Pregnancy

Understanding Labor Induction

Induction of Labor

Induction of labor is when labor is medically initiated before it naturally begins on its own. This is done for a variety of reasons, but it is a decision that you make with your doctor or midwife, usually later in your pregnancy. That said, there are a few instances when you might know earlier in your pregnancy that an induction might be the best thing for you or your baby.

Why Is Labor Induced?

Labor can be induced for many reasons.

Labor should only be induced for valid medical reasons because of the risks involved with induction of labor. Some of these medical reasons include:

  • Infection

    Having a uterine infection or an infection of the amniotic sac (chorioamnionitis) is a reason to induce. You do not want the baby to live in an infected environment. Typically an induction is done while simultaneously treating the infection. This may also cause the amniotic sac to release prior to the start of labor, without regard to the length of gestation.

  • Diabetes (Gestational or Type I and II)

    Gestational diabetes or type I diabetes are both common reasons that mothers are induced at the end of their pregnancies, but before the fortieth week. The World Health Organization (WHO) says that if gestational diabetes is the only complication, you could consider going to the forty-first week of pregnancy, but many practitioners are worried about increased weight in the baby, the potential for shoulder dystocia, and stillbirth.

  • High Blood Pressure in the Mother

    When a mother experiences high blood pressure in pregnancy it can place her health and the health of her baby in jeopardy. This can occur at any point in pregnancy, but it more often occurs at the end. It may be something that happens suddenly or that slowly builds over time. Having high blood pressure may also be a symptom of preeclampsia or eclampsia. Untreated, high blood pressure can lead to severe complications including stroke in the mother, and death in the mother or baby. Once a pregnancy has reached thirty-seven weeks, there is often little question of if induction would be more beneficial than waiting when a mother has certain blood pressure readings. Your doctor will help you figure out what is the best practice given your specific symptoms.

  • Completion of Forty-Two Weeks of Pregnancy

    A pregnancy that continues past the forty-second week is considered to be too long for an average gestation. At this point the American College of Obstetricians and Gynecologists (ACOG) says that, even without medical reasons in the mother or baby, timing alone is sufficient enough reason to induce.

There are several other reasons why labor may induced as well, including premature rupture of your membranes (PROM), which may or may not be occurring with an infection; it may also be indicated if your baby does not do well on a screening test like a non-stress test (NST) or bio-physical profile (BPP), or if your baby is experiencing intrauterine growth restriction (IUGR).

Talking with your doctor or midwife is important to understand why an induction of labor is being recommended and what your options are.

What Is a Social Induction of Labor?

A social induction is also known as an induction for convenience of either the doctor, the midwife, or the family; it's also another name for an elective induction.

It may be done to get the practitioner that you want, to aid in family scheduling, or to try to pick a certain birth date. This is highly discouraged due to the added risks of induction of labor (more on this below). Labor induction for any reason should not be considered until after thirty-nine weeks when possible.

What Are the Risks of Inducing Your Labor?

There are several risks associated with labor in general that may be more common with an induction of labor. For this reason, there should be clear and specific benefits to outweigh these risks for you or your baby before agreeing to the procedures suggested. The risks of induction can include:

  • Increased risk of prematurity, even if you believe your baby is term: Your pregnancy may be, say, thirty-eight weeks, but your baby may respond more like a baby born at thirty-six weeks. This can be very problematic and mean anything from a stay in the neonatal intensive care for breathing difficulties to problems maintaining body temperature and feeding.
  • Placental abruption: This is where part of or the whole placenta prematurely separates from the wall of the uterus. As a result, the mother experiences internal bleeding and the baby is unable to get oxygen because the supply has been cut off from the uterus.
  • Fetal distress: This is when a baby does not tolerate an induction well. This is typically found with fetal heart rate monitoring. (One of the added procedures when doing an induction is continuous fetal monitoring to watch for signs that your baby's heart rate is too fast or too slow, or simply acting erratically in relation to the contractions.)
  • Uterine rupture: This is where the force of labor contractions can result in a tear in the uterus.   This may occur if you have had a previous uterine surgery, like a Cesarean section, but in rare instances can happen without any risk factor.
  • Increased risk of Cesarean section: Contractions can start with the introduction of medication, but your cervix can't always be convinced to open. Sometimes an induction is stopped and a mother is sent home to try again later; other times, she needs to deliver immediately, and a C-section is the best option. Reasons for the latter can include complications from the induction, such as fetal distress, abruption, or a uterine rupture.
  • Increased use of procedures including pain relief, continuous fetal monitoring, and other interventions (even when they were not originally planned): Spontaneous labor and induced labor can feel very different. This may mean that what you had planned to use for coping methods may not be adequate. If labor is longer because it is being artificially started, you may also become extra tired.

