Welcome to the MamasteFit podcast. In today’s episode, we will be talking about:
- Induction of labor
- When and why your provider may recommend an induction
- What is involved with an induction
- What questions to ask your provider about induction
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Gina: Welcome! In this episode, we will be talking all about induction. What is it? Why and when is it recommended? What is involved with an induction of labor along with some risks and benefits?
And then we will also be discussing some common fears that people have associated with having induction including fears that I had during my first labor when I had an induction scheduled.
What is an induction?
Roxanne: All right, so an induction is a procedure where they’re trying to stimulate labor using various interventions, and there are medical interventions and then there are natural induction methods as well that we still consider interventions. So induction methods, the goal is to stimulate our labor hormones by using either a synthetic version or just getting something to stimulate those hormones to start the positive feedback loop of labor.
So what is that? That is involving two main hormones, our oxytocin in our prostaglandins, and they kind of talk to each other to stimulate labor and sustain labor until baby is born.
Which one starts labor? We don’t really know, but let’s pretend it is oxytocin in this situation. So oxytocin is released by our brain. It’s our love hormone.
It is what causes uterine contractions. So the contractions start. This is going to push baby down towards the cervix. So it’s stimulating pressure on the cervix. When the cervix is manipulated or there’s pressure applied. This releases prostaglandins in our body, which those prostaglandins then tell our brain to release more oxytocin the cycle continues again until it’s either interrupted by something or a baby is born.
And talking a little bit about those natural induction methods, when we think about the positive feedback loop, we think these natural methods are trying to stimulate our natural hormones of oxytocin and prostaglandins in a way to stimulate labor. But with these natural induction methods, they are still an induction method in a way. So we are still trying to force our body into labor when it’s not necessary really ready for labor.
Natural Induction Methods: It's Still Induction
Gina: As do I have found that the more we force labor to happen, the harder labor seems to be. And so in my own experience with Sophie’s birth, we did a membrane sweep at 41+2 and I had just essentially prodromal labor or kind of this start soft labor pattern for the rest of the day into like early the next morning before labor actually started for me.
And so I was kind of irritated essentially for about 12 to 16 hours before Labor actually began. And I felt like her labor was a little bit longer. It just took longer to like get going. Like I was stuck in her early labor pattern for a really long time for my third baby.
Now, would her labor have still been the same even if I didn’t get the sweep? Maybe. But I do feel like I did kind of push things to stir and then maybe that is what led to that labor just being like a little bit harder than my other two. But we do need a kind of balance like what we’re trying to decide to do. And so for me in North Carolina state, you can only give birth at home with the midwife that I have between 37 and 42 weeks.
If you’re outside of that window, you have to go to the hospital. So if you’re a preterm, you would have to go to the hospital. And then if you exceed 42 weeks, you would go to the hospital to have a medical induction. So I was getting close to that 42 week mark and I did not want to have to transfer my care to the hospital for going past my due date.
Now, I would have totally transferred care if there was like a complication that had developed, or something was wrong with me or my baby whereas being in the hospital would have been a better option for us. But I didn’t want to have to go to the hospital because I was too pregnant. And so my midwife and I talked about it and we opted to try a membrane sweep to see if that would kickstart things for me.
So I was already three centimeters. My cervix was already pretty soft. And so I was I just needed that little bit of like push to get going. And again, I was just in prodromal labor for like 12 to 16 hours and probably didn’t get like amazing sleep. And so I started my labor a little bit more tired and then it just took like a really long time for things to like start moving along.
And so again, but you got to kind of balance the waiting versus trying to force things to happen and what it is that you want to do.
So there are a lot of other natural induction methods which for most of us means anything that is not Pitocin or a medical intervention. And these natural induction methods can include:
- nipple stimulation,
- Eating dates,
- Evening primrose oil,
- Sexual intercourse with semen in orgasm,
- A midwives brew with castor oil
- Membrane sweeps.
And so those are some of the options. There’s tons of foods and stuff if you Google like the old wives tale, if you eat pineapple or spicy food or you bounce on a ball, that’ll it’ll kickstart labor. I personally have not found a movement that kickstarts labor personally, but everyone has their own opinion on that. How effective each of these methods is going to be is really going to depend on how ready you are to be in labor.
So if you’re like not ready to be in labor and you’re not going to go into spontaneously for a few weeks in your 37 weeks, like doing all of the natural induction methods is probably not going to work for you. And so you’ve got to be kind of like close to going into labor. And so these natural induction methods are doing one of two things, and some of them are doing like a combo of both.
They’re either softening the cervix by releasing more prostaglandins or they’re increasing contractions with oxytocin. So again, back to that positive feedback loop, oxytocin causes those labor contractions or those uterine contractions. Prostaglandins is helping to soften the cervix and kind of the combination of the two stimulates labor.
Nipple Stimluation: Release Oxytocin to Start Contractions
And so with oxytocin trying to release that, naturally we can do nipple stimulation, which you can do with your hands or with an electric pump.
There are some small studies that show if you do this for like an hour or two a day over several days, your level of oxytocin will be higher.
