Induction of Labor

Today, we are joined by Dr. Lisa Levine, a Maternal Fetal Medicine specialist, who talks to us about induction of labor. 

We answer the following questions: 

1. What is an induction of labor?
   • So first, of all, remember: labor is when a pregnant person has contractions of their uterus, or womb, and their cervix starts to open. If everything goes well, at the very end, the person is able to push and deliver their baby (or babies) vaginally. Labor induction, is very simply put, getting someone into labor who is not yet in labor. I often say it is like “jump-starting” labor. And the goal is for that person to give birth vaginally.
2. Why do we perform an induction of labor?

   • We absolutely would love if every pregnant person could go into labor on their own. That would make our jobs easier! However, there are some people who, because of medical problems they had before pregnancy, or medical problems they develop during pregnancy, need to be delivered earlier so that they and their babies can stay healthy. After a certain point, staying pregnant may not be the healthiest option for that person or for their baby. Some people may also choose induction after a certain point for their own reasons, such as help with childcare or needing to go back to work, but that does not usually happen before 39 weeks. There are many reasons to be induced, and you should talk to your doctor about when it is safest for both you and your baby to undergo an induction.

   • Most people will be given a due date for their pregnancy the first time that they see a doctor. This is done by using the first day of your last period (if you have regular periods) and an early ultrasound. The “due date” simply means that that is the day that you will be forty weeks pregnant. That’s it. It is not a magic day that your body will suddenly go into labor, or a day that you HAVE to be delivered by, unless you are told by your pregnancy provider.

   • We call a “term” pregnancy, meaning a fully developed pregnancy, anywhere between 37 and 42 weeks. And usually, that is when pregnant people will go into labor. So, most people are not considered “early” or “preterm” if they go into labor, say… when they are 38 weeks and 2 days-which is just 12 days before their due date. And for most people who don’t have medical problems before or during pregnancy, it is totally fine for them to go into labor sometime between 37 and 42 weeks.

3. When do we perform an induction of labor?

   • That depends on the patient’s medical condition, how the baby is doing inside, and a lot of other factors. This would have to be a discussion with your doctor. Most of the time, that date will be in the 39-40 week range, but if you develop high blood pressure of pregnancy, have a more serious medical condition or we think that baby is not doing well, we may recommend earlier.

     Also, for patients and babies that are healthy overall, if they go past their due date, we would also monitor them and their babies very closely because of that tiny increased risk of stillbirth. Therefore, your doctor may talk to you about induction of labor at 41 weeks or bring you in for monitoring of the baby if you are past 41 weeks and want to try to go into labor on your own. We usually do not recommend going past 42 weeks, because of that increasing stillbirth risk.

4. What do we do for induction of labor, and what can patients expect on the labor floor?

   • The first thing to expect is that we have to do a lot of stuff upfront to make sure that we are giving you the correct medicine to put you into labor and caring for you in a safe way. This will include bloodwork to see what your blood counts are and what blood type you have, testing you for some sexually transmitted infections, like HIV and syphilis, as well as an ultrasound to determine that the baby is head down. We don’t recommend induction if the baby is in any other position. We will also put in an IV so that we can give you medicines through it to help with your induction.

     We also put two monitors on your belly: one is to listen to the baby’s heartbeat, and the other is to monitor your contractions. Finally, we also have to do an internal vaginal exam to see how dilated and thin your cervix is.

   • If your cervix is not very dilated or not thin (we mean anything under 3 or 4 centimeters), we would recommend first starting with some medicine that you take by mouth or that we place in the vagina. This medicine is called misoprostol, which is a medicine that can help soften and thin the cervix and get it to open up a little bit more. The second thing we may recommend is something called a “Foley” balloon, which is a thin tube that has a small, inflatable balloon at the very tip. Your doctor will place the foley balloon into the cervix through the vagina, and then inflate the balloon with some water. That balloon pushes on your cervix and allows the cervix to release natural hormones that thin the cervix and get it ready for labor. Typically, the Foley balloon stays in place for 6-12 hours. When it comes out, your cervix will be open 3 or 4 cm. Misoprostol can be used separately or at the same time as the Foley balloon.

     This whole process is called “ripening” of the cervix and we recommend doing this if your cervix is not very dilated or is not thinned out because there are studies that show that we are more likely to achieve a vaginal delivery if we first get your cervix to open up and thin out a little before we start IV medication.

   • if the patient wants some kind of pain medication, they can receive it. These include IV pain medication or an epidural. But I understand that you have an anesthesia podcast already dedicated to this topic, so I won’t go into that as much.

     Then, after the patient’s cervix is 3-4 cm dilated, as long as the patient and the baby are still doing well, we will start with some medication that goes through the IV. A lot of people will have likely heard of it: it’s called Pitocin. Pitocin is just the brand name for the hormone that your own body makes called oxytocin. Oxytocin is something that a pregnant person makes during labor, and it helps to create contractions and continue the labor process. Essentially, we are just giving you a synthetic hormone your own body makes to put you into labor. Another method is doing nipple stimulation with our labor floor protocol, because stimulating the nipples can also release natural oxytocin, achieving the same effect. Another method would be breaking the bag of water around the baby, because that can also release hormones that speed up labor.

5. Why do we need to monitor the pregnant person and baby during induction of labor?

   • we always have the two monitors. One is to check on the baby’s heart rate through something called a “doppler,” which is like an ultrasound, and the other is a pressure sensor to monitor contractions. Usually, both of the monitors go on the pregnant person’s belly.

