The MamasteFit Podcast Episode 111 – Is “Induction” a Bad Word?!

Gina: Welcome to the MamasteFit Podcast. In this episode, we’re going to be talking all about labor induction. Is it bad? Should you never be induced? We’re going to discuss all of the nuances of whether or not you should be electively or medically induced or should you always wait for spontaneous labor.

Welcome to the MamasteFit Podcast. We’re talking all about labor induction today because every time we post anything about labor induction interventions, there’s usually a few comments on it that is, “You should NEVER be induced.” “You should ALWAYS wait for spontaneous labor.” “If you have a medical complication, you should just wait for it to become an emergency.” “If it’s an emergency, then if you’re not getting induced, you’re having a C-section.” And so we’re going to kind of talk about the nuances of why you may or may not want to be medically induced, or why you may or may not want to be electively induced. What is the difference between those two? And so we’re going to have, I think, a really good conversation today on this episode. I hope we have, hopefully, good conversations every episode.

But we’re going to talk all about the nuances of labor induction because similar to everything else in labor, there is no one way to do everything. There’s no one best labor position. There’s no one best way to push. There’s no one best way to do anything, and it’s all about our individual preferences and values and what type of experience we’re looking for. So if you’re looking for a very low intervention, unmedicated birth, and you are really healthy with no medical complications, probably waiting for spontaneous labor could be a great idea. If you are wanting a low intervention unmedicated birth, but you have severe preeclampsia, we may need to consider a labor induction. So we’re going to kind of talk about the nuances and help you understand that there is no one right way to do anything when it comes to birth.

So first, Roxanne, what is a labor induction in case any of our listeners are not aware of what it is.

Roxanne: So, a labor induction is using either pharmacological, so medicine, or non-pharmacological methods to star to labor. So we’re inducing, or starting, labor. The goal of an induction is to stimulate the labor progress, and that’s important to know what the goal of an induction is because, having a baby is the goal of an induction, but it’s not to give you every single intervention until the baby is out of your body. It’s to give you every intervention until your body is in labor, and like actively having contractions with cervical dilation and your baby moving down through your pelvis.

Gina: And now there are a few different steps that we can take within a labor induction. But it’s important to note that, so I’ve supported like dozens of labor inductions- Roxanne, you’ve probably supported hundreds at this point- and every one of them has been very unique. There’s no one way that labor induction happens. Not everybody goes in and gets some sort of cervical ripening, and then they go to mechanical dilation, and then their water’s broken, and then they have Pitocin, and then the Pitocin goes to here, and then after four days they have their baby.

It can really vary from person to person. I’ve had folks where they, their water gets broken and their baby just falls out of them, and we’re like, “Okay, cool.” I’ve had folks that were in labor for four days. And so it can- and they’ve gotten every intervention- and so it can really vary from person to person, how a labor induction will even go. And even between pregnancies with the same person it can also vary- sometimes it’s the same, sometimes it can be very different from pregnancy to pregnancy as well.

And so when we talk about labor induction, it’s important to know that there are a lot of options available to help you get into active labor. But you don’t always need all of them, and you don’t always kind of start in the same point. So how would a provider decide or recommend we start a labor induction?

Roxanne: So first we always look at the history. So what type of history do you have? Is this your first baby first induction? Or, have you had babies before vaginally or have had you had a previous C-section? Because that does change what options are available to you.

With vaginal deliveries, previously, like if you’ve had a baby before, usually you don’t need as many induction methods, because your body kind of like kicks into labor quicker, but all of the options are available still. If you’ve had a C-section before, we normally will not offer cervical ripening agents such as cytotech or cervidil because there is an increased risk of uterine rupture- like six times the amount as like a normal induction would, with those medications. So many providers don’t even offer it for induction. It’s contraindicated, but the other ones are available to you.

Once we figure out the history, we then look at the cervix. What position is the cervix in? Is it soft or firm? How open is it? And then also what is the baby doing? Is the baby like very engaged, or still very high up? All of those things will give us a score, and this is known as the Bishop Score. Based off of the Bishop Score, we will determine which method is appropriate at that time. Usually if you are not dilated- less than three centimeters, or your cervix is still very thick and hard, even if you are maybe two or three centimeters- we normally will start with either a cervical ripening agent or a mechanical dilator, either both at the same time, or one or the other.

And this is because prostaglandins are very important in labor, not just for softening and ripening our cervix. But prostaglandins are really also helpful in creating coordinated uterine contractions. So the prostaglandins have all of the muscle layers of your uterus speak to each other so that you can have that coordinated uterine contraction. Because oxytocin by itself, while really great at causing contractions, that are not always coordinated contractions, because those muscle layers are not talking together without the prostaglandin. And this is why you can release oxytocin during pregnancy, with either orgasm or like hugging someone and feeling happy throughout all of your pregnancy, and it’s not going to put you into labor, because prostaglandins is a very important puzzle piece to the whole labor progress. Like without the prostaglandins that we’re releasing at the end of pregnancy, oxytocin doesn’t do as much of a job. So that’s why prostaglandins, if your cervix is not ripened, likely, you don’t yet have the communication between those uterine layers. So even if you’re like three centimeters but still pretty thick, normally we’re going to try to implement some sort of prostaglandins.

And then that’s when we move to either rupture of membranes or Pitocin. Depending on the provider, depending on the situation, we would always love it and preferred if you’re water ruptured on its own, because I feel that is like a sign that your labor is progressing naturally at this point, and also baby is likely in an optimal position for your body that caused the water to break. But, sometimes we do have to break it. But it’s kind of just person dependent at that point. Some people will then need both Pitocin and artificial rupture of membranes, sometimes they need neither of them, sometimes they just need one of them. But that’s usually how the induction will progress based off of that first Bishop Score. And then we’re just kind of routinely checking in throughout.

Gina: So a few things. First, are there ways that somebody could improve their Bishop Score in preparation for labor? Let’s say they know they’re getting induced, or they’re choosing an induction. One of the ways that I have researched to be beneficial to helping improve Bishop Score is walking towards the end of your pregnancy, a few times a week. Some of the studies, it was four times a week, 40 minutes at a time. Others were 3 times a week for 30 minutes. Both of those can be helpful in regards to just bringing baby a little bit lower.