The medical staff assisting you will work to reduce the risks when possible. This may mean additional monitoring (including blood pressure monitoring and fetal monitoring) or medications to ensure you and baby stay as healthy as possible. When induction is needed for medical reasons, the benefits of induction outweigh these risks. This is a decision to be made between you and your practitioner.

How Is Labor Induced?

Labor can be induced a number of ways. Some of the more common methods include:

  • Breaking the bag of water (amniotomy): A small hook-like device is used during a vaginal exam to gently nick the amniotic sac and create a tear to allow the fluid to release. The sac does not have nerves, so neither you nor the baby will feel the tear. What you will feel is the vaginal exam, the release of the water, and the movement of the baby.
  • Pitocin: This is the synthetic version of a natural hormone to start contractions. It is given via an IV line, and you'll be monitored to gauge its effectiveness. Dosing can be increased to create a realistic contraction pattern.
  • Prostaglandins: These are typically delivered via the vagina as a gel or suppository, but there are other forms. The goal with these medication is to allow the cervix to soften and prepare to open. It is often a starter method that is later combined with another option.
  • Foley catheter: This is a catheter with a balloon that is placed through the cervix and expanded.
  • Stripping the membranes: This is an office procedure and one of the only methods not used in the hospital. During a vaginal exam, your doctor or midwife will insert his or her finger into your cervix and attempt to separate it from the amniotic sac without breaking your water. This may or may not cause contractions and/or cramping, and sometimes spotting.

Natural Methods of Labor Induction

Many women are turning toward more natural methods of labor induction with some success. The definition of natural really varies in terms of the level of intervention required. The most common home induction tricks can include:

  • Nipple stimulation: This can include manual or oral stimulation of the nipples. Some use a breast pump to help release natural oxytocin to cause labor to begin.
  • Castor oil: This is typically taken orally in a variety of recipes. It causes diarrhea and potentially dehydration, so it should only be used with the advice of your practitioner.
  • Sex: While the studies are mixed as to whether or not sex will bring on labor, the female orgasm does release oxytocin into the body, and semen does contain small amounts of prostaglandins. As long as it's something you want to do and your water isn't broken, most practitioners think this is a great method to try.
  • Relaxation and visual imagery: This is done as a way to relax you if you are feeling particularly anxious about the upcoming labor, being a parent, or whatever may be mentally preventing you from going into labor. Whether it brings on labor or not, it's a great way to promote rest, which is beneficial at the end of pregnancy and will help you when labor does finally start.

Augmentation of Labor

Sometimes labor stalls or is delayed at various stages. If your health or that of your baby would benefit from labor continuing more quickly, your practitioner may prescribe an augmentation of your labor. There are multiple methods of augmentation, including the use of Pitocin, amniotomy, and other natural techniques that can also be used as a primary induction of labor method.

What to Ask if Labor Induction Is Suggested

If induction of labor is brought up, be sure to ask your practitioner the questions you need answers to to feel confident about making a decision. Here are some to consider:

  • Why are you recommending an induction of labor?
  • Are there any alternatives to induction of labor?
  • What would happen if I were to wait for labor to begin naturally?
  • Is there some additional testing that we can do?
  • What does induction of labor look like for your practice? For my situation? What methods would be used?
  • What are the risks of induction for me personally? For my baby?
  • If there are added risks, what can be done to mitigate them?
  • Can I have some time alone to think about this and talk with my partner?

These conversations are important for you, your baby, and your practitioner. This will help make sure that everyone understands what is going on and what the best thing is for you and your baby.

Sources:

American College of Obstetricians and Gynecologists. Labor Induction. January 2012.

Boulvain M, Stan CM, Irion O. Elective delivery in diabetic pregnant women.Cochrane Database Syst Rev2001, Issue 2. Art. No.: CD001997; DOI: 10.1002/14651858.CD001997.

Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2

Gülmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub3

Jozwiak M, Bloemenkamp KWM, Kelly AJ, Mol BWJ, Irion O, Boulvain M. Mechanical methods for induction of labour. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD001233. DOI: 10.1002/14651858.CD001233.pub2

Obstetrics: Normal and Problem Pregnancies. Gabbe, S, Niebyl, J, Simpson, JL. Fifth Edition.

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