Induction: Getting Labor Started
What is it? Using
interventions to start labor, rather than waiting for labor to start on its
own. Most methods either aim to ripen the cervix with prostaglandins (natural or
artificial) or aim to start uterine contractions with oxytocin (or pitocin, an
Why would labor be induced? There are
several possible reasons. Those nearer the top of this list are cases where the
benefits of induction likely outweigh the risks. Those nearer the bottom of
this list are more controversial, and the risks are more likely to outweigh the
the baby or mother has a severe health condition which makes it riskier to
continue the pregnancy than to induce; severe pre-eclampsia,
diabetes with complications, a baby who is not growing well, etc. (For an
example of specific medical criteria, click here.)
It’s estimated that this rationale for induction only applies to 3% of
breaking. If mom is more than 35 weeks pregnant, and it’s been more than
24-48 hours since membranes ruptured, most caregivers recommend induction
to reduce risk of infection.
baby that’s “overdue” – pregnancy lasting over 42 weeks.
baby or mother has a milder health condition that might mean the benefits
of induction are worth examining.
pregnancy lasting over 41 weeks.
baby is “too large.” Although this is a common reason for physicians to
recommend induction, research seems to indicate that there are not
significant benefits to inducing labor.
or preference. Of the mother, or the caregiver. The risks typically
outweigh the benefits.
How common is it? Numbers
range radically from hospital to hospital. In Seattle in 2001, amongst the hospitals that
would disclose the data, rates ranged from 15-30% of women. (The hospitals that
wouldn’t disclose were informally estimated at being as high as 50%.) In the Listening
Mothers nationwide survey (2002), 44% of women reported that their
caregiver tried to induce labor. 18% cited a non-medical reason as the only
reason to induce labor. 16% reported that a combination of medical and
non-medical reasons led to the choice to induce.
Will induction start a labor? Your
readiness for labor is influenced by many factors, including fetal maturity and
cervical readiness. Trying to induce labor can be frustrating and emotionally
exhausting if it fails.
Induction is more likely to
succeed if your body had already begun to prepare for labor. Ask your caregiver
about using a Bishop score to help determine how “ready” your body is for
labor. This assessment of your cervix looks at: dilation, effacement, cervical
position, cervical consistency, and baby’s position. If these signs are
positive (Bishop score >6), you’re “favorable for induction”. If not, it may
be possible to wait a few days before inducing, or your caregiver may recommend
using cervical ripening agents first before using Pitocin.
What are the risks of induction? Induced
contractions may be more powerful, and have a longer duration than non-induced
labor, so they may lead to a more painful labor. This increases the chance that
pain medication will be used, with the possibility of risks related to the pain
medication. The longer, stronger contractions can interrupt blood flow and
oxygen to the fetus, and lead to drops in baby’s heart rate, so continuous
monitoring is needed.
The induction consent form for a Seattle hospital states
that risks may include “a longer labor time, a higher chance of forceps and/or
vacuum use during delivery, a higher chance of a cesarean section delivery,
more bleeding or infection, a longer hospital stay and longer length of
recovery.” For first time labors, inductions increase the risk of cesarean by
two to three times.
What can you do about it? If your
caregiver has recommended induction, you could consider asking whether it would
be appropriate for you to try some natural methods of induction before moving
on to medication. These include:
If your water has not broken, you could try intercourse: semen contains a
small amount of prostaglandin, and orgasm causes oxytocin to flow. If your
water has broken, oral or manual stimulation of the clitoris also can lead
to orgasm, and thus to contractions.
stimulation releases oxytocin: stroking nipples, using a breast pump, or
oral stimulation. Discontinue if contractions come more than every four
minutes, or last longer than one minute.
on spleen 6 point: lower leg, 4 finger-breadths above inner ankle bone.
Apply pressure in on-off cycles of 10-60 seconds each for up to 6 cycles.
or castor oil. Bowel contractions may stimulate uterine contractions. This
isn’t pleasant, so usually only used to avoid medical induction methods.
preparations and homeopathic remedies. Contact a trained practitioner for
How your caregiver can help with
preparing your cervix for labor.
the membranes, also called stripping the membranes. Caregiver inserts a
finger into the cervix, and separates membranes from lower uterus.
Increases prostaglandin production.
Uncomfortable, can cause increased risk of infection. May accidentally
lead to AROM.
Artificial Rupture of Membranes / Breaking the Bag of Water. During a
vaginal exam, the caregiver inserts amniotomy hook through the cervix, and
makes a hole in membranes, releasing amniotic fluid.
Increases prostaglandin production. When used with Pitocin, reduces
length of labor compared to Pitocin alone. Painless.
Increased risk of infection. Sets time limit on labor. May intensify
contractions. May be harder for baby to change position. Most appropriate
and most effective is used in late labor.
Either a gel (Prepidil) is placed within or around the cervix with a
syringe, or a tampon-like insert (Cervidil) is placed inside the vagina
with a time-release medication.
May help the cervix dilate more quickly, which may trigger onset of
labor. Improves success of Pitocin induction. The Cervidil insert can be
removed if contractions become too strong or frequent.
Can over-stimulate uterus and cause fetal distress. Possible nausea,
vomiting, or diarrhea. Gel is difficult to remove.
/ misoprostol. A tablet is placed in the vagina behind the cervix, or
More likely to start labor than prostaglandins. Low cost.
May cause excessive, frequent contractions. Not approved by FDA for labor
induction; few scientific trials have been done to establish effective
dosage, effectiveness, and safety for mother and baby. Risk of uterine
rupture, especially in VBAC moms.
How your caregiver can stimulate
oxytocin. (Pitocin) Given by I.V.
Causes uterine contractions and dilation of cervix. (Most effective if
cervix is ripened before pitocin begins.) Can be adjusted to adjust the
strength and frequency of contractions.
Uterus may become over-stimulated, leading to long, strong, painful
contractions. These, in turn, may lead to fetal distress. Requires
constant fetal monitoring.
Summary of induction risks. All of
the forms of induction can lead to stronger, more painful, and more frequent
contractions, which may lead the mother to use pain medications she might
otherwise not require. These powerful contractions may also limit oxygen supply
to the baby, so increase the risk of fetal distress. Also, due to the
uncertainty of due dates, and the variation in the amount of time any given
baby requires to reach maturity, early induction carries a risk of causing
premature birth. There is a significant increase in the chance of cesarean.
This increased cesarean rate does
not seem to lead to better outcomes for babies: a study titled “First Births –
A continuous Quality Improvement Project” showed that by reducing inductions in
first-time mothers by 22%, there was a corresponding decrease in cesarean birth
by 21% with no change in newborn outcomes.
It’s important to clearly discuss
these issues with your caregiver. If the induction is being done for
convenience, or for unclear medical issues, then the benefits of induction may
not outweigh the risks.
Questions to Ask Your Caregiver if
Induction is Recommended:
1. Why? What are the reasons why
it would be better to deliver the baby sooner?
2. When? Is this something
that needs to happen today? What would happen if we waited a few more days?
3. How? Could we start with
one of the non-medical options and see if that works?
Compiled by Janelle Durham. For
sources, see “Common
Variations in Labor”.
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