Roxanne: 30 times?!

Gina: Or, THREE times a week for 30 minutes.

Roxanne: Oh my gosh, I thought you said 30 times.

Gina: Go for 30 walks.

Roxanne: 30 times?!

Gina: Just walk nonstop.

Roxanne: I was like that’s just walking the entire day!

Gina: No, three times a week, for 30 minutes each, has been shown to improve your Bishop Score.

And the biggest thing is like when baby comes down and applies more pressure against the cervix, this stimulates the release of prostaglandins. You can also do things like evening primrose oil- I would definitely talk to your provider before you start inserting things into your vagina.

Roxanne: But these are things that you can talk to your providers about if you know you’re going to be induced as well.

Gina: You can go for walks regardless, either way.

Roxanne: Yeah.

Gina: That’s probably totally fine to do. Before you use evening perm oil, I would definitely have a conversation with your provider because there is like some evidence to support that it can help with softening the cervix, but there is some concern that maybe it could also cause your amniotic fluid sac to get thinner, or if you had a previous C-section, it can cause your scar to get thinner. And so this is why I would recommend having a conversation with your provider. There is research to support that it could help with softening the cervix, but before we really take any sort of like supplements or insert things into our vagina, I would definitely like have a convo.

Roxanne: Always talk to your provider.

Gina: For sure.

Other things are just doing like upright exercises, so like sitting on your birth ball and moving around can help to improve your Bishop Score. Doing like deep squats and different like mobility exercises- prenatal yoga has been shown to help improve it. And so we just released an induction prep workout on the YouTube channel if you wanted to do a lot of these upright mobility exercises, you can check that out.

During labor, things that can help to continue to improve your Bishop’s Score is to labor in upright position. So there were some studies that showed after somebody got a Cook’s catheter- which is really similar to a Foley bulb, where they insert it into the cervix and that pressure helps to stimulate the opening of the cervix- if they sat on a birth ball and they moved around, their cervix was like much softer after the fact, as opposed to somebody who laid down. Now it can be really uncomfortable to sit on something with a Foley bulb in, so just be mindful of how it feels for you. But moving in upright positions during the induction process can also kind of help to progress things.

Roxanne: Motion is lotion.

Gina: Now coming back to Pitocin and water breaking because that’s always kind of like an either or. It’s like, which path do you want to take?

Roxanne: Yeah.

Gina: So we’ll discuss this, and then we’ll come back to deciding to get an induction, or whether or not you want to, depending on if it’s elective or medical.

Roxanne: Yeah.

Gina: So kind of the key things that I think about when I am like helping my clients through decision making at this point is, what type of monitoring option does the hospital have? Because if you’re on Pitocin, you’re typically going to be continuously monitored, while if you have your water broken, you don’t always, you’re not always continuously monitored. Sometimes you are, but sometimes you’re not. And so if your hospital only has a wired monitor, like it’s attached to a device that doesn’t really move around the room, this could potentially limit your freedom of movement. And if you’re really wanting an unmedicated birth, it may be helpful to do having your water broken instead.

Now, this is not saying this is what you should do, this is just things that I think about. However I agree with you, where it’s almost a little bit better if your water breaks on its own. I usually find that if somebody’s water breaks on its own, typically they’re babies in a better position. And so that’s always kind of like my concern if we break the water too early, if baby’s in a little bit of a funky position it maybe a little bit harder for them to kind of lose their cushion and get into their better position. So those are kind of things that I’m thinking about.

When it comes to Pitocin, you can always turn it off. If your body is not reacting well, baby is not loving it, it’s a little bit too much for you, contractions are getting too close together, you can always turn it off. But, you can’t really reseal your amniotic fluid sac. So for me, it’s something that you can take back, while having your water broken, you can’t always take it back. So you can always try Pitocin and see if it’s working for you and if it’s not, it’s easier to turn it off and then try having your water broken versus the other way.

So these are just things that I kind of ponder when I’m like helping my clients, or if I was thinking about it for myself. It doesn’t mean that’s what you need to do, but it’s just some things to consider when kind of deciding between the two. And every provider will have kind of their preference based on what probably most of their patients seem to like or what seems to work better for them and their experience. And so again, these are like good conversations to have with your provider as well.

Roxanne: And there is a difference between like how we would offer pain relief during an induction if someone is wanting an epidural or not wanting an epidural. So if we are on Pitocin, or they’re not epiduralized but they want an epidural, when we break water, this increases the intensity that you experience because the amniotic sac is basically the cushion between your baby’s head and your pelvis. And so when we take away that cushion, it’s just baby’s head on the cervix, directly in the pelvis, and this increases the intensity a lot.

So if we know you want an epidural and we’re thinking we’re at the point that we’re going to offer breaking your water, we always give the option of, “Hey. We know you want an epidural, this is part of your plan. We can break your bag of water now, if you’re okay with that, or, we can get an epidural and then break your bag of water.” And then maybe during that whole process, your water will just break on its own while we’re waiting because once you get comfortable and relax. And this is always, usually, an offering that we offer, if we’re going to break their bag of water during this induction process and they want that epidural. Why? You know, if we can give them the option of not experiencing this huge shift in labor, we always offer that.

If you don’t want an epidural, obviously we’re not going to offer that option because like you don’t want it, so. But if I know that someone wants an epidural and I know that there’s an increase in intensity, I always explain, “Hey, this is where we’re at in the induction process. We’re thinking maybe we could break your bag of water to help things progress since we either can’t go up on Pitocin or you didn’t want Pitocin.” And then we give them the option of getting their epidural now versus waiting until after. And sometimes, a lot of the time, they’re like, “Yeah, I would rather not have that,” or, they want to wait and experience if you contractions with their water broken. And then usually they’re like, “I’ve changed my mind. Please come quickly. I have some regrets about not getting it before.”

Gina: Yeah, I usually find that just waiting, and just, if you’re having the contractions, just wait for AROM and then when you relax, it’ll probably just break on its own, too. Or just, it’ll just break when you’re pushing. Like you don’t have to break your water if things are progressing, for sure.

And then with Pitocin, once you’re in active labor, you can also potentially turn it off. Now, I would say it’s not super common, like I don’t see it in practice very often. But once you’re in active labor, like in theory, your body should just kind of continue on its own and so you could potentially even turn off Pitocin and no longer be on anything as well.

