Click here to learn the 6 STEPS TO MAKE INDUCTION SAFER AND MORE SUCCESSFUL
Before I write about the actual procedure of labor induction, it’s important to understand the risks and benefits of induction of labor, how common it is, and reasons why women need to be induced, or why they might consider saying no to induction and letting labor begin on its own. If you just want to know about the induction of labor procedure, just scroll down.
HOW MANY LABORS ARE INDUCED?
According the Listening to Mothers III survey, 41% of pregnant women had their labor induced. 44% of those women said their labor was induced because they were close to or past their due dates and their babies were full term.
Being close to or past your due date* is not listed as a medical indication for induction of labor unless your pregnancy lasts longer than 41 to 42 weeks* according to the March of Dimes. Yet, a lot of women feel pressured by their doctor or midwife to induce labor at 40-41 weeks, or even before 40 weeks. Many doctors sweep the membranes or offer to sweep the membranes as early as week 39. Sweeping the membranes is presented as having no risks. Yet, it may offer misleading information of no clinical value, increase your risk of premature rupture of membranes, and increased risk of infection.
The last few weeks of pregnancy are important for your baby. Your baby’s brain and lungs
are still developing, and your baby has more time to gain weight, which helps baby maintain their body temperature outside the womb. These last weeks and days are crucial to your baby having a healthier start to life outside the womb. Studies show your labor will go much smoother and you’ll have less complications if you wait for labor to begin on its own.
WHAT ARE MEDICAL REASONS FOR INDUCTION OF LABOR?
- You are getting close to being two weeks past your due date or 42weeks gestation. These days many doctors and hospitals will induce at 41 weeks even though there is no medical evidence backing up this policy of induction for most women at 41weeks gestation.
- Your bag of waters has broken but labor has not begun within 12-24 hours. This is called Premature Rupture of Membranes (PROM). According to Evidence Based birth If women with PROM are not induced, around 45% will go into labor within 12 hours (Shalev et al., 1995; Zlatnik, 1992). Between 77% and 95% will go into labor within 24 hours of their water breaking (Conway et al., 1984; Pintucci et al., 2014; Zlatnik, 1992).
- You have an infection in the uterus called Chorioamnionitis
- Your baby is not growing and is less than 10% of gestational age. This is also called intrauterine growth restriction.
- There is not enough amniotic fluid surrounding the baby. This is diagnosed with a non-stress test. See this post on preparing for a non-stress test.
- High blood pressure
- Placental abruption when the placenta comes away from the wall of the uterus causing hemorrhage.
- Other medical conditions like kidney disease, or obesity.
ARE YOU REALLY PAST YOUR DUE DATE?
One of the most common reasons for induction of labor is going past your due date. ACOG ( American College of Obstetrics and Gynecology) states that “Postterm pregnancy refers to a pregnancy that has reached or extended beyond 42 0/7 weeks of gestation from the last menstrual period (LMP), whereas a late-term pregnancy is defined as one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation (1)” Contemporaryobgyn.com
THE MOST ACCURATE WAY TO ESTIMATE YOUR DUE DATE
According to ACOG.org, 40 weeks or 280 days is the average length of a pregnancy. But, remember that is an average. That means there are many people whose pregnancies last a longer time than that and a shorter time than 40 weeks. Your doctor or midwife tells you a due date and you share that date with all the people you know and love. What you don’t know is that only 4% of babies are born on their due date! Yep! It’s true. You have a 96% chance that your baby will NOT be born on that magical date.
Most accurate predictor of your due date? A research study done in 2013 in the UK found that ultrasound done between 11-14 weeks gave the most accurate predictor of due dates – better than using last menstrual period and ultrasounds before and after the 11-14 weeks.
7 RISKS OF INDUCTION
- Premature Birth
What if your due date is not accurately calculated?
Using the last menstrual period LMP is less accurate when your period is not exactly 28 days apart each month. Your baby may not be as far along as the doctor estimates. Your baby’s brain is growing at its most rapid rate in the last 4 weeks of your pregnancy. Your baby’s brain at 35 weeks weighs on 2/3 of what it will weigh at 39-40 weeks. According to the March of Dimes,
- “In the last 6 weeks, your baby’s brain adds connections needed for balance, coordination, learning, and social functioning.
- During this time your baby’s brain doubles in size
- Babies born early have more learning and behavior problems in childhood than babies born at 40 weeks
- Admission of babies to the neonatal intensive care unit – drugs used to induce labor can cause babies to be born prematurely, or have adverse side effects from the drugs used in labor. Babies born early have more feeding problems and breathing problems than full-term babies”
- Cesarean surgery. 25% of inductions in first time mothers will fail. This means that your induction will end in a Cesarean section, which is major abdominal surgery.
- Fetal heart rate troubles. Some medications like Pitocin, or Cytotec (Misoprostol) can cause tetanic (sustained muscle contractions) contractions. These contractions are harder, last longer, and can be more frequent. They can lower the baby’s oxygen supply and lower baby’s heart rate causing the need for a cesarean.
- Hemorrhage after birth. The medications used in the induction can increase the risk that your uterine muscles won’t effectively contract. This leads to excessive bleeding post-birth. This is a real risk for the mother.
- Longer hospital stays. Your labor may be longer than a labor that begins naturally. If your induction fails you will have a cesarean and will stay in the hospital longer post-surgery to recover.
- Increased need for pain medication. Contractions induced with synthetic hormones tend to be more painful and stronger. A vacuum- or forceps-assisted vaginal birth – babies need to be pulled out because mothers’ ability to push is inhibited by pain medications
- Increased risks of infection if your care provider ruptures your amniotic sac.
- Why are you recommending induction of labor?