I tend to find that nipple stimulation is more successful if you’ve had something else is happening, like, you’ve been having some prodromal labor or your water has broken like something else has been going on for a nipple stimulation to be really effective in my opinion. And I do find it to be an effective induction method. If like your water has broken but you don’t have contractions, for example.
Sexual Intercourse and Orgasm: Release Oxytocin to Start Contractions
Other things that we can do to help release oxytocin is going to be to have an orgasm, either with sexual intercourse or for masturbation. If you have a male partner, semen has prostaglandins. So if your partner finishes that with a combination of an orgasm, we’re kind of kickstarting our own little feedback loop.
There is like a really small study with like 12 people in it, that of the people that were having sexual intercourse after 36 weeks, like they went to labor like four days early. So if that’s the motivation that you need to have some quality time with your partner, go for it.
We bring up this study in our childbirth education course, the partners always look at their one that’s pregnant and they’re like, “Hey, do you want to go home, and I’ll soften your cervix tonight.” So, whatever, whatever you need, there you go.
Castor Oil: Not Our Recommended Option
Something else that could help kind of stimulate that oxytocin release is going to be castor oil. Now, castor oil is at the bottom of my list, of recommendations for natural induction methods. I would not recommend it. And actually, not because it’s dangerous for you or for your baby, but it’s just a horrible time.
And so castor oil most of the time is thing going to make you really nauseous or it’s going to make you people that cause the laxative and so the thought processes that stimulate the GI tract, which is why I sometimes like spicy foods seems to help and that will stimulate the uterus to start contracting. Now it can be really hard to relax after you’ve ingested castor oil because you are having liquid poo come out of your butt like 3 to 4 hours after you take it.
And so it’s really hard to relax your pelvic floor when you’re trying to keep all of this liquid inside. So, I have found that my clients who have taken castor oil are like a midwives bru, which is like a mixture of a bunch of different ingredients. Usually, it’s like nut butter, apricot juice, and then castor oil.
They still have a bad time, like all of them are like shitting themselves, and like they’re having a really hard time relaxing during their labors. And their labors are really hard, and I think it’s because they’re clenching their pelvic floor the whole time. So very bottom of my list. Now, again, if you are going to risk out of your birth location and this is like your last ditch effort to get you going, like that’s another conversation.
So it’s all about like kind of looking at your own scenario. If you’re just tired of being pregnant, maybe don’t, it’s usually not a good time.
Roxanne: And with castor oil, a lot of midwives will say like using it before 41 weeks is usually not super effective anyway because most of the time after 41 weeks, your body is a little bit more ready to go into labor where it will actually stimulate labor. The only other chance before 41 weeks that it could potentially work is if your water has broken but contractions have not started.
Dates: Soften the Cervix
Gina: So again, these natural induction methods like doing them is not bad or like wrong by any means. Just know that there are still interventions that could potentially make labor a little bit harder, but kind of assessing your individual situation is going to be really important.
So I personally did a natural induction method which was going to help to release prostaglandins, which is the second part of the options that you have that are going to help to soften the cervix.
Eating dates has been supported by research to help soften the cervix. Really any time after 36 weeks, you have to eat a lot of dates. So it’s like 4 to 6, like large dates. It’s a commitment and it takes about 21 days for you to start to see the effects of it. You’re probably going to not like dates after a while, so for me personally, I do not like dates anymore after attempting that.
Roxanne: And if you have diabetes or gestational diabetes, obviously eating six dates, which are a very high glycemic food that has a lot of sugar in them, probably is not recommended for your blood sugar levels. So either spreading them out or like mixing them into foods that will keep your blood sugar at a normal level or avoiding this option is recommended.
Evening Primrose Oil
Gina: Another option for prostaglandins is going to be evening primrose oil. Evening primrose oil can thin the cervix and make it softer. And there is research that supports that. It can help if you’re already in it. An induction to help improve your Bishop score, which is the favorability of your cervix. And Roxanne will kind of break down what a Bishop score is a little bit later.
But because evening criminal oil is a thinner there is some worry that it could also cause problems. So causing your water to rupture because it’s also going to be thinning the amniotic fluid sac. And so it’s kind of weighing the two of them. Now, evening primrose oil is only effective for softening of the cervix if it’s inserted vaginally, not taken orally.
Orally does nothing. And so if you’re going to use this option, it needs to be inserted vaginally.
Membrane Sweep
The next option that’s going to help to soften the cervix and release those prostaglandins is going to be a membrane sweep. And again, these are usually most effective after 41 weeks, but they can be very painful. So I had a membrane sweep my first pregnancy where I was passed 41 weeks and I was trying to like get things going before my scheduled induction and it was so painful, but I was also like almost zero centimeters.
My cervix was probably very long and hard and so it was just like not a comfortable thing. I was like crawling up the table away from the provider. But in my most recent pregnancy, I had a membrane sleep when I was 41 weeks, but my cervix was super soft. I was already three centimeters. It just felt like a cervical exam. It wasn’t painful at all for me.
And so for some folks, memory slips are super painful, and for others they are not painful at all. And so for me, I’ve kind of experienced both sides of that, but it is invasive. There’s a potential that it can break your water and it can sometimes be really painful.