Roxanne: And some places will, once you reach that six to seven centimeters, they’ll turn it off to see what happens. In some places, I’ve not worked in a hospital that did it routinely. But while we’re monitoring the contractions, we’re monitoring: are they getting too close together? And that’s when we should start decreasing the Pitocin, because that means that their body’s own oxytocin is now kind of kicking in, and now there’s like too much oxytocin and Pitocin that’s causing those contractions to get too close together. Or even just too strong.

Gina: So what would you recommend- because I’ve seen this happen, where the way that we’re monitoring that contractions are too close is with the fetal monitor and the toco- what would you recommend if the toco is not working? So the monitor, for our listeners, that is tracking your contractions. So it’s not working very well and it’s not picking up the contractions, but you as the person in labor, know that your contractions are like back to back. And so I essentially had this happen where the contractions were back to back, the Pitocin was probably too high- I’m not a nurse or a medical provider, so I’m not going to tell somebody what’s happening- contractions were back to back and I kept bringing the nurse in to be like, “Hey she’s having a nonstop contraction, like she’s not doing well. I’m pretty sure we’re going to see baby not doing well. Can we like look at the Pitocin,” and her response was, “She’s not having any contractions,” because the monitor’s not showing them.

Roxanne: Yeah. And I mean that’s…

Gina: So how, what would you recommend in that moment?

Roxanne: I mean, that’s like a whole issue with continuous fetal monitoring in a way, is that we almost become too reliant on the contraction monitor. But sometimes they do not pick up contractions at all. As long as baby’s heart rate is doing well, that’s not a sign that we would need to turn off the Pitocin or have them lay in the bed to see what baby’s doing. But that would be a clue to me that I need to continue to adjust the monitor to be able to find the contractions because if they are too close together, we do need to turn it down or potentially turn it off.

So in those instances where I’m not able to pick up contractions at all, I would usually go based off what they are saying the contractions are. Or, I would sit in the room to see how long the contractions are lasting and how close they are together. Because if I’m able to palpate when a contraction comes or if they’re unmedicated, they can tell me when the contractions are coming, then I’m able to time it out myself. Because our hands usually aren’t going to let us down. palpating, sometimes the monitors are going to let us down. So we should always be going in there and palpating regardless. But if you are noticing that the contractions are not picking up on the monitor. Then they’re not going to be able to titrate the Pitocin appropriately, and if they are going back to back, that means that we do need to adjust the Pitocin. But saying that just because the contractions, that they’re not having any contractions because they’re not picking up on the monitor, is not an appropriate response if they are obviously very actively.

Gina: She was very obviously having contractions. She ended up having an emergency C-section.

So, I feel like sometimes folks end up in those situations where maybe their labor was not being managed properly with a labor induction, and then it leads to outcomes that they were not expecting. And I think this is what causes the message that inductions are bad, you should never get induced, just always wait for spontaneous labor. As a nurse and as a student midwife, what would you recommend a family do if they find themselves in an induction that they are not sure is being managed properly. Because obviously like we don’t want somebody to do their own Pitocin, like they shouldn’t be managing that, but they should feel like they are a part of the decision making process. And if they’re having concerns, what would you recommend they do? And think about it being a person who is conflict-adverse.

Roxanne: Yeah.

Gina: So I’m not going to be like, “I fire you as a nurse,” that’s terrifying, I think. What would you recommend.

Roxanne: I mean, obviously I don’t think that you as the person giving birth should ever feel like this is something you need to do. I feel like I’m just going to go ahead and put it on the partners or the support people in the room to be, if they’re concerned to be like, “Hey, I think we are confused. We are concerned, and we are just, we would like some questions answered that, could we speak to the midwife or the OB, like with the nurse so that we are all on the same plan.” Because we feel if you feel confused during your induction process, or you’re concerned about your induction process, then we did not answer all of your questions appropriately for you to feel safe and supported during this induction. So I think, will potentially, if you’re in a certain hospital, your midwife or nurse be annoyed about it and maybe not come off as friendly during this process? Potentially. But I think saying, “Hey, like I understand you’re the expert in inductions, but I’m the expert in my body, and this is what I’m feeling in my body and I’m starting to feel a little concerned and unsafe. And I just need you to reassure me that things are okay, and that the way that this induction is going is okay. Or we need to address it so that it is okay.” Because again, we are, I don’t know what you feel in your body. I can only tell you what are the recommendations for induction, what are the recommendations for induction medications, and like the process that we do. I can’t tell you what you’re feeling within your body. You have full autonomy, we’re all adults, and you get to decide what we do. And if you no longer feel safe, even if you already gave us your consent for this induction, you can always change your mind and be like, “No, I’m good. I would like this not to be happening.” Obviously if you break your water that’s like a little bit less, we can’t let you go home with that, but like at any point you could just be like, “I no longer consent to this and I would like it to stop.”

Gina: So essentially having a conversation of, “This is how I’m feeling.”

Roxanne: Yeah.

Gina: “Can we, can you help me not feel this way anymore?” I think it’s like a really good place to start.

Because it’s always, it’s even hard for me as a doula when I, I have a little bit more knowledge than my clients do on kind of like how this should maybe be running, but it can be really hard for me in that moment, too, to help them kind of navigate it without being this source of conflict. Because typically, like when I am trying to help urge them to be like, “Hey, something is you don’t seem like you’re enjoying yourself right now, and not in a, ‘this is uncomfortable way,’ but in a, ‘this is scary for you’ way.”

Roxanne: Yeah.

Gina: Whenever I am the one that is trying to help encourage the conversation, usually there’s a lot of hostility towards me where I’m the problem as the doula, because I’m the one that’s making them ask questions and making this process more challenging. And so I think that’s where, for the doulas that we see commenting on our posts that have like hostility towards inductions, for the families that are commenting on the post saying, “Inductions are bad,” I think this is where that, that fear is coming from is, either witnessing experiences that were not supposed to be the way that they were- like that woman should not have had, or should not have needed that emergency C-section because the Pitocin was being given potentially incorrectly. I’m not going to make a judgment, but I that was my viewpoint on it.

