactly how the process will unfold- however our baby teaches us that life involves surprises and changes of plans. You may have to call your boss and tell them you will not be back to transition projects to a coworker, or call your mother who is across the country and tell her she needs to fly in sooner, or call the neighbor to let the dog out or pick up your toddler. I know when I recommend induction it often leads to stress and anxiety due to the loss of control. The unpredictable nature of pregnancy and giving birth can be scary and lead us to want to control every possible aspect, however sometimes we have to lean into the discomfort and uncertainty and trust in our bodies and our care team. I am never trying to take away your autonomy or force medical interventions when I recommend an induction. Please remember I am doing it because I really truly care about you and your baby and want to make sure both of you have the best possible outcomes.