And so with all of these natural induction methods, like talk to your provider about their recommendations if you’re pending an induction, like I would say, like if you’re just tired of being pregnant, maybe not something that’s necessary to do, but with any of these options, especially the ones are they’re a little bit more invasive like evening primrose oil being inserted or a membrane sleep like discussing with your provider like their recommendations and they’re like opinion on them can also be really helpful. Ideally, we just wait for spontaneous labor in a perfect world, but sometimes that’s not always the best option.
So Roxanne, what are some reasons that you may need to have your labor induced instead of waiting for spontaneous labor?
Roxanne: So there are really two main reasons for labor induction. Instead of waiting for labor, the first and more common reason is a medical reason where it’s either a medical complication that showed up during pregnancy.
So, a new onset condition or one that was there before pregnancy. So was preexisting. Examples of new-onset are:
- Gestational diabetes;
- Gestational hypertension, new elevated blood pressure during pregnancy;
- Too much or too little amniotic fluid also called oligo or polyhydramnios;
- Cholestasis of pregnancy;
- IUGR which is intrauterine growth restriction, where baby is measuring smaller and the percentile is dropping, which is concerning;
- Pre-eclampsia;
- Thrombocytopenia of pregnancy, which is low platelet levels, which platelets are really important with clotting, this can be a concern during pregnancy;
- Post-term inductions. These are still considered medical induction days as a medical need. And usually is around 41 weeks preferably. But some providers kind of consider post-term induction any time after 40 weeks.
And this is in that medical category because the risk is that the placenta may not be able to transfer nutrients and oxygen to baby as effectively as it ages. And this could lead to baby not tolerating labor the longer you wait.
Potentially preexisting conditions can range from either preexisting heart conditions that you have type one or type two diabetes, to chronic hypertension (elevated blood pressure prior to even getting pregnant). Any prior obstetric histories that are like complications are pertinent. So if you’ve had a prior fetal loss, especially later trimesters, so especially the third trimester of fetal loss where your baby had passed in the womb, sometimes they will induce earlier to potentially avoid that complication in this current pregnancy.
But honestly, the risks of reasons that they can induce you for medical reasons are so long I couldn’t even list all of them. These are just the most common that I’ve seen in my experience. And then the timing of the induction is really dependent on the condition and your provider. So for example, with gestational hypertension, the recommendation is 37 to 39 weeks and some providers say, “well, it starts at 37, I will recommend this induction for all gestational hypertension patients, and that’s when will induce everyone at 37 weeks.” But some providers are okay with waiting until that 39 for gestational hypertension at 39 weeks instead of the 37 which gives you a couple more weeks to stay pregnant and potentially go into spontaneous labor on your own.
And then it kind of depends on the severity of the condition as well. So asking these questions with your provider, if they’re recommending induction for a medical reason:
- Asking them, well, when is the best time that we should be inducing based off of like your governing body’s?
- What if I don’t want to be induced at that time?
- Is there a way that we can just monitor maybe closer and try to either wait until baby a little bit older to induce or potentially wait until baby is displaying some more symptoms?
You can always not show up; like no one will come to your house, throw you over their shoulder, and bring you to the hospital because you have a scheduled induction that day. But knowing the risks and benefits and making an informed decision for yourself based on your provider’s questions and answers can be really beneficial.
Gina: So choosing no to induction is always an option, but saying no because you’re afraid of induction or you don’t want to be induced without fully understanding, like why induction is being recommended and kind of your options that is not always the best option either. And so we can use different methods to ask questions, to gather information, to help us better understand is this the best option for us and what options do I have so we can still feel empowered in the decision because we’ll have folks that’ll email or message us, “my providers are recommending induction. Do you think I should be induced?” And we’re like, “Well, we don’t know what your medical situation is. We’re not your medical provider. We’re not going to give you medical advice, but ask questions until you feel confident.” That is the best decision for you. If you’re afraid of induction or something about this story is scaring you, then we need to address those fears so that we can better understand.
Is this a good option for me? Is my provider trying to coerce me into a course of action that’s better for them versus for me? Or is my provider just not maybe explaining things to me in a way that I understand so that I could understand where they’re coming from? Because everybody wants you to be safe and to be healthy.
They may not be totally looking at like how you want to go into labor and how you want your labor to go, like how you want your birth story or your birth experience to be because there are a lot more focus on whether are you in your baby safe.
And so having that conversation with them is going to help you better understand that this is a good option for you or hey, we can take some more time and here are some other options that we have. So just saying no because you’re scared is usually not our recommendation, not that we’re giving you recommendations.
Roxanne: So the other option for induction, aside from medical reason, is an elective induction. And this is an induction after 39 weeks that has no medical reason. And the reason that these are recommended more so especially recently, is because there was a study released in 2018 that was called the ARRIVE trial. So the ARRIVE trial came out and they set out to learn if by inducing people at 39 weeks, this would lead to fewer complications in deaths for infants compared to waiting for labor.
What it actually found was that there was a decreased risk for C-sections if induced at 39 weeks versus waiting for labor. But there was actually no improvement in the complication in death rate for infants. So this study came out and practice changed dramatically in OB care where elective inductions were offered to everybody, sometimes even without proper informed consent on the risks and benefits of the elective induction.