Roxanne: Yeah.

Gina: She was not being given it correctly.

Roxanne: But with your experience and your understanding of the situation and you as someone who has a medical, somewhat medical experience.

Gina: Yeah.

Roxanne: You seeing that and experiencing that with your knowledge, you can make a little bit more of an educated guess of what happened. Whereas that family, like they were just fearful the entire time because they don’t know what, what caused it. And they’re like, “What is happening?” So that’s even more scary for them. And when you are fearful during an induction, you’re not releasing your own oxytocin and potentially inhibiting the Pitocin from doing the job that it needs to, because that fear that you’re holding onto and you’re feeling unsafe in these environments is just perpetuating this fact that this induction is going to potentially lead to, like unwanted outcomes. And it’s not to say that it’s your fault, it’s no one’s fault with that induction, but like you feeling unsafe is potentially our fault as your healthcare team because we should help, within reason. Like I can’t help everybody, like, if you have a lot of like anxiety, I don’t know if I can cure everyone’s anxiety. But if you feel unsafe because of something that I did, that is my fault and I need to relieve the fears that you’re having around an induction, especially if it’s medically recommended.

And so by you saying, “Hey, I feel concerned and I’m confused about what is happening. Can you just either clear things up or make me feel less concerned?” Me, as a provider, would be like, “Oh yeah, let’s explain this in a way that you understand, or let’s come up with a new plan that you feel comfortable with.”

Gina: Let’s take a break from this week’s episode to hear about our podcast sponsor, Needed. Needed is a nutrition company that specializes in optimizing nourishment for the perinatal timeframe. It is a brand that Roxanne and I have been involved with since the beginning. We personally use them. We continue to use them now in the postpartum timeframe, so they’re a brand that we truly trust and love, and they are third party tested, which is a really big deal when it comes to supplements.

One of our favorite products from Needed is their complete plan because it gives you all the stuff that you need. And then you can also a la carte extra things, depending on your individual needs. The complete plan has their prenatal vitamin, it has collagen, it has pre and probiotics in addition to their Omega-3, which are all products that I really love.

And what’s super cool is Needed just finished doing a study to check on their prenatal vitamin in comparison to others. And the women that were taking their prenatal vitamin had higher levels of vitamin B, 6, and 12, selenium, vitamin D, vitamin K two, in addition to riboflavin, which was all really big deals because a lot of us have some nutrient deficiencies that we’re working on as people. And so Needed’s approach to studying women’s health is a huge thing to me, and so that you can know that their prenatal vitamin is really high quality.

Roxanne: And one of the things that I like about their complete plan is that one, it makes it really easy to decide what you need during pregnancy because it comes just, it arrives in a plan and then it just arrives on your front door. But you can still make choices within that plan with their different prenatal options of their prenatal capsules and their essentials, or their full version, as well as their prenatal powder, which I really liked during first trimester when I was not about taking capsules. And then their omega also comes into variations of a vegan option as well as their fish option that came out that doesn’t have fish burps, which has probably been my favorite thing about their omega is it may have a little fishy taste, but I’m not burping up fish flavor.

Gina: Yeah.

Roxanne: So we really like their complete plan and cannot recommend them enough. And if you want to try them out, head to thisisneeded.com and use code MAMASTEPOD to get 20% off your first order.

Gina: I also find that, coming back to just like a normal induction, that there’s usually a lot of time.

Roxanne: There’s a lot of time.

Gina: To make choices. Like it’s not a boop, boop, boop, it’s usually, “Hey, let’s get you checked in,” that might take a few hours, and then, “Okay, this is, we’ll do a cervical exam. Okay, this is your Bishop Score. This is our recommendation of how we should start it. How do you feel about that?”

Roxanne: Yeah. There’s lots of time to talk.

Gina: Alright. And then it’s like if you start with cervical ripening, you’re going to sit there for 12 hours.

Roxanne: Yeah.

Gina: And take a nap.

Roxanne: Yeah.

Gina: And then after that, maybe we’ll start with a mechanical dilation for a few hours. Take another nap. I mean, sit on your birth ball, move your hip around. And then, “Okay, let’s see what the progress is. Hey, do you want to start Pitocin now?”

Something else that I will sometimes find, and I know I keep saying we’re going to get to what are different types of induction, is if somebody is wanting a lower intervention birth but they have to be induced, or they’re choosing to be induced because of medical reasons, or just their own choice, if you decide to be induced, I support you in whatever it is that you want. If you’re wanting a lower intervention birth, taking your time with the process can be really helpful. So while you have a Foley bulb, if you’re like, “Well, I don’t really know if I want to get Pitocin,” this is usually like a big thing for a lot of my clients, they’re like, “I don’t really know if I want the Pitocin.” Okay, well, while you have your Foley bulb or while you do your cervical ripening, maybe we’ll try the breast pump and see if we can get some of that oxytocin flowing too in a different way. I’ve had success as a doula where somebody has a Foley bulb and they use, the breast pump to get things going. You, I mean, you gotta set the mood though. You can’t be like watching…

Roxanne: Law and Order SVU.

Gina: Law and Order, Toy Story, with like super loud music, while you’re doing work. Like we need to get into the vibe. We need to get into the mindset of labor. So we have our Foley bulb, we’re sitting on our ball doing our thing using our breast pump, however your midwife or provider recommends you use it, because everyone’s like a little bit different with what they recommend, and we’ve dimmed the lights, we have soft music playing. If your into aromatherapy, you’ve got your oil diffusing or you got your little aromatab sticker. You and your partner are just like quietly talking to one another, but you’re letting yourself come into that space, and that is what’s really going to help you get into labor. Because I’ll have some clients that’ll be like, “Hey, I did the nipple stimulation, nothing happened.” I’m like, “Did you turn the lights off?” and they’re like, “No. We were watching like Law and Order.” And I’m like, “Yeah, okay, well turn the lights off!”

Roxanne: Yeah.

Gina: So you gotta also set the mood.

Now if you do eventually need Pitocin, because you’ve been there for a day and things are just not progressing, it’s okay. Like, you didn’t fail if you do need more intervention to get things going. You could try other things, but it’s okay if you do end up using Pitocin as well.

Other things to consider with Pitocin is if you’ve been on it for a prolonged period of time, you could ask for it to be turned off and take like a break.

