Inductions

Artificial inductions of labor have become commonplace in the United States. Approximately one in five births is begun artificially and this number continues to rise. Inductions are performed for both necessary medical reasons and unnecessary non-medical reasons (also known as an "elective induction"). Inductions have, directly and indirectly, contributed to many of the climbing cesarean rates and numbers of premature births in the country.

Medical reasons for artificial inductions can include, but are not limited to:

diabetes
high blood pressure
severely post-term pregnancies

Elective inductions may take place for:

convenience of doctor
convenience of mother/family (either for planning purposes or to guarantee that a particular provider will be "on call" at her birth)
fear of a large baby
the mom is simply tired of being pregnant, and wants "it over with!"

Methods of artificial induction may include:

Pitocin (stimulates contractions)
Prostaglandin Gel suppositories (ripens the cervix--Cervidil and Prepidil)
Cytotec (stimulates contractions)
Artificial Rupture of Membranes (AROM)

A recent study published in the American Journal of Obstetrics and Gynecology suggests that using medications to artificially stimulate labor should be reserved for situations where there is a clear risk to either the baby or mother in continuing the pregnancy. This Belgium study, which included over 15,000 births over a span of about one year, observed a significant increase of use in pain medication and in cesarean sections being performed in the group whose labors were induced. Cesarean sections were attributed to fetal distress and stalled labors. This group also contained more vacuum and forceps deliveries, as well as more babies admitted in the NICU. (Neonatal Intensive Care Unit)

Benefits of Artificial Inductions:

If a mother develops high blood pressure which cannot be controlled, the risks of continuing the pregnancy for the mom may outweigh the risks of the induction.

Likewise, in post-term pregnancies in which the baby is showing decreased ability to thrive, inductions have undoubtedly saved the lives of many babies.

If the mother's water has broken and she is delivering in a hospital, many hospitals/providers will only allow the woman approximately 24 hours to deliver before rendering a decision that a cesarean will be necessary. Pharmaceutical induction may be necessary to avoid a cesarean section if her contractions do not begin after awhile.

Some of these benefits are subjective--it depends on where you deliver and who your provider is. For example, if delivering in the hospital, pharmaceutical induction might be necessary to beat the "cesarean clock" after rupture of membranes. This 24 hour time frame is fairly standard for hospital delivery. If you are delivering at home, however, the "cesarean clock" in this situation may be very different, if not non-existent.

For those with a true medical need, inductions can be literally, a life saver to moms and babies. For those that are medically unnecessary or "questionable", each mother should weigh the risks and benefits carefully with her provider.

Risks of Pharmaceutical Inductions:

Pharmaceutical inductions (inductions by medicine) are often more painful than spontaneous labors. (80% of moms say that Pitocin contractions are stronger than natural) It is entirely impossible to accurately mimic the gradual progression of spontaneous labor contractions when using an artificial labor stimulant. Often times, the contractions brought on by the artificial substances, are much stronger and have been known to contribute to increased need for pain medication in the mother and fetal distress (due to baby not tolerating the longer periods of decreased blood flow and oxygenation to the uterus) . An overworked and tired uterus can be blamed for third stage hemorrhaging (after the birth of the baby and placenta), and in rare cases, even uterine rupture. For these reasons, women who are choosing a VBAC should weigh the risks of medical induction VERY HEAVILY.

Because of the risks of fetal distress, it is a necessity that the babies are monitored even more closely--usually by continuous electronic fetal monitoring. Another risk for the baby is possible immaturity of the lungs at birth. Babies lungs mature at different rates; whereas one baby may have perfectly mature lungs at 40 weeks, another baby may need an extra week (or longer).

In many cases, labor initiating medication will be given through an IV--thereby limiting the mother's movement.

Because labor is often induced before mother nature has readied the baby and the mother for birth, the mother's body is often not as yielding as it would be if she labored spontaneously. It is because of this, that some inductions could very well be longer than spontaneous labors.

Sometimes the plans for induction simply fail--especially if the mother is induced before 40 weeks or when her cervix is still found to be firm. In these instances labor will be "cancelled" for the time or a cesarean section may be ordered. Failed inductions are one of many reasons given for cesarean sections in the US.

If your doctor wants to induce with medication, ask him/her what your Bishop's score is--this helps indicate if your body is ready to give birth. If this number is under 5, your labor is likely to be unsuccessful, and you have a greater chance of ending up with a cesarean section.

Risks of AROM (Artificial Rupture of Membranes) Inductions:

AROM prior to the start of labor has been linked to infection, particularly if labor contractions do not commence for awhile after. The chances of infection increase as time elapses and with each vaginal exam performed.

If the amniotic sac is broken before the baby's head is engaged in the pelvis (the baby is said to still be "floating"), there is a risk of causing a prolapsed cord. The gush of waters carries the cord into the pelvis, or even into the vagina-- in front of the baby's head, hence causing the head to compress the cord. Because of the severity of this situation, an emergency cesarean section would be performed.

In some women, even those who are full term, the breaking of the membranes is not enough to start labor. Most providers will begin discussing augmenting with medication within an hour or so of the AROM if contractions do not begin. Unlike some pharmaceutical inductions which may be terminated if labor doesn't start, there is "no turning back" once the bag of waters have broken. The "cesarean clock" will begin ticking from the time of rupture as most providers feel the risk of infection rises after 24 hours. In other words, if it doesn't look like the birth will take place within 24 hours of when the mom's water is broken, most providers will start talking about a cesarean section being needed.

Breaking of the waters removes the cushioning from the baby's head. Babies could have more severe molding in their heads due to the extended periods with the lack of cushioning. Some studies noticed abnormal fetal heart tones (possibly leading to fetal distress) in healthy babies after AROM.

As mentioned about pharmaceutical inductions, there is an increased chance of the baby being born before he/she is ready.

Induction Alternatives:

If you are facing an induction (or want to get labor started!), you might have success by:

having intercourse without a condom (semen contains prostaglandins which are will help ripen the cervix) This should be an option only if the bag of waters is still intact.
nipple stimualtion and female orgasm (both of these release oxytocin)
accupressure-- the roof of your mouth, the webbing of your fingers between your pointer finger and thumb, and above the ankle about four finger spaces are all pressure points that may be able to initiate contractions in some moms.
Castor oil--"flushing out" the system can sometimes give moms a launch into labor, despite the very unpleasant side effects.
Enemas--work on the same principle as castor oil, though some literature will state that enemas do not bring on labor.
All in all, none of the natural induction methods will be likely to work unless you are close to labor, anyway!

"Stripping of the membranes" --separating the amniotic sac from the lower uterine walls/cervix--has also been used to induce labor, though it is a fairly uncomfortable/painful procedure. There are the risks of inadvertently rupturing the membranes and/or leading to an infection. Success for this route is hit or miss--often with the "misses" leading to patterns of frequent contractions which are strong enough to keep you awake, but not strong enough to launch you into labor. However, if induction is imminent and cannot be avoided, a recent study has shown that "Membrane sweeping at initiation of labor induction increased the spontaneous vaginal delivery rate, reduced oxytocic drug use, shortened induction to delivery interval, and improved patient satisfaction." (Obstetrics and Gynecology March 2006)