And then again, taking into consideration your birth wishes, some people would just go to their appointment at 39/40 weeks, and their doctor would be like, okay, like you have an induction scheduled for you tomorrow. Like we’re giving your baby an eviction notice like we’ll see you then and not really discussing what that entails, what that induction looks like.
And that’s usually the issue that I have with it is that people were coming to the hospitals scheduled for an induction and they’re like, “okay, so like, I’m going to meet my baby here soon.” And I was like, “No, your cervix is closed. This could take 3 to 4 days.” And they’re like, Nobody told me this. And I was like, These are things that would have been great to know during that prenatal visit where they scheduled this induction.
Questions to Ask for Elective Induction
And I also know, like with elective induction, this option may be a great option for people like I know people who choose to have elective inductions, who know all of the risks and benefits, and that is their choice. But there are also people who are not given the choice to make the decision for themselves, and that’s when it kind of becomes an issue.
ACOG, which is the governing body of OBGYNs, has even released guidelines on the use of inductions as elective inductions. And they even do not recommend that everyone should have an elective induction. They should really be considering three things before even offering you an elective induction:
- Is what are the values and preferences of your birth and wishes that you’re wanting from your birth?
- What are the staffing and facility resources that are available? So like we have to be able to assist these longer labors and inductions on our labor and delivery units, but not every hospital can accommodate that. So some hospitals have three labor beds and if you have all three of those beds held up by an elective induction, that is going to potentially take three days. If someone else comes in in spontaneous labor, they’re going to have to deliver in triage or in the hallway. So that just doesn’t make sense. Or if you only have four labor nurses, you can’t call in all of your elective inductions at night because then it’s just not doesn’t leave a nurse available to take somebody who does come in in spontaneous labor or comes in with a complication like off the street.
- And then the last is what is the protocol for failed induction? And I hate using the word failed because it has so many negative connotations with it. But like what is there a protocol for calling an induction that is not progressing and potentially needs to have a C-section? Having a set standard protocol before they can decide like, “hey, this induction is not moving towards vaginal delivery, we are recommending a C-section” is the best way to kind of avoid unnecessary C-sections potentially.
Reasons Elective Induction May Not Be Ideal
But not all hospitals have a protocol. Sometimes they leave it up to the providers to make that judgment call at the moment. But some providers may have less leeway in their judgment, while others may be more patient with their judgment. So not having that protocol, it could potentially lead to an increase in C-sections where maybe there are other options available and reasons.
And it might not be the choice for you like personally, like one: you’re wanting a low intervention birth, an elective induction is not the option for you because it’s going to have a ton of interventions because they’re trying to stimulate your labor. It’s just not an option to go there and only use natural induction methods to be electively induced at that point you should of just stay at home.
If your provider has a high C-section rate, especially if it’s with inductions, this is probably a sign that there may not be as patient with your induction and it may lead to a C-section. So every provider has a different C-section rate and usually providers will have an idea. So you can ask them like, “Oh, what is your primary C-section rate?”
So the primary C-section rate is how many first-time C-sections are they doing on a person, regardless of if they’ve had vaginal births before, like primary C-section? Is this the first time that they’re having a C-section? What is that provider’s rate? They may not know specifically, like, oh, people who are induced, this is my C-section rate, but they should know their primary C-section rate.
And then you can decide based on that rate that they give you or you can even look it up. I think that there are websites that you can even look up. Leapfrog, I think, is the one that I can think of off the top of my head. But nationally, our C-section rate is about 30%. So if your provider is above that elective induction, maybe not the best choice.
If your provider is below that, maybe they are very patient with the process and have a high likelihood of leading to a vaginal birth.
And then the last one, your birth location does not provide medical induction options. So a.k.a you’re delivering in and out of hospital birth a freestanding birth center, or you’re delivering at home. An elective induction is 100% not available for you because they cannot do the medical induction methods out of the hospital. So they can’t give you Pitocin at home. They cannot give you like cervical ripening agents when you’re at home to try to stimulate labor, they can use a little bit of those natural induction methods, potentially with the membrane stripping, breaking your bag of water, potentially giving you some other things to stimulate labor.
But they cannot use like the normal medical interventions for induction. And with the ARRIVE trial, it’s important to note in the ARRIVE trial, the C-section rate, just like normal C-section rate for people who came in spontaneous labor was 22%. So I said the national average of our country is 30% for C-section rates. And in this study it was 22% for spontaneous labor and 18% for elective inductions.
Those two numbers are incredibly low when you think about like what is our national average. So, there is a thought that providers in the study, like the different hospitals in the study, knew which hospitals were a part of this ARRIVE trial. They did not necessarily know who was being elective induced and who was being like who was waiting for spontaneous labor, who are a part of this trial.
But they knew that this hospital was a part of this ARRIVE trial and they’re looking at elective inductions. So they could have potentially been altering the way that they may normally have practice. That altered the results leading to this way crazy lower C-section rate or that the hospital could have just been really great and that’s just their normal C-section rate.
So thinking about that, like if you know that the national C-section rate is 30% and then in this study it was like 18 and 22%, it makes you think that maybe like something was off. So if you think about it in a way, these providers might have known that someone was going to go back and look at all of their notes for the patients that were a part of the study to see what they did, if they followed protocol, if they followed standards.