- What are the risks to my baby and me if I wait for labor to begin naturally?
- Do research studies confirm that inducing labor in this situation is safe and will reduce my risk of an unhealthy outcome? Can you give me the resources to look at these research studies?
- Can we try more natural methods of induction before using drugs? See my article on natural induction techniques.
- Is induction likely to be successful for me?
- Is my cervix ripe? (Your provider can tell you if your cervix is ripe. Women who are induced before their cervix is ripe are much more likely to have cesareans, even if cervical ripening drugs are used.)
According to Lamaze.org you should talk it over with your doctor. In many cases, you can even ask, “Can we have time to think about it?” That time may be a few minutes to a few days. Don’t forget to consider asking that important question.
The Labor Induction Procedure
You will check in to the hospital in the early morning or in the early evening. That may depend on the doctor’s or the hospital’s schedule. Or your doctor may give you a cervical check in the office at your prenatal appointment. During the cervical check, the doctor may sweep or strip your membranes. This procedure does not require you to be in the hospital.
- Sweeping or Stripping the Membranes – your doctor will separate the amniotic sac from the inside of the uterus. They may massage the cervix too. It may be uncomfortable or painful. This change in the cervix will set in motion the stimulation of prostaglandins. Prostaglandins help to ripen and soften the cervix to help start labor. Studies showed sweeping the membranes can increase your chances of going into labor within 48 hours. The risks are possible breaking the amniotic sac raising the risk of infection, discomfort or pain, contractions that don’t lead to labor, and, if your due date is wrong, an early or preterm birth.
Since there are increased risks of needing a Cesarean birth, most doctors and hospitals will require that you not eat and drink during the labor – even though research studies do not support this rule. Hospitals and doctors haven’t caught up to the most recent research and changed their protocols. Inductions can take 24 hours or much longer, depending on how ripe your cervix is, so talk to your doctor about eating and drinking in labor. Ask questions!
Once you’ve been admitted and you are in your labor and delivery room, one or more of the following procedures may be done. You will be hooked up to monitors to record baby’s heart rate and your contractions, pulse, blood pressure, etc:
- Foley bulb – is the least invasive because it doesn’t use any synthetic hormones or medications. It is a catheter device that is put into the cervical opening and filled with saline solution to inflate the catheter like a balloon. It adds pressure to the cervix and causes natural labor contractions and encourages dilation. It will fall out on its own once your cervix has dilated to 3cm. If you’re lucky, the contractions will continue, on their own. If not, you will need medications to cause labor to progress.
- Cervidil – is a synthetic hormone that is similar to prostaglandin and is placed in the vagina next to the cervix. Prostaglandin is both produced in your own body to help soften and ripen the cervix. Also, sperm contains prostaglandin. That’s why many birth professionals encourage you to have sex to help the cervix prepare for labor. The Cervidil is designed to soften your cervix and help it ripen. A ripe cervix will more easily thin out (efface) and dilate (open) and allow labor to progress. Cervidil comes in the form of a vaginal insert that can help start labor and can be removed if necessary.
- Pitocin – is a synthetic form of oxytocin given intravenously (through an IV drip), the hormone also known as the “love hormone”. Although there are big differences in the two. Oxytocin is made in the pituitary gland. Pitocin is given via an IV. The amount will usually begin at the smallest possible dose, but will gradually be increased by your nurse until your contractions are 2-3 minutes apart. It can also be tapered off or stopped completely if your contractions become too strong and too close together. You will only be given Pitocin to start your labor if your cervix is ripe – meaning soft, thinning out, and beginning to open. If your cervix is still not ripe, the Cervidil or Foley bulb are more likely to be used to start your labor. Then Pitocin will be introduced once the cervix is “favorable”. The risks associated with Pitocin are contractions that are too strong, long, and close together, fetal heart rate dropping indicating fetal distress, rupture of the uterus, fetal death, and you may not eat or drink during the long process of labor because you are at a higher risks of needing a cesarean.
- Cytotec or misoprostol – is considered safe and effective for induction of labor. It has NOT yet been approved by the FDA for induction. It is a medication approved for the treatment of ulcers. According to Medscape.com, “In August 2000, the manufacturer of misoprostol warned against its use in pregnancy because of its abortifacient properties and cited reports of maternal and fetal deaths when misoprostol was used to induce labor, fueling the misoprostol controversy.” Its’ effects are similar to prostaglandins, and it has been shown to be effective at starting labor. Some doctors insert it vaginally and others prescribe it orally. The benefit is that it is very effective in starting labor. There are many risks associated with using Cytotec/misoprostol. The complete list of risks is here. Some are uterine hyperstimulation, uterine rupture, retained placenta, potential maternal or fetal death.
Decades of research has shown that letting labor begin on its own is the safest route to a healthy birth, baby, and mama. Giving a woman’s body the chance to produce the necessary cocktail of hormones for labor, birth, and breastfeeding is always easier on the mother and easier on the baby. Inducing labor gives women a higher chance of a Cesarean birth, more pain in labor, and health problems with the baby. Make sure the reasons given for your induction of labor are not reasons of convenience but are based on medical evidence that show that your baby is better outside of the womb than inside.
Have a safe and healthy birth!
There is no substitute for the relationship between a medical professional and his or her patient. See your treating physician, osteopath, nurse practitioner, midwife or other qualified healthcare provider regarding any questions you have about your personal health and any medical condition you may have, including pregnancy. This information does not substitute for a care provider-patient relationship and should not be relied on as personal medical advice. The views and opinions expressed in these articles are those of the author(s) and do not necessarily reflect the official policy or position of my employer. No information found on my website or blog should be relied or acted upon by you without first consulting your own treating healthcare provider.