Roxanne: Yeah.

Gina: So this was something for one of the inductions that I went to that was like four days long, was once we started hitting the evening and like things just weren’t quite like picking up. It was like, “Hey, can I turn it off and go to sleep? Because, I don’t want to be awake for four days.” And so it was kind of like a balance of okay, well, do you want to still be here in three days, or do you just want to be super tired in three days? And so we would turn the Pitocin off, by “we” I mean like the nurse would turn it off, I was not. We would talk with the midwife, we’d kind of go over a plan of action. And they would turn the Pitocin off, she would, take a shower, she would kind of reset. She would sleep for a few hours and she’d wake up, eat breakfast, which is a huge thing- sometimes if you’re being induced for a prolonged period of time, you’re not only super tired, you’re also super hungry.

Roxanne: Yeah.

Gina: And then we would restart it. And then eventually, like she got dilated enough with the Pitocin and baby was low enough, they’re like, “Hey, would you like us to break your water?” and she was like, “Yeah, I think now we’re at a good point where that makes sense,” But it took a little bit of time to get there. And then they broke her water and it was pretty quick from there. And now she could’ve maybe if she broke her water on day one, it would’ve been fine, but like she wanted to take her time with the process. And she felt better and more confident and comfortable being really patient with it. And so if you are being induced, you can absolutely take your time with each step of the process, have long conversations. I mean, we would talk for an hour.

Roxanne: Yeah.

Gina: With the midwife, about pros and cons of each decision because she felt really anxious about it. And it was like, well, we want you to feel confident in whatever decision that you make. And she was being induced for a medical reason. She felt comfortable that it was a good decision for her.

So let’s talk about what are the different ways, or different… WHY are people choosing to be induced? Because again, we have that sector, that’s like, “No one should ever be induced. You should only go into spontaneous labor. If you don’t go into spontaneous labor because it’s an emergency, just have a C-section, you don’t have time to be induced.” So we’ve got like that sector, which seems very extreme to me. And then you have the other side that’s like, “Everyone should be induced. Why would you go past 39 weeks? Think of all the risks that could happen during that timeframe. Like, why would you not be induced? Think of your baby.” So there’s two very far extremes. Most of us are in the middle.

Roxanne: Just like most things.

Gina: Most us are in the middle for mostly everything. The two ends are very loud, though!

So you can either be electively induced, where there’s no medical reason other than you just want to. Or you can be medically induced- there’s something going on that maybe it’s not as safe to continue pregnancy.

With elective induction, and then I’ll have you talk about medical induction, it is just because you want to. Like, maybe, so for us, we live in a military community. Some of my friends will get induced because their husbands are only here for a short period of time. Like they’re in the middle of their deployment, they came home for the baby to be born and they’re about to go back, and they want to really prioritize time with him being here. And so they will get induced at the beginning of his like two weeks off so that they can have a baby and he can help take care of it.

Roxanne: And with elective induction, it’s important to note no provider will electively induce you before 39 weeks. It is after 39 weeks and there is no medical indication. If you are 38 weeks, I’m so sorry. They will not electively induce you.

Gina: Yeah, I guess I should have started with that. Anyways, let’s talk a little bit more about elective induction and then just jump into medical induction.

So that’s one of the reasons that I find people will be electively induced, is scheduling.

Roxanne: Scheduling. And sometimes providers won’t even really tell you that there’s an option. They’ll just, you’ll show up at your like 38 or 39 week appointment and they’ll be like, “Okay, we scheduled your induction next week.”

Gina: Oh, that happened to me. I was not pleased

Roxanne: And there’s no conversation. And with elective inductions, there was a study that came out called the Arrive Trial that determined, with their math, that by electively inducing people at 39 weeks, this decreased the rate of C-sections. There are flaws and many published studies about the flaws that are within the Arrive Trial- we can do literally an entire episode on it. But basically the Arrive Trial, two big flaws with it is that the reason they did the study was to determine by electively inducing, did this decrease newborn morbidity and mortality? Did this decrease like the number of injuries to babies by electively inducing at 39 weeks? Spoiler alert, it did not decrease. But it decreased the C-section rate in the elective induction group versus expectant management, which was people waiting for labor to happen on its own. But they did not sub-categorize out these two groups out into people who actually were induced and who actually gone into spontaneous labor. Just like we know, people have their babies at 37 and 38 weeks, spontaneously. So if those people were in the 39 week induction group, they were still included within the numbers of the people who were induced at 39 weeks, even though they were not induced, they went into spontaneous labor. And similarly, within the expectant management group, there was a very high number of people within this group that were actually diagnosed with gestational hypertension or preeclampsia, like higher than the national average within this study. And as we know, the recommendation for those diagnoses is a medical induction, but they didn’t sub-categorize that group out either. So these people who were after 39 weeks being induced for something that developed during pregnancy were still included in the numbers of someone who was like expectantly managed and went into spontaneous labor on their own.

But there was another study done in the nineties that did sub categorize those two groups out, and they found that people who went into spontaneous labor had the lowest risk of C-section, the next lowest were people who were induced earlier, and then the highest rate was people who were induced when they were like 33, 34 weeks, which like we don’t even recommend anymore.

Gina: 43 not 33.

Roxanne: Oh, 43 and 44 weeks, which we don’t really recommend anymore.

Gina: Yeah, we don’t recommend 34, 33 weeks either!

Roxanne: So we knew that the people who were 43 and 44 weeks were going to have a little bit of an increased C-section rate, but the Arrive Trial did not do that by telling us that, yes, these people were electively induced and their C-section rate was lower than anyone else’s, because they didn’t separate the groups out.

With the Arrive Trial though, their recommendation within it was that, does this mean everyone needs to be electively induced at 39 weeks? No. That is not what this Arrive Trial meant. This just gave it as an option. So if you want to be electively induced at 39 weeks after understanding that there were increased risks associated with it, such as a longer hospitalization, like long induction stay, like you’re going to be in the hospital longer because of this induction. There were increased risks with inductions for babies. Yes, potentially a decreased risk in C-section based off of this one study that no one can replicate. And like going over all of the risks associated with an induction, and after that you then deciding that, “Yes, I think this is the right choice for me,” versus you just showing up at your appointment and them telling you that you’re going to be induced, that was not what they wanted. This was not what they wanted. They wanted you to be fully informed of the risk, and then you decide that, “Yes, I would like to be induced at 39 weeks.”