     Sometimes, it may be hard to keep the baby’s heart rate on the monitor if the baby is moving around, if the baby is small, or if the baby is very low in the pelvis. It may also be hard to monitor contractions from the outside, especially if the pregnant person is moving around during labor or if there is more soft tissue between the monitor and the uterus. When this happens, we may suggest placing monitors that actually go inside the uterus, and this can only be done once the bag of water around that baby is broken.

     One is a pressure catheter that can more easily measure the contraction timing and strength. This is called an intrauterine pressure catheter, or we often refer to it as an IUPC. This is a very thin, plastic tube that goes into the uterus and stays in until the baby comes out. This does not harm you or the baby in any way.

     Another is something called a fetal scalp electrode, which is like a little clip that goes on the baby’s head. This clip can be a better way to track the baby’s heart rate on the monitor if we are having trouble getting it from the outside monitors that go over the pregnant person’s belly. This also gets taken off once the baby’s head is coming out or crowning. Again, this does not harm you or the baby in any way. Both of these things are tools that we have to better monitor the pregnant person and baby so that we have more information on how to best guide our patient’s labor.

     We then slowly increase the Pitocin until we achieve a good contraction pattern that is changing the cervix every few hours, but is not so much so that the baby is not able to tolerate it.

   • I’d like for people to imagine that labor is like running a marathon. For some people, labor can certainly take many hours, or even days! So just like how labor can put stress on your body, it can do the same thing for babies and placentas. We never want to cause stress to the baby, which is why we monitor and try to prevent it.

     You can become very tired from labor, but your baby, can tire out much faster. This stress on the baby and the placenta can mean decreased oxygen going from the placenta to the baby, and we can see signs of that on baby’s heart rate monitor. Now, the heart rate monitor is not perfect, but signs that babies are not getting enough oxygen could be the heart rate dropping after contractions. Another way is if we see that the nice squiggly pattern of the heart beat is looking more like a flat line. We call that “variability.” A nice squiggly pattern means good “variability” which is a sign that the baby is getting good oxygenation. Once that “variability” goes away, we can’t be sure of that anymore. We don’t really mind if that squiggly patter goes away here and there but when it goes away for a while, that makes us more concerned.

     If that happens, that’s a sign that we need to give the baby a break and slow down on the medication or stop it altogether to decrease the contractions. If that still doesn’t help the baby recover from this stress, then that may be a sign that we need to do a C-section because we don’t want the baby to be deprived of oxygen for a long period of time -- that could mean bad things for the baby, like brain damage. It is often the contractions that are causing the stress and, unfortunately, you can’t have labor without contractions! So even if we stop the medication that is giving you contractions, we will need to at least try to restart it to see if we can get you into labor.

6. Does induction of labor increase cesarean section rates?

   • No. We have good studies that show that the act of inducing labor itself does not increase the rate of C-section. Patients who are induced do have a longer labor than patients that come in in labor but inducing labor itself does not increase the risk of a C-section. However, many people who require an induction of labor often have medical conditions or their babies may have medical conditions that make it more likely for them to need a C-section.

     So, for example, one reason that we may recommend an induction of labor at 37-39 weeks is for something called fetal growth restriction, or when babies are very small and not growing well on the inside. A very small baby could be a sign that the placenta isn’t working very well to get the baby the oxygen and nutrients that it needs. In this instance, we would recommend an induction of labor between 37-39 weeks depending on how small the baby is and some other factors because we believe that it is safer for the baby to be fed and supported on the outside rather than on the inside.

     Now, you can imagine that if the placenta isn’t working well already, that labor can put even more stress on the placenta and the baby, and that baby may not do well during labor. That baby is more likely to need a C-section. It’s definitely not a hard and fast rule, and we absolutely still encourage certain patients with small babies to try for a vaginal delivery, because most of the time, small babies can tolerate labor very well. However, we know that there is a higher risk of needing a C-section.

7. How long does an induction of labor take?

   • The reason we recommend an induction of labor is because we think that for the health of the pregnant person or baby, we should have the baby sooner rather than later. Usually, we do this because the pregnancy is making a medical condition that the person had prior to pregnancy worse, or the pregnancy itself is causing a health problem. Sometimes, like we mentioned before, it could also be because the baby is not doing as well on the inside, and we think that the baby would be better supported in the outside world, and what we can offer in the NICU.

     Because of this, we want to try and make the labor process as quick as possible without harming the pregnant person or baby. Again, we do this because we think staying pregnant longer can make the health of the pregnant person or baby worse. So our patients may hear from their doctors different methods of trying to make labor go a little faster.

     We understand that labor and birth is a very special time for parents, and we certainly will try to do everything that we can to make that experience as individual for each person as possible. However, we also want to make sure that both the parent and the baby are safe and healthy, and sometimes, that may mean speeding up the labor process.

   • I wish I could give you an absolute number for that but an induction can take anywhere from 12 hours, all the way up to 48 hours from start to finish! We know labor is a bit longer in first time parents. About 70-80% of first time parents are delivered within 24 hours of having their induction started. But that means that 20-30% will still be pregnancy after 24 hours. So it is a long process and it is important to be prepared for that. The process is a bit quicker for patients that have had a baby before. For them, about 90-95% are delivered within 24 hours and more than half are delivered within 12 hours. These percentages are somewhat based on which methods we use to start the induction and also how open and thing your cervix is as we talked about before. But that is about as much information as we know!