Induction: the why & the how…

Some women need to be induced for medical reasons, or choose to be induced for other reasons. No matter what your birth circumstances, the most important factor in having a positive birth is feeling informed and empowered in all your decisions. This implies that you are first given the opportunity to make the decision for yourself, rather than having your care provider make it for you.  If you know you would like to give birth in a hospital, and are planning to have or need an induction, it is important to educate yourself ahead of time so that you know what the procedure involves, and can give a TRULY informed consent. That way you will feel in charge of your birth experience, which will increase the likelihood of feeling good about your birth experience after the fact.

INDUCTION: Labor Induction is defined as a procedure used to stimulate uterine contractions during pregnancy before labor begins on its own. This means that someone is initiating the labor process rather than having the baby initiate it when ready. If you’re doctor recommends induction, it is important to weight the risks and benefits before agreeing. First of all, know that ACOG (the American Congress of Obstetricians and Gynecologists) does not support induction before 41 weeks without medical necessity.(Source ACOG) Ideally, induction will be recommended only in situations where the risks of continuing the pregnancy are greater than the risks of induction, and when your Bishop Score is favorable. If you don’t know what your bishop score is, you can calculate it with the information obtained from a cervical exam by using this calculator. It is basically a calculator that tells you how ready your body is to go into labor at that moment. A bishop score lower than 6 or lower has a low chance in ending in a successful vaginal delivery, while a bishop score of 8 or higher has a good chance. Here are some situations in which induction may be less risky than allowing the pregnancy to continue:

  • You have a medical condition that is putting you or your baby at risk, such as Preeclampsia or Gestational Diabetes. Please note that both of these conditions can be managed, but they can also have life threatening complications for both mother and baby. If you’re doctor recommends induction, ask all the questions you may have about your current condition and its effects or possible effects on your and baby. This way you feel fully informed before deciding to move forward with your induction.
  • The placenta has peeled away from the uterine wall, either completely or partially. This is called a placental abruption, and it can deprive the baby of oxygen and nutrients. In the mother, it can cause heavy bleeding and hemorrhage. In this case, the baby must be born. Depending on the severity of the abruption, either an induction or a cesarean section will be required.
  • The placenta has begun to deteriorate. This naturally occurs as the pregnancy reaches term and goes beyond. Once you have reached full term (41 wks) your OB or midwife may choose to begin Biophysical Profile and Non Stress Tests to keep track of the health of baby. These tests will give your care provider the information necessary to know if your baby is doing well in utero, and if the placenta is still in tact. Signs of placental deterioration will show up on these tests, and if they are present,  you and your care can then come up with a plan for induction or cesarean birth.
  • Your baby has IUGR, or Intrauterine Growth Restriction. This means that baby is not growing at the expected pace. This is often a sign of a placental or umbilical cord problem, which means that baby is not getting enough nutrients. If you are past 34 weeks, induction will be recommended, however if you are not that far along, baby will need to be monitored further until he/she is old enough to be delivered.
  • There is an infection in your uterus
  • Your water has broken, but you are not having contractions, also known as premature rupture of membranes or PROM. when PROM occurs, it is safe to wait 48-72 hours without an increase risk of infection to the baby or mother (Source: Evidence Based Birth)
  • You are approaching two weeks beyond your due date. Keep in mind that you are not considered full term according to current ACOG guidelines until you are 40 wks 6 days. Also, a newborn has the best chance of not suffering any complications postpartum if it is born between 39 and 41 weeks. (Source: Evidence Based Birth)

So now that we know why inductions are performed, lets talk about how they are performed. There are three steps involved in induction: 1.)ripening the cervix, 2.)rupturing the membranes, and 3.)stimulate contractions.

  1. RIPENING THE CERVIX: The cervix is naturally positioned at the back of the vagina. Throughout most of your pregancy, it is hard and closed, protecting the baby from external elements. When your baby is mature enough to be delivered, the body begins the process of ripening the cervix, which includes effacement & dilation. Effacement is measured in percentages, 0% being a cervix that is still hard and thick, and 100% a cervix that is completely softened and thinned. Dilation is measured in centimeters, and represents the opening of the cervix from 0 cm to 10 cm. Ripening the cervix can be done in many different ways:
    • Foley Cathedar is a device that
  2. RUPTURE OF MEMBRANES: This is also known as breaking your water, or an amniotomy. It is not always done during an induction, but sometimes, this can trigger contractions to begin naturally due to the increased pressure on the cervix. The procedure involves your care provider inserting an amni-hook into cervix, and create a hole in the amniotic sac, thus allowing the amniotic fluid to escape and removing the cushion otherwise provided between the baby’s head and the cervix. There are, of course, risks involved in an amniotomy, as with any procedure, and it is important to know these risks in order to make an informed decision on whether or not to consent to this procedure. According to ACOG, an amniotomy should be performed when a mother’s cervix is dilated and effaced, and the baby’s head has moved down into the pelvis (Source: ACOG)
  3. MAKING CONTRACTIONS:  At this point, your body is ready to begin responding to contractions (or as ready as it is going to be). Hopefully, you are given some time to see if the previous procedures trigger contractions. If you are not, or your body does not begin to contract naturally, then medically induced contractions are necessary. In a spontaneous birth, the body releases oxytocin, which triggers uterine contractions. In an induction, synthetic oxytocin, in the form of pitocin or syntocinon, will be used to trigger contractions. Ideally, you will be given a slow drip of pitocin to see if your body begins to react and produce oxytocin on its own. This will help keep contractions more manageable as well. This is because in natural labor, the contractions increase in intensity over a long period of time, which gives the body time to build up it’s own supply of natural endorphins to reduce the perception of pain. If the pitocin is increased slowly, the body is given a chance to respond with endorphins before the pain becomes too much to bear.

I hope this is helpful to any moms who are faced with the decision to consent to an induction or not. I’m listing some other great resources for you to look over as well. Feel free to comment with any questions. Thanks!

Other Resources:

10 Things I wish every woman knew about induction of labour by Sara Wickham 

Evidence on Inducing Labor for going past your Due Date, from Evidence Based Birth

What is the evidence for Induction or C-Section for Big Baby? by Evidence Based Birth

Induction for Advanced Maternal Age, by Sara Wickham

ACOG Labor Induction Resource Overview

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