Because if you’re wanting a low risk intervention birth, like the induction is not the right option for you, personally. And there are way other cheaper ways that we can decrease the C-section rate, such as having just midwifery care in general, like water therapy, like hydrotherapy and water birth, having a doula present or just a continuous labor support are all really cheap- cheaper ways than like hospitalizations to decrease our C-section rate. Along with just like using labor comfort techniques and movement during labor- way cheaper to implement than elective inductions for everybody. And this is also why some practices don’t even offer elective inductions in their practice because they are just not able to handle that.

Gina: They’re very resource intensive.

Roxanne: They’re very resource intensive, and they don’t have the staffing or the hospital capabilities to do them. So it’s a nice offering. If some people really want and they understand the risks and benefits of having an elective induction, I fully support your autonomous, you’re a fully grown adult, you can make that autonomous decision about what is happening to your own body and your own baby. But I don’t love when people don’t get that choice and they’re just told that they’re getting an elective induction.

Gina: Yeah, no, I completely agree.

For my first pregnancy, that’s what it felt like. I just showed up and they’re like, “Oh, here’s your induction date,” and I was like, “What do you mean?” But I was not very confident in being able to have a conversation because it, they did not present it to me in a way that felt like, “Let’s talk about it.” And so that was, it was really scary for me as I was navigating that. And I know that it’s really scary for other folks that find themselves in that situation where they’re like, “I wasn’t planning this. Like that, that’s not what my birth vision was for myself.” And I think it’s okay to have a vision of what you’re wanting your experience to be. Like I’ve gone on to have three really amazing experiences that were aligned with what I was wanting, and I was really happy to have those experiences. There’s more than just surviving birth, like we can also be happy with how we were treated during it. If the conversation about an elective induction is like that, that is not appropriate in any way.

I would say the only time that I’ve really seen people choose an elective induction, not to say that these are the only reasons that someone could choose, would be for scheduling purposes, or they are just like super uncomfortable and over it. That’s really like the only times, but I mean, and maybe it’s just not the people that I’m even interacting with.

Roxanne: Yeah.

Gina: But yeah, if you’re weighing the risk and benefits and for you, you’re like, “Nope, this is good to me,” that’s fine.

Roxanne: That’s fine.

Gina: It sounds good to me.

Roxanne: I fully support anybody’s informed choice.

Gina: Yeah.

Roxanne: But, the informed portion of that choice is important.

But other than elective induction reasons, obviously the other option is a medically recommended induction- and it’s always medically recommended, not medically required. No one’s going to come to your house or force you to show up on Labor and Delivery. We’re going to give you our medical recommendation based off of your situation, and then you still get to make the choice based off of your own personal beliefs and preferences.

But the most common reasons for a medical induction are gestational hypertension, preeclampsia- so elevated blood pressure during pregnancy, either affecting your entire body or just blood pressure. And then gestational diabetes that is diet controlled later in pregnancy or medication controlled. The timing of the induction is dependent on the type of gestational diabetes, as well as how controlled those blood sugars are. Even if you’re on medication, but the blood sugars are no longer controlled in any sort of way, they will likely recommend it earlier in the pregnancy, than the 39 week, which is usually the 39 week medical gestational diabetes induction.

Other reasons are like too little fluid or too much fluid sometimes later in pregnancy. There’s also growth restriction, so if baby is measuring very small, so less than 10 percentile, or it just dropped off very suddenly, so that’s either intrauterine growth restriction, or just fetal growth restriction, one or the other words, depending on the person. Another really common reason is cholestasis.

This is like when you have like a buildup of bile acids within your body due to something that’s going on with your gallbladder and liver. And this is usually not an issue for you, you’ll have like itching of your palms and the bottoms of your feet, and maybe just like itchy all over honestly, and just really uncomfortable. Some people will have It feels like their heart is racing out of their chest. Everyone kind of has a different experience with ICP or cholestasis, but they normally recommend induction earlier on because if those bile acids, depending on the levels, if they get too elevated, this can cause issues for babies such as stillbirth. I don’t know the specific percentages, which I should learn, but there is just an increased risk depending on how high those bile acid levels get.

Those are probably like the top reasons that I usually see for inductions. There’s so many other reasons though. Obviously many people know about the advanced maternal age, and obesity, as reasons that are used for inductions, but like them just by themselves are never usually reasons that I see like in my practice as reasons for inductions. There’s also like thrombocytopenia, which is low platelets during pregnancy that can just occur during pregnancy. If these people are on some sort of medication, there’s like a window where it’s like the safest for them to deliver because obviously platelets are really important for clotting, and we want you to be able to clot during your birth, which is a time that a lot of us will bleed. So that is another thing that we likely recommend inductions. There’s so many other reasons though that like I could literally list, it’s like the packet of induction timing for different like disorders or complications that arise either during pregnancy or a preexisting, is like so long on the ACOG’s website, which is the governing body of obstetrics in the United States. It’s so long because there’s so many different things and there’s so much nuance associated with it that there’s recommendations for induction timing, as well as recommendation for different antenatal testing, which is the like biophysical profiles, the non-stress tests, and just like monitoring babies. Because again, these are all recommendations, but you still get to ultimately make the decision of what happens to your body and baby’s body. So, it is always a really great time to have a conversation if you have some sort of medical complication that arises on the timing of your pregnancy delivery.

Gina: Yeah. Because you could be induced potentially even before 37 weeks if the complication is fairly severe. Usually I see it starting anywhere from like 37 to 39 weeks. I’ve seen folks go past 40 weeks like with medical complications because it’s all individual. So there is like a general recommendation, but you as an individual are still your own person, and similar to how every induction is different for every person, the recommendations for you as an individual are also going to vary based on what’s happening for you. And so this is where having shared decision making with your provider is super important.

And if you are not feeling like you could have conversations with your provider and your earlier in your pregnancy, I would find a new provider. If there’s anybody that has probably the biggest impact on your birth experience and your pregnancy experience is going to be your provider. And so if you feel uncomfortable having conversations with them, if you leave feeling uneasy from your prenatal appointments, if you feel like you couldn’t ask them questions, these would all be red flags to me that I need to seek care from somebody else.