So it’s similar to like if my toddler, I tell her she can’t eat any cookies and I’m standing right there watching her. She’s probably not going to go grab a cookie. I mean, she might, but most likely, like, you’re not going to grab a cookie when your mom is watching you because you don’t want to get caught. It’s like they weren’t in the study.
Potentially they would have grabbed that cookie. I cannot confirm or deny if these are true allegations, but these are my thoughts with the ARRIVE trial because like they set out to see if like neonatal complications were going to be adjusted. And in actuality, they found that the rate of C-section was actually decreased. Is elective induction the best way to avoid having a C-section and elective induction at 39 weeks?
Ways to Reduce the Risk of C-Section
- Having a midwife as a provider
- Homebirth or Freestanding Birth Center
- Having a doula or continuous labor support
- Intermittent Auscultation or Monitoring
- Planned Water Birth
Is that the best way to reduce your chance of having a C-section? There are so many other ways to reduce your C-section risk other than having an elective induction that are less time consuming in a way. So having a midwife just in general has lower C-section rates, midwives have lower C-section rates, especially if you are out of hospital.
So, homebirth or freestanding births centers have really low C-section rates. If you have a doula, or having someone provide continuous labor support, they say this can decrease your C-section risk 25%.
Gina: So one of the reasons why I think having a midwife especially with out-of-hospital care and then I do look at help reduce the risk of having cesarean birth is one if you’re out of hospital you don’t have the same options available to you as a provider. So my midwife at home, did it have the option to have a cesarean birth?
If I had a labor stall, like she had to use other things to help try to stimulate my labor like she didn’t have the option to hook me up to an IV and give me pitocin because my labor was slow. We had to explore other things to help progress my labor. And so we’re going to look at, well, what’s baby’s position?
And like, how are you feeling? Like we’re going to explore other things when it comes to having a dialog with you. And obviously, I advocate for doula here as I am one and I think I’m amazing. But having a doula that’s giving you continuous labor support is a similar thing. So doulas are different than midwives. A doula is not a midwife.
A midwife can provide some similar support as a doula if they have the capacity beyond providing medical care. But a doula is a nonmedical like birth buddy essentially, so they’re there to provide you support and they tend to have the most emotional connection with you out of all the members on your birth team, besides your birth partner, who ideally has the most connection with you.
And so as a doula, I don’t have access to medical skills or I don’t have access to medical interventions to help progress your labor. And so I’m going to be looking at things with a different lens. I’m going to be looking at your movement patterns. I’m going to be paying attention to your subtle cues, and your temperament, giving you labor positions like helping you with comfort techniques.
And so I’m going to use a different set of skills to help progress really work because I don’t have the option to give you Pitocin. I as a doula am not going to give you a C-section. And so those are probably some reasons why midwifery care, out-of-hospital birth and having a lot of help to decrease the cesarean birth rate is because we have a different set of tools that are available to us that are beyond Pitocin and beyond necessary.
It’s not that either of those options is not a valid thing to choose at any point, but we are going to have other things to bring to the table to kind of enhance your labor experience.
Roxanne: Intermittent auscultation versus continuous fetal monitoring. If you are only monitored intermittently and not continuously, you are more likely to have a vaginal birth and C-section. And intermittent auscultation has been proven to be a safe method of monitoring baby in low-risk pregnancies. This also gives you more movement freedom during labor, which movement during labor is another way to decrease your C-section risk.
Just like a side benefit of planning a water birth, which I’m always a huge fan of because I loved my water birth. This also decreases your C-section risk. For some reason, I’m not entirely sure why planning a water birth decreases it, but that’s another way to decrease your C-section risk.
And all of these methods cost less money, and they’re less time-consuming than coming in for an elective induction that potentially could take 3 to 4 days.
And it’s important to note that, like with all of those other options, the risks associated with them are pretty low whereas induction, I mean, induction is not zero risk. Everything we do in life has risks, but inductions have a little bit more risks for you and your baby with labor, and understanding those risks and benefits and being able to make that choice for yourself on whether or not you want to be electively induced is what I advocate for.
So, asking the questions if your provider is saying to you at 39 or 40 weeks that they have scheduled you for an induction without giving you the choice to say yes.
Gina: And so when it comes to Labor induction, it’s a valid option to take, especially if you have a complication or pregnancy and continuing your pregnancy may not be the best option for you and your baby.
Or if you do decide that you want to be electively induced. And I mean, we live in a military community where sometimes birth partners have really unpredictable schedules, where they went away on deployment. They’re only home for like two weeks for the birth of the baby. And so we’re kind of on a timeline. And so elective inductions can make total sense if it’s for family planning reasons, like, hey, I can only have the grandparents come and help me out postpartum with my other kids if they’re here for these like two weeks.
And so elective inductions are a valid option if it works best for you and your family, medical inductions can be a valid option to give birth, especially if we’re having complications where your pregnancy is potentially not as safe to continue as doing the Labor induction.
But when it comes to induction, a common trend that I see as a doula a common trend that I felt for myself was the fear of induction.
