We know how you feel. It's been a long pregnancy and you want it to be over. You've got plans to make, Grandma's plane ticket to book and childcare arrangements to organize. You're uncomfortable and exhausted. We understand, really we do. That's why we're going to talk about induction of labor. We're not necessarily going to schedule one, but we know it's a reality in many pregnancies. Sometimes, inductions are necessary and appropriate. Sometimes they're a lousy idea. Let's talk it out, shall we?
What is an induction?
Induction means we start labor for you instead of waiting for it to start on its own. We use two types of medications: Cervical Ripeners and Pitocin. Not every patient needs both.
Cervical Ripeners are pills, gels and tampon-like applicators, inserted into the vagina. They help the cervix prepare for labor. Pitocin is a synthetic version of Oxytocin – the hormone that causes contractions.
Why do an induction?
There are many good medical reasons for induction. The American College of Obstetricians and Gynecologists list these common indications for "getting the ball rolling."
* Your pregnancy is post-term (more than 42 weeks).
* You have high blood pressure caused by your pregnancy.
* You have an infection in the uterus (chorio-amnionitis).
* You have premature rupture of membranes (your water has broken).
Induction may also be recommended if your baby is showing signs of poor growth, circulation or other health concerns. He or she might be healthier if delivered sooner than later. Maybe, Baby's getting so big, we're worried he/she won't fit through the pelvis; or the placenta isn't working as well as necessary to continue a healthy pregnancy.
Maybe you'd be healthier if delivered sooner than later. Certain medical conditions make it tougher to hang in there for the last weeks of pregnancy: high blood pressure or Pregnancy Induced Hypertension, Diabetes, heart disease, history of herpes or other medical conditions.
There are also some good social reasons for induction but not as many as you'd think. We understand how miserable women get during those last few weeks but unfortunately, if your body or baby isn't ready for labor, induction may do more harm than good.
Karen Parker Linn, CNM says: "I'm happy to do inductions where there are good reasons. If a mother or baby's health is in danger – that's a no-brainer. The harder decisions come when Mom's just uncomfortable, anxious or has extenuating circumstances (like difficult childcare arrangements or a husband who's being deployed) and wants an induction but isn't physically ready. We hate to be the bad guy and say "No" but we're not doing anyone any favors by taking shortcuts that aren't safe."
Karen says the most difficult inductions are the ones that are medically required but resisted by the patient. "I hate being the person to present induction as the best option when patients are fearful and resistant. There's a lot of press and even movies that present Pitocin as an evil drug leading to that slippery slope of intervention and c/section. First, the momma must accept that induction is being recommended out of concern for either her health or the baby's and not for provider convenience or some other sinister reason. Then we can talk about approach. There are alternatives to Pitocin that are sometimes appropriate such as releasing the bag of waters. Many patients don't even want an IV, let alone drugs so I know they must travel a long way in their thought process to accept induction. The absolute key is talking with your provider about your fears. Then we can address them in an acceptable way and make a plan that softens the road between completely natural and artificially opening the door to the birth."
How do we know you're ready?
First, we make sure you're very close to your due date. Though 38 weeks is usually considered full term (most baby's are fully developed by this time), due dates can be inaccurate. We don't want to risk delivering a premature baby.
We also check your cervix to make sure it's ready for labor. If it's soft, starting to thin out (efface) and dilate (open up) and baby's head is low in the birth canal, chances are good labor will progress well. If the cervix isn't ready but an induction is medically necessary, we'll use cervical ripeners to help get the job done. Induction sometimes takes longer than many patients expect; even a couple of days.
Here's how it works:
If your cervix needs "ripening" your nurse will start fetal heart monitoring, check your cervix, and insert the cervical ripener. There are a few different types and we'll select the right one for you. Cervidil is like a tiny tampon that stays in all night and is removed in the morning. Misoprostil (a quarter of a pill) and prostaglandin gel are inserted behind the cervix and may require repeat doses.
Sometimes, cervical ripening is all that's needed to get labor started. Usually, however, it only produces mild cramps (if anything). You'll probably sleep most of the night (if you're restless, we'll offer a safe sleeping pill) and we'll start Pitocin in the morning.
Your nurse will start an IV and hang two bags of fluid that drip into one IV site in your arm. One contains a plain, non-medicated IV solution called Lactated Ringers (LR). The second bag contains Pitocin diluted in LR. It's infused through a computerized IV pump that gives very precise doses – exactly as much as you need and no more. Your nurse will increase (or decrease) the dose about every 20 minutes until you're in an effective contraction pattern.
Since we want to make sure we don't give you too many or too few contractions, we'll use fetal heart monitoring to watch baby's heart and your contractions almost all the time. Don't worry – you can still move around; use a birthing ball and rocking chair and change positions.
We'll check your cervix occasionally for change and progress. Don't be surprised if you don't make a lot of progress on your first day of Pitocin. Some moms, especially first-timers, need an additional night of cervical ripening followed by a second day of Pitocin before they deliver their baby.
We're often asked if Pitocin makes labor harder and more painful than a "natural" labor. Well, yes and no. Yes: Pitocin helps you achieve strong, regular contractions every two to three minutes. Yes: It puts you into labor. And No: Every labor has strong contractions. It just might take longer to get to the same strength "naturally."
Maybe yes; maybe no.
Karen Parker-Linn, CNM says, "If you or your baby isn't physically ready for labor – forget the begging. It's not worth the risks."