Understanding Induction of Labor: A Comprehensive Guide
Induction of labor is a procedure involving the use of medications or various mechanical methods to initiate labor artificially. It's essential to be well-informed about this process, as it can be a common aspect of childbirth. The rate of induction of labor in the U.S. has risen steadily from 9.6% in 1990 to 27.1% of all births and 37.8% of first-time births in 2018. And the cesarean rate continues to increase in many regions across the nation. Acquainting yourself with the induction process in advance can provide valuable insights for your birth plan, making the entire experience smoother when the moment finally arrives.And possibly avoiding unnecessary unwanted outcomes.
There are different types of labor inductions, medically indicated or elective. Medically indicated inductions are recommended when there are compelling medical reasons to initiate labor, such as maternal or fetal health concerns, gestational complications, or specific medical conditions that necessitate intervention.
Medically Indicated Induction of Labor:
Medically indicated induction of labor is a carefully considered and recommended procedure performed for specific medical reasons, aiming to protect the health and well-being of either the expectant mother, the baby, or both. This type of induction is typically initiated when there are compelling medical concerns that outweigh the benefits of continuing the pregnancy to its natural conclusion. Here are some common scenarios and medical reasons that may necessitate a medically indicated induction of labor:
1. Post-Term Pregnancy: If a pregnancy continues beyond 42 weeks, the risk of complications may increase. In such cases, healthcare providers may recommend induction to reduce risk.
2. Maternal Health Conditions: Medical conditions that pose risk to health, such as preeclampsia, gestational diabetes, chronic hypertension, or certain heart, liver or kidney conditions, induction may be recommended to manage or mitigate these conditions.
3. Fetal Complications: If there are concerns about the baby's well-being, such as intrauterine growth restriction (IUGR), or abnormal fetal heart rate patterns, induction may be necessary to ensure timely medical attention and intervention.
4. Ruptured Membranes: When the amniotic sac has ruptured (water breaking) without contractions starting within 24 hours, there can be an increased risk of infection – especially in those who have tested GBS positive. In such cases, induction may be recommended to initiate labor and prevent infection. In this case, it is important to limit cervical exams as this is one of the leading risk factors of infection.
5. Infection or Chorioamnionitis: If one develops an infection in the amniotic fluid or uterus (chorioamnionitis), induction may be required to expedite delivery and reduce the risk of complications for the dyad.
Medically indicated inductions are typically guided by careful assessment of the specific medical condition, the gestational age of the pregnancy, and the overall health of the dyad. The timing and method of induction will vary depending on the circumstances and the urgency of the situation. Healthcare providers should thoroughly discuss the reasons for the induction, the potential risks and benefits, and the best approach to ensure a safe and successful delivery.
Is low amniotic fluid by itself a reason to induce? What about big baby? Or Gestational Diabetes? How about going past due dates? If you are the kind of person that likes to understand the reasoning behind why things are being recommended to you, it is important to do some digging.
Elective Induction of Labor:
Elective induction of labor refers to the deliberate initiation of labor for non-therapeutic reasons, meaning there are no pressing medical concerns that necessitate immediate delivery. Instead, an elective induction is typically chosen based on the preferences of the expectant parents and/or healthcare provider for reasons unrelated to medical necessity.
Here are some common reasons why individuals might opt for elective induction of labor:
1. Convenience: Some expectant parents may prefer to schedule the birth around a specific date, such as the availability of family members or the obstetrician, or to avoid potential complications like delivering during holidays.
2. Personal Comfort: Those who have experienced a challenging pregnancy, have discomfort, or are anxious about going past their due date may choose elective induction to alleviate physical or emotional discomfort.
3. Timing: In some cases, healthcare providers and expectant parents may agree to elective induction if the pregnancy has reached full term (usually defined as 39 weeks or later) and there is a desire to avoid a potential late-term pregnancy or complications associated with post-term pregnancy.
4. Previous Birth Experience: If one has had a previous rapid labor and is concerned about not making it to the hospital in time, they may opt for elective induction to ensure a controlled and timely birth.
5. Unknown: Some parents may find themselves on the induction schedule without really understanding why they are being recommended to be induced. Sometimes the induction is scheduled when it is, because the hospital calendar is open and the space needs to be filled.
It's important to note that elective induction should be a carefully considered decision made in consultation with a healthcare provider. Inducing labor when there is no medical necessity carries some potential risks and may lead to longer labor, increased likelihood of interventions, and cesarean, and potential complications for the dyad. Additionally, it should be noted that induction can significantly alter your planned labor strategy around comfort measures, coping, and relaxation techniques as well as some of the interventions you were hoping to avoid.
Healthcare providers will generally assess overall health, the baby's well-being, and the readiness of the cervix before agreeing to an elective induction. They will also consider the gestational age, as elective inductions are typically recommended after the pregnancy has reached full term to minimize potential risks to the baby. That being said, it is rare for a provider to turn down a requested induction once on reaches 39 weeks.