The Fear of Induction: Pitocin
There’s a lot of misconceptions about Pitocin and there’s a lot of fear involved with being induced, especially if it’s a change from your birth plan. And so I would say for the majority of my clients, most of them are planning a low intervention birth, either out of hospital or in the hospital, most of them don’t want to have an epidural.
Some of them do, but most of them are looking to go into spontaneous labor. Like, I don’t really have a ton of clients that hire me that are like, “Hey, I’m planning to be induced at the end of my pregnancy.” Now, there are some of them that do know that the likelihood is a little bit higher based on preexisting conditions.
But overall, when it comes to being induced, a lot of them get like really scared and afraid in the moment. And so, for me personally, during my first birth, I went past my due date, my provider just kind of told me that this was my induction day. And for the hospital where I was giving birth, it was ten days past the due date was like the standard.
And so, the nurse practitioner just didn’t want to have a conversation with me about it. And I was really taken aback because I had felt like very empowered and that I should advocate for myself and I didn’t know what to do when she would it entertain and conversation with me. And so I was like really afraid of Pitocin and I was really afraid of induction kind of quote unquote, like ruining my birth plan and my birth dream.
Like I wanted to have an unmedicated birth. I wanted to feel that power giving birth unmedicated. And so I share more about my first birth story in episode two of our podcast. But I was really afraid of Pitocin and I didn’t understand it. I just thought I was this like horrible drug and I thought it was just going to ruin my experience in hindsight.
Now, like, the more I know about induction and the more I understand about the different methods that are utilized, induction isn’t as scary as I thought it was. And what I remind my clients of this of like, Hey, I know that Pitocin sounds really scary. You’ve heard all these horror stories about Pitocin, like it’s going to be okay.
Like it’s not an immediate 0 to 1000, like an intensity. It is still a gradual build. There’s things that we can do to kind of enhance your natural oxytocin flow fetus. It is not evil by any means. It can be really helpful. They kind of like kickstart things as well. But would it have been really helpful for me was to understand what induction was, what the options were like, kind of what to expect with an induction.
And that was the conversation that my provider was not willing to have with me in that moment. It was just kind of like a rush in and out.
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Roxanne, could you explain what someone could expect if they were going in for an induction, whether it was for medical reasons or for an elective reason?
Labor of Induction Timeline:
- Admission
- Vaginal Exam to assess Bishop Score and decide on the initial plan
- Saline Lock and IV placement
- Medical Induction Methods
- Will vary depending on your Bishop Score
- Cervical Ripening
- Mechanical Dilation
- Augmentation with Pitocin
- Artificial Rupture of Membranes
Roxanne: Yeah, and that is a very common thing, is that people are very fearful even when they arrive for their induction, they are like, I’m really nervous about this. Like I don’t know what to expect. And then this is like things that I kind of go over. So one is what to expect when you arrive for your induction.
So first you’re going to be admitted to labor and delivery. So they’re going to give you a gown if you want to wear it. Also, know that you don’t have to wear the hospital gown if that makes you more comfortable. And then they can give you underwear. Even if you want to wear underwear, and then they’ll do a vaginal exam.
Once you’re fully admitted, you, like have your I.V. in place.
The Bishop Score: The Assessment of the Cervix
And based on this vaginal exam, they’re going to develop a bishop score. Bishop score is based on the dilation of the cervix, and the position of the cervix, because usually the position of our cervix is posterior. Posterior means behind baby’s head. And that is why when you have a cervical exam when you’re not really ready to go into labor, that cervix is being protected.
So, it’s being protected by being posterior so that it feels like a lot further away of something that enters the vagina. But that means that your provider has to reach all the way behind your baby’s head to find the cervix. That feels like they’re reaching for your brain, not comfortable. And there are things that you can do to kind of make it a little bit more comfortable.
But because of just the position of that cervix, it’s really uncomfortable. But as you progressed through labor, that cervix moves more anterior, so more towards the front, so it’s easier to find the cervix.
The other thing they’re going to look at, so this is how thin the cervix is. What station is your baby in your pelvis? And then what is the consistency of the cervix?
So is it really soft or is it like really, really, really hard based on these five things that you get a certain number of points depending on what your score is on each of those five things. And if your bishop’s score is greater than a six, they say that your cervix is favorable for either going into spontaneous labor or it’s favorable for an induction to lead to that vaginal delivery.
If your bishop score is really low, where your cervix is closed, it’s very thick and posterior and baby’s like not engaged in the pelvis at all. This does not mean that you’re not going to have a vaginal birth and your induction is going to take forever. Because I’ve seen people who’ve have these low bishop scores of like zero or one who have their baby in like 12 to 24 hours.
So it’s really just like a tool that they use to kind of have an idea of how long this process is going to take. But that’s really all it is for. And that also helps them decide what method they’re going to use. They’re then going to implement these induction interventions to help Labor start on its own until the point that it’s either self-sustaining or a baby is born. You may need all medical induction methods. You may only need one. It’s really just the goal is to get you into labor and have a baby.
Cervical Ripening Agents: Soften the Cervix
What are the methods of induction though? So for medical induction, there are four main methods, the first one being a cervical ripening agent. So, this is usually used when your cervix is not open at all, such as closed, one or two centimeters, but it’s still very thick.