And so you should leave your appointment’s feeling good. Like just check in with yourself after your appointment and be like, “Do I feel good? Do I feel confused and uneasy? Do I feel indifferent in either direction?” And then just kind of make an assessment for yourself. And now obviously, like it’s easy for us to say, “Just find a new provider.” It does depend on availability. Who takes your insurance? If you live in a small town, you may be limited. So if you are feeling like really uneasy with your provider and you’re unsure… if like you don’t have a feeling that they want to have a conversation with you, this could be like really helpful to have additional people there to help advocate for you. So either having a doula, having another family member or friend in addition to your partner, be there to help support you, can be really helpful because you may need more of that advocacy during your labor experience.

So, Roxanne, what is shared decision making and what are some of the top questions that somebody could ask their provider even earlier in pregnancy about labor induction to get a better idea of what to expect and to help them decide whether or not they do or they do not want to be induced.

Roxanne: So, great, so shared decision making is like a conversation and communication tool that is like very harped on in my like, midwifery school. But it’s basically, I will explain the evidence of all, whatever we’re talking about- so the evidence for why we’re recommending an induction. We explain what the evidence is, why we’re recommending it for you, and then we wait for your feelings, like thoughts and feelings on it. And based off of like your thoughts and feelings then we continue to kind of go over a little bit more in depth evidence, and we have a conversation together to come up with a plan that we both feel comfortable with.

Obviously, it’s your body, so I always kind of start with that, that you are a fully grown, autonomous adult. This is what we’re recommending based off of X, Y, and Z. This is what evidence shows us is beneficial for this. This is the timing recommendation for induction that we recommend. These are the antenatal testings that we would recommend. What are your thoughts and feelings about this? And then they share their thoughts and feelings. And then we kind of have this conversation back and forth. It sounds like it takes a really long time, but it really doesn’t, and it honestly makes it way less stressful, for me as a provider. And also less stressful for them as a person because they’re feeling like they’re a part of the decision making and they feel like they have all of the tools that they need to then make the decision of what they want to do. It’s never my decision what they do. It’s always their decision. And then, and it’s obviously, it’s my comfort level within it, determines like how involved I’m going to be within it. Obviously, if they choose to have a, I don’t know, primary C-section, like obviously that’s not me, I don’t do that. But like at any point in these shared decision makings, however we get to the plan is based off of what they decide. So they always hopefully leave these conversations feeling safe and supported and confident that the choice is the right choice for them.

Gina: Absolutely. So some of the questions that I would ask if I was being, if you were my midwife and you were like, “Gina, you need to be induced.”

Roxanne: I wouldn’t say that.

Gina: But questions- well yeah, you wouldn’t say it in that way. You would have a, we would have a conversation on why you would recommend that.

If your provider is not trying to have a conversation with you or you are, after the conversation, you’re still kind of confused, the first recommendation, first question that I would probably ask is, “Why do you recommend an induction? What is going on with me currently that you are recommending it right now?

Roxanne: Yeah.

Gina: Or next week. Because it can be like, “I understand that I have hypertension, but what about my hypertension right now is telling you that I need to be induced now, as opposed to monitoring it. And if you don’t recommend, if you, support me not being induced right now, how are we going to monitor me to continue my pregnancy? Like I would really like to go into spontaneous labor, or I would like to you know, be closer to 39 weeks before we get, before I get induced. Or closer to 40 weeks before we get induced.” So those would kind of be like, would be like the first question I would ask.

Roxanne: Yeah.

Gina: Why are you recommending a medical induction? What is happening with me right now and my health that you are recommending it more like now versus later? If we choose to do it later, how can we continue to monitor me and my baby to make sure that it’s still safe for us to continue pregnancy? Because again, like the closer you get to 39, 40 weeks that maybe an induction will not be quite as complicated. Maybe there’s going to be less steps. Maybe your baby won’t need quite as much support after birth as well. But maybe if you don’t do it right now, it’s not going to be good for either you or your baby. And so figuring out what the range is, I think is really helpful. So have a better understanding of me as an individual, not just as a number in a study. What is going on with me?

The next thing that I would probably ask is to get some clarity on what to expect with an induction. How do you manage induction? And this could be a question you asked way earlier in your pregnancy, too. You don’t have to wait until you’re in line for an induction. You could say, “Hey, like how does your clinic generally manage inductions? Like where do you normally start? What interventions do you commonly use? Like how do you go about it?” And have ’em kind of talk you through, “Oh, okay, well, you know, this is what you can expect if you come in. You know, we’ll kind of get you settled in a room and then we’ll talk about like our general plan of action. We’ll see if you want a cervical exam, and from there we’ll kind of go to this step,” and then just have them walk you through. And then after that, I would probably ask if you weren’t familiar, like what kind of like labor comfort items are available? Do we have a tub, do we have a shower? Can I use them during my labor? Because some like hospitals have like weird rules about certain things. Like, do you have wireless monitors? Are they portable? Do I have to be continuously monitored? And so just go through your birth plan, essentially. If you find a standard birth plan online, like we have a birth plan as well, and just kind of go through that birth plan to have an idea of what’s available to you, because you’re no longer going to be able to labor at home as long as possible, and then show up. You’re going to do all your laboring there.

Roxanne: Yeah.

Gina: And so those would be kinda like my top questions that I would be asking. What else would you add to that?

Roxanne: I would also ask their policy on eating. So, will I be able to eat during this induction? Will we be able to like, take pauses to either shower or eat throughout it? I think the eating portion is often like the forgotten portion where like someone has been being induced for 24 hours and we’re like, “Oh yeah. Let’s just continue on to the next step,” instead of being like, “Hey, they have not probably eaten in 24 hours, let’s give them a meal.” Yeah.

Gina: Let’s pause to eat.