Ultimately, the decision to undergo elective induction should be made after a thorough discussion between the expectant parents and their healthcare provider, taking into account both medical and personal factors, and weighing the potential benefits and risks associated with bypassing the hormonal physiology of labor, and inducing labor before the body was primed for spontaneous onset.
Stage 1: Cervical Ripening
Before labor can commence, your cervix must undergo a crucial preparational transformation known as cervical “ripening." Typically, the cervix naturally softens, thins out, and begins to open in preparation for childbirth. However, in certain situations, it may require a gentle nudge to get the process started. For first-timers, the cervical ripening phase is usually the longest phase where the cervix is being prepared for the introduction of Pitocin to stimulate uterine contractions.
During this initial stage, your provider will recommend specific methods or medications to initiate cervical ripening before moving forward to the next phase. The choice of approach is ultimately yours, and it's essential to discuss these options thoroughly with your healthcare provider. The methods available for cervical ripening include:
1. Dinoprostone Vaginal Insert:
An FDA-approved medicated removable vaginal insert, resembling a tampon, placed by your OB or midwife.
2. Dinoprostone Cervical Gel:
Another form of the FDA-approved medication dinoprostone, administered through a syringe in and around the cervix.
3. Pill (Cytotec®/misoprostol):
A medication given orally or vaginally. This option is most commonly used due to its low cost – however it is not FDA-approved for cervical ripening, and is used “off-label” for labor induction as well as in the immediate postpartum period in the case of excessive bleeding.
4. Balloon Catheter:
A device equipped with a small inflatable balloon on one end. The catheter is placed in the cervical opening, filled with saline, and remains inside the cervical opening. The pressure (and the additional release of prostaglandins) causes the cervix to dilate further, until it eventually falls out once dilation of 3-4 cm is achieved.
5. Stripping the Membranes:
A procedure performed by your OB or midwife, involving the separation of the membrane connecting the amniotic sac to the uterine wall. This triggers the release of prostaglandins, which can lead to contractions.
It's crucial to remember that all medications must undergo rigorous testing and meet FDA regulations before they can be marketed. FDA approval signifies that the benefits of the product outweigh the associated risks for its intended use.
Stage 2: Stimulating Contractions
Once your cervix has sufficiently softened and thinned, the second stage of induction involves stimulating your body to initiate contractions, if they haven't started as a result of the ripening process. Depending on your specific circumstances, various methods can be employed:
1. IV Drip (Pitocin®/oxytocin):
This involves administering medication, such as an artificial form of the body’s hormone Oxytocin, through an IV to encourage contractions. The dosage starts small and is gradually increased until contractions become strong and frequent enough for delivery.
2. Amniotomy:
This procedure employs a small hook to rupture the amniotic sac, commonly referred to as "breaking your water," to initiate contractions. This isn't usually recommended until other methods of labor induction have been considered or tried, typically when the cervix is sufficiently effaced and dilated, often around 4-5 centimeters.
3. Nipple Stimulation:
Nipple stimulation is a natural method used to induce uterine contractions. By gently massaging or rolling the nipples, it can trigger the release of oxytocin, a hormone that plays a key role in labor. This method is generally considered safe, but it should only be attempted under the guidance of a healthcare provider to prevent overstimulation of the uterus.
4. Walking:
Walking is a straightforward non-invasive approach to encourage uterine contractions. The act of walking can help the baby move deeper into the pelvis, putting pressure on the cervix and promoting contractions. It's a gentle method that many find beneficial in the early stages of labor to progress and alleviate discomfort.
5. Orgasm:
Orgasm-induced contractions can be a natural way to stimulate labor. Sexual activity, including orgasm, releases oxytocin, which can trigger uterine contractions. While some have reported success with this method, it may not be suitable for everyone, especially if there are medical complications or concerns. It's crucial to discuss this option with a healthcare provider to ensure it's safe and appropriate for your situation.
6. Acupressure:
Certain points on the body can be massaged, in an attempt to stimulate uterine contractions. This method can be tried in conjunction with walking, and nipple stimulation to get labor going in a more gentle way before trying pharmacological options.
We understand that this is a lot of information to absorb, but being well-informed empowers you to make the best decisions alongside your OB or midwife when the time comes to bring your child into the world. Childbirth can be an overwhelming process if going into it unprepared, so gathering information about induction and labor while creating your birth plan is crucial. Here are some questions you may want to discuss with your healthcare provider:
- Is induction medically necessary in my case?
- How will induction contribute to a safer delivery for me and my baby?
- What are the risks associated with induction for me? For my baby?
- What are the induction methods you recommend in my particular case, and why?
- How does induction impact my birth preferences/plan?
- What is the plan if adverse reactions occur with the medications given?
- What happens if the medications or methods do not result in a normally progressing labor?
- What additional options are available to support the best possible outcome for my childbirth experience?
- How will induction impact my labor preferences and goals?
Read more about labor induction in academic article titled, “Maternal perceptions of the experience of attempted labor induction and medically elective inductions.”
Evidence Based Birth has a Digital Pocket Guide for Induction that might interest you!