If your cervix is really not effaced at all, so like 50% or less a cervical ripening agent can be very beneficial. So, if you think about like a rubber band, if you have 12 rubber bands in your hand and you try to open them and pull them apart, it takes a lot more effort than if you had one band pulling it apart, and that’s similar with the cervix.
So if we think about the effaced one of our cervix, if our cervix is very thin, it’s a lot easier for it to then dilate rather than if it’s very, very thick.
So there are two main types of cervical ripening agents that are used. One is cervadil, which is like a tiny, like thin piece of fabric that has medication inside. It has a tail that they place next to your cervix and it just releases medication slowly over 12 to 24 hours, depending on your provider. They just leave it there and it causes your cervix to thin out efface. Sometimes it can cause contractions, but that’s not the goal. The goal is to thin out that cervix. This one is nice because once they place it, they just leave it there until they pull it or you go into labor so you don’t need vaginal exams and you can kind of just relax and rest as you can.
The other option is cytotec. This is a small, tiny, tiny pill that they’ll either place vaginally or you can take orally. And this is given every 4 to 6 hours depending on your provider. So this one does require more vaginal exams. There are going to be giving you more doses potentially over time, whereas with cervadil they place it.
You can sleep overnight with Cytotec they’re going to have to come and wake you up after 4 to 6 hours to check your cervix and then give you another dose. They can give you multiple doses of the cytotec and they can place the cervical more than once. The goal is to get that cervix thinned out before they move to the next step.
Mechanical Dilators: Open the Cervix
The next step is usually some sort of mechanical dilator. So this is where they’re placing something either called a Foley bulb, where you use a catheter to help open the cervix to cause it to open forcibly in a way. But it’s also like a natural kind of nonmedicine option because it’s not introducing any medicine to the body. It’s hopefully trying to stimulate our own release of prostaglandins to see if we can stimulate labor that way while trying to dilate the cervix.
Mechanical dilators are used commonly with Pitocin, but more studies are showing using it in combination with a cervical repeating agent is a little bit more effective at stimulating labor.
Pitocin and AROM
The next two options are artificial rupture of membranes (AROM) or Pitocin.
These two depend on their provider of which one they’re going to implement.
With artificial rupture of membranes, some providers will do this one versus starting with Pitocin first, and this is when they’re breaking your bag of water to hopefully allow baby to drop further into the pelvis and put more pressure onto the cervix to hopefully cause it to dilate with artificial rupture membrane.
They don’t need to continuously monitor. You have a little bit more freedom of movement. So this is a choice some people make to use for their induction.
Then some people choose to start Pitocin first so that they have strong contractions before breaking their bag of water. Because that bag of water is a cushion between your baby and your pelvis, and having your water broken can make contractions a lot more intense.
Gina: The thing to remember about AROM is having a water broken versus pitocin is if you have your water broken, you can’t reattach it. Like we can’t like put your water bag back together and like push it back up in there while Pitocin, they could always turn off.
Another perspective to take in addition to if your hospital has wireless lights or portable monitors where you can still move around freely, then maybe you want to opt for Pitocin, even though you have to be continuously monitored because you can still move freely versus having your water broken.
Now, if your hospital only has a wired monitor where you’re kind of stuck like six feet from the monitor, then maybe you may prefer to have your water broken so you can move around freely. And so those are some different considerations that some of my clients have had when trying to decide which one they want to do. Again, all of the interventions still come with some sort of risk, but you also want to look at what are the benefits or how will my care change if I take this intervention versus the other one.
And so weighing those two options with your provider to understand, like your individual labor situation, because for some folks your water breaks and like labor just goes on like really quickly from there.
And for other folks who just need like a little bit of pitocin to like get things going and then their water breaks spontaneously. And so understanding your individual situation, kind of the options available to you in the hospital, and having the conversation with your birth team can be really helpful to decide like which one you want to do.
Pitocin
Roxanne: Pitocin is probably the one thing that everybody is most fearful of when they hear that they have to have a medical induction here. “Pitocin contractions are a lot more painful. They’re like really hard on my baby. If I get Pitocin, I’m going to have to have a C-section.”
Pitocin is a tool that is beneficial, especially like if you need an induction and you can’t wait for labor to start on its own. Pitocin is there to stimulate contractions. Pitocin is a synthetic version of oxytocin. So oxytocin is the love hormone we release and when we’re happy, we feel loved, safe, and supported. The oxytocin crosses our blood-brain barrier, releasing an almost euphoric feeling when we have oxytocin released in our bodies like it, we’re very happy when we’re releasing oxytocin.
About the only similarity with oxytocin that pitocin has is that it causes uterine contractions, but otherwise, it is really a completely different drug. It does not cross our blood brain barrier, so does not give us that euphoric feeling.
It is not released in the same manner where it’s like it’s just a constant dosage where they’re going to increase and decrease it a little bit. Whereas oxytocin is very cyclical where it’s changing like at any given moment, the amount of oxytocin rushing through your body is different.