Roxanne: Will you pause during inductions to allow me to eat meals, or am I allowed to eat during the induction process until a point? And if there is a point during the induction process, or labor process in general, that you will not give me any food- I say “give me,” because you’re still a fully autonomous adult. If you find food and eat it, I’m not going to slap it outta your hands. But like before we will not give you any food anymore, or recommend not eating anymore, what is that time? Is it like when I get an epidural, or is it when you start Pitocin, even if I don’t have an epidural? So some hospitals have different kind of recommendations for all of those things. And then, when do I need to be monitored? Do they monitor the entire time regardless of the induction method, or if you break my water, I don’t need to be monitored, but if I’m on Pitocin, I do. If I have a mechanical dilator, do I need to be monitored or can I like move around freely without a monitor on? And same with Cytotech and cervidil, the cervical ripening agents. Also, do you do any like cervical ripening at home? Does your clinic offer like placing a Foley bulb in the clinic and then sending me home? And then I can labor at home with my induction, and then just come in the morning or when the Foley bulb falls out. Or will they place like cervical ripening agents, again, in the clinic, and then send me home on it, and that I just show up when I’m either in labor or the next morning so that I can sleep in my comfy bed rather than this like uncomfy hospital bed.

So those are probably the three questions that I would ask. Because not every clinic does outpatient inductions, but if your hospital doesn’t have the resources, maybe doing outpatient inductions would be easier for you, because then it doesn’t hold up a entire hospital bed, an entire nurse. Then you can eat at home!

Gina: Something else that I would recommend if you’re like, “Yep, I’m deciding to get induced,” is to get a cervical exam at that appointment so that you know where you’re at already, because that can really change what time you show up. Because if you are like at zero centimeter, super thick, you’re probably going to show up at night so that they can start cervical ripening overnight, and then in the morning they would start like the next step, potentially. If you were already like three centimeters dilated 80% effaced you’re going to show up in the morning, like you’re going to sleep a full night in your own bed and then you’re going to show up in the morning. So those would be like a time where I would say a cervical exam can be really helpful to gather information because that can really change. When you show up.

Roxanne: Yeah. The last question that I would ask is, for whoever the provider is, if they know the provider that is going to be on that day for your induction, like what is their C-section rate? Because every provider has a, especially if they’re like an OB and if they’re the one managing your labor, what is their C-section rate? Because every provider has a different C-section rate. And potentially someone who has like a very high rate, will maybe be less patient with the induction process than someone who has a lower rate.

Gina: Yeah, I think that’s a really good question, too.

So when it comes to labor induction, we’ve kind of got two ends of the spectrum that are sometimes very loud. We have the side that is like, “No one should ever be induced. If it was really medically necessary, you would just have a C-section because it would be an emergency.” Like it’s important to note, just because it’s not an emergency right now, doesn’t mean that it could eventually become one with the path that we’re currently going down.

Roxanne: I think it’s also important to note that, like why are we waiting until there’s like literally a life or death emergency to decide?

Gina: Yeah, like that seems, it seems weird to wait until that point, because there are things that could happen along the way that are detrimental as well. So just because it’s not like life or death right now, like nobody’s actively dying right now, doesn’t mean that it’s not medically necessary to do. And I think it’s important to understand that if you are choosing to be induced for a medical reason, for an elective reason, it is your decision.

Roxanne: It’s still your choice.

Gina: And if you feel confident that this is a good decision for you, don’t even bother with listening to people that are trying to dismiss your experience.

And then on the other end of the spectrum, if you are wanting to have a low intervention birth, you are really wanting to go into spontaneous labor, you’re working with your provider to kind of monitor your health and your babies, and you feel comfortable waiting for labor to begin on its own or going to a certain point…

Roxanne: Kudos.

Gina: That’s great! Like that’s a decision that you’re making and you should feel confident in making that decision based on a conversation with your provider. So both of those situations require conversations with our provider and using them as a resource to help us navigate this part of our pregnancy.

Roxanne: You’re a team.

Gina: We’re a team. And so again, the two ends of the spectrum, “Everyone should be induced. Why would you go past 39 weeks? You hate your children if you don’t.” And then the other end, “If you get induced, you hate your children.” Everyone is like, “You hate your baby!” for some reason! But where most of us are in the middle, it’s reasonable to decide to use medical interventions to help support your labor with just shared decision making with your provider. Like you should feel confident and comfortable with the decision. Nobody should be coercing you in either direction, by any means.

And so we hope that the information that we share with you at MamasteFit helps you feel more confident to make decisions that work best for you and for your family. Like we never want to coerce you or to force you to go down a certain path because it’s the, “best,” by any means- because there is no one best way for anybody. Even the way that we push is going to be different from person to person, even from our own experiences. So even if we were like, “This is the only way to do things,” it would not be beneficial for everybody. And so we really hope that the information that we share with you helps to empower you along your journey.

And so if you want more support throughout your pregnancy, check out our online prenatal fitness programs. Check out our online childbirth education course. The prenatal fitness program is designed to help you move confidently throughout your pregnancy to feel comfortable. We really debunk a lot of misinformation that is involved with prenatal fitness. Can you exercise at all? Yes. Yes, you should.

Roxanne: Please do.

Gina: It’s really helpful for you. Exercising throughout your pregnancy can actually reduce your risk of developing a lot of these prenatal complications or decreasing the severity of them, and so it’s incredibly beneficial to move throughout your pregnancy.

But if you’re confused join our program where we offer you daily workouts so that you can move confidently and be pain free and prepare for birth and prepare for the postpartum. Our childbirth education course is going to include a lot more on all of these different interventions, how we can navigate them, the risks and benefits, good questions to ask your provider. We have an entire section on planning for birth, in addition to what to do if you have to be induced, there’s a whole like flow chart of like questions and stuff that you can ask. And there’s tons of information in the course. We probably include way too much for how much we charge for it, but.

Roxanne: That’s our gift to you.

Gina: We want to make sure that it is accessible to as many people as possible, which is why we create so much content on our podcast, on our YouTube channel, on our Instagram, because we think that everyone deserves to have a good and amazing labor experience.

And if you want to check out any of our online offerings, you can use code STORY10 to get 10% off any of our online offerings, and you can bundle them together to save an additional 15% off.

Roxanne: And this podcast is sponsored by needed. Needed is a nutrition company focused on the perinatal timeframe that we both utilize during our pregnancies and still to this day. We love it. And if you want to check them out, go to thisisneeded.com and use code MAMASTEPOD to get 20% off your first order.