During labor, with oxytocin, you get natural pauses in your labor depending on that positive feedback. Maybe you need to rest. Maybe you need to like eat something so your body’s going to slow labor down, whereas with pitocin you get no rest. It’s just pitocin in going until you have a baby. So you don’t get those natural pauses in labor with pitocin and with pitocin, it is a synthetic version of oxytocin where it’s hopefully going to tell your brain start stimulating and releasing oxytocin as well.
So sometimes we need to really monitor Pitocin closely because if you start to release your own natural oxytocin, but we’re still giving you the same dosage of pitocin, this could cause your contractions to come too close together or last too long. And cause distress for your baby.
Pitocin is a high-risk medication that we should be monitoring, and that is why they have to continuously monitor you. But other than causing uterine contraction, it does not work in the same way as oxytocin. With oxytocin, again, it crosses that blood brain barrier. So it gives you this euphoric type of feeling that accompanies your contractions.
So your Pitocin contractions do not have that feeling, so it’s just contractions. Whereas with oxytocin you have like maybe takes the edge off a little bit. So the contractions strength of pitocin and oxytocin may be different. It may also just be the same. But you perceive the contraction of a pitocin a lot differently and it’s usually perceived as a lot more painful.
So if you need pitocin for your induction, it is not going to cause your labor to be completely harder than if you went into spontaneous use labor with oxytocin. It is a tool that we can use to help stimulate labor in. Our goal is to hopefully be able to turn it off because your labor is self sustaining because you’re releasing your own oxytocin with pitocin.
It’s also beneficial during the postpartum, especially if you are having postpartum hemorrhage. So when we think about pitocin like there is immediate fear that a lot of people have with it, but it also is a really good tool that we have. All of the induction methods that we’ve discussed is a really good tool that we have for people who do not have the option to wait for spontaneous labor or do not want to wait for spontaneous labor.
But fully understanding all of these options can help kind of take away that fear associated with the induction process, because you fully understand and you can kind of make more of informed decisions on your induction and be an active participant in your birth process.
Gina: And so when it comes to Labor induction, again, it’s a valid option to give birth. It can be a really good choice to make. It could also be a choice that you can wait on as well. And so this is we’re having in depth conversations with your provider can be really helpful.
And so we can use the acronym BRAIN when it comes to making informed decisions.
- Benefits: We can understand what are the benefits. Why are you recommending this to me? How is this going to improve my birth outcomes? How is this going to improve my care for both me and my baby?
- Risks: What are the risks of this recommendation? How are those risks going to be mitigated? Why are these risks worth taking? Are these risk worth taking for me and my family?
- Alternatives: What are the alternatives? Well, there are options. Do I have do I have to be induced right now? Can we do extra monitoring to kind of check on and baby, what other options do I have besides induction or is induction the best option for me right now?
- Intuition: The next one is going to be intuition. What is your gut telling you? And then I also like to think, do you feel confident that this is the best decision for you? It doesn’t have to be the decision that you like. Like you may want to have a low intervention birth and you don’t want to be induced, but you know that it’s the best decision for you and you feel confident that you have enough information to make that decision.
- Nothing: And the last one is going to be nothing. What are the risks and benefits of just taking more time before we make a decision? Do I have time to make a decision? Like what are the alternatives available to me? Because sometimes the alternative is no or doing nothing. And again, we don’t recommend that you just say flat-out no to induction because it can be a very good thing to do.
Induction is are not evil. But again, weighing kind of the risks and benefits of them and understanding what induction is, how does your provider manage induction? That can be a really great question to ask them too. Like if I have to be induced or you’re recommending induction, what could I expect? Like how does your clinic, how does your hospital manage inductions? What could I expect that to look like?
The other thing to ask is how will these different interventions change my care? And so if you’re trying to decide between having water broken or getting Pitocin, like understanding how your care may look different with each of those situations will be really helpful to help you make that decision as well.
Because what we don’t want to do is to make a decision and then be surprised when you have to be continuously monitored all of a sudden or your care has really changed, like they only want you to stay in the bed and that’s really hard for you to cope with your contractions.
And so when we’re trying to decide whether or not we want to have an induction or we want to continue our pregnancy, we could use the acronym BRAIN.
So what are the benefits? What are the risks? What other options do I have? The alternatives? What is my intuition telling me? What is my gut? Tell me and do I feel confident in this decision? And if not, I have more questions to ask and then what if we do nothing or if we take more time?
And so you can use those questions to kind of prompt the conversation with your provider so you have a better understanding of what to expect and whether or not this is the best decision for you.
Because again, induction is not evil, pitocin is not evil, but it’s not always the answer either. Like it’s not everybody needs to be induced, but there are some folks that that is the best decision for them based on their individual circumstances.
Conclusion:
Roxanne: So just to wrap it up, induction is not inherently bad. Sometimes it is necessary for your specific case and for your specific labor, understanding the risks and benefits and being able to make that decision for yourself and feel confident about that choice can make a huge difference in how you experience your birth.
Gina: If you want to learn more about Labor induction, what are your birth options? How can we facilitate this conversation with your provider? Join our childbirth education course. We have an entire section in, of course, about birth planning and what to expect during your birth so that we can feel confident that it’s the best decision for us, that we can feel confident and make a decision throughout our entire birth, and we can feel confident that we can facilitate that conversation so that we can have the best care with our chosen birth location and birth provider.
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