Guide for a Healthy Pregnancy
WHEN YOUR LABOR NEEDS TO BE INDUCED
What is induced labor?
Sometimes risks to a mother and her baby make it safer to deliver the baby before labor starts on its own. Induction is an attempt to imitate natural labor and birth by causing contractions of the uterus.
A woman’s labor starts with contractions. They open, or dilate, the cervix to prepare for the baby’s birth. We do not fully understand what makes this happen naturally. It is thought to be controlled by hormones, which are chemicals made by the body.
Why might my clinician want to induce labor?
There are several reasons why your labor may need to be induced. Common reasons for an induction of labor include (but are not limited to):
- Being one to two weeks or more beyond your due date
- High blood pressure
- Ruptured amniotic sac (bag of waters) not followed by labor
- Suspected infection in the amniotic fluid
- Kidney disease
- Concerns about the baby’s growth or well-being
Sometimes your clinician will recommend induction for other reasons, which she/he will discuss with you. Be sure you understand why induction of labor is recommended and what the benefits and risks are in your case.
How is labor induced?
There are several ways to encourage labor to start that can be done at the office or at home. Some women try breast stimulation, taking castor oil, or using herbs to bring on labor. Always discuss these methods with your provider before trying them.
“Sweeping the membranes” (also called “stripping” the membranes) can be done in the office by your OB care provider during a vaginal exam. This procedure involves sweeping the exam finger around the lower edge of the bag of water (membranes) to gently separate the membranes from the edge of the cervix. This may stimulate contractions and hopefully labor in some women. This quick procedure can be uncomfortable and often there is some light vaginal spotting and cramping afterwards. If successful, labor will start within 24 hours. Sweeping the membranes is only effective in a small number of women. However, it may be worth a try as it is a minimally invasive method of trying to induce labor. Remember, women often have several hours of cramping after sweeping the membranes, but then don’t go into real labor.
Ripening agents: Several agents (prostin gel, Cytotec, Cervidil) can be used in the hospital to help ready the cervix for labor in women whose cervix is long, closed or “unripe.” These “ripening agents” are easily inserted in the vagina and work for 4 to 12 hours. They hopefully cause the cervix to soften, shorten and begin to open. They do this by causing cramping and contractions of the uterus. Often multiple doses over many hours are required to get the cervix ready for labor. Your baby is monitored for 1 to 12 hours after the use of the agents (the length of monitoring depends on the method used). If you are having contractions on your own, it may not be safe to use these medicines.
You may be given one or more doses of these agents. Depending on your response and condition, you may be sent home (with arrangements to return the following day); be admitted to the hospital for observation; or begin labor after their use. After the ripening agents have their effect, you will be re-evaluated. Your OB providers will decide whether to repeat the ripening agent or move on to Pitocin (see below). Sometimes ripening your cervix requires a day or more when your body is not ready for labor. Also, induction of labor, like natural labor, almost always takes much longer if this is your first baby, so be prepared!
Sometimes clinicians will recommend amniotomy (breaking the bag of water) to induce labor. This procedure is done during a vaginal exam in the hospital. Your baby must be low in the pelvis and the cervix must be open some for a provider to break the water. This method is not always effective, and works best on women who are at least a few centimeters dilated and have had a baby before. Like all medical inductions of labor, there are risks and benefits from inducing labor this way. Your OB providers will discus these with you prior to breaking the bag of water.
When your cervix is “ripe” or ready for labor, Pitocin may be used to bring on contractions. Pitocin is a synthetic hormone, identical to the hormone “oxytocin” which is made by your body and causes contractions. Pitocin is added to IV fluids and given through your IV in slowly increasing doses to cause contractions and hopefully make your labor start. Response time varies – some women start having mild contractions within a few hours of Pitocin being started. A quick response is more likely if you have had a baby before. Many women need 6 to 12 hours or more of Pitocin to enter active labor (when the cervix dilates at least a centimeter an hour). Occasionally (especially if this is your first baby) you could be on Pitocin for a day or two before labor starts, and in a small number of women Pitocin doesn’t work at all and the induction is stopped.
Often it is necessary to use a combination of methods (such as Cytotec to ripen the cervix, followed by Pitocin and breaking of the bag of water) to induce labor.
How long will the induction process take?
No one can accurately predict how long it will take to induce your labor, or how long the labor will take once it starts. Sometimes it takes just a few hours. However, if the cervix is unripe (hard, long and closed) it takes many hours or even a whole day or more for an induction to work. Just like natural labor, induction takes longer for women when it is their first baby. If labor does not occur on the first day, you may be sent home. You and your clinician will decide if you need to return another day for another attempt, or wait for natural labor. You will be sent home only if your water has not broken, and you and your baby are doing well.
Be patient, bring things to do to stay entertained, and make sure you have adequate child-care arrangements for several days for your other children. Waiting for induced labor to start can be tedious and nerve-wracking – just like waiting for spontaneous labor to start.
Does induction always work?
Induction of labor usually (but NOT ALWAYS) works. If your body just isn’t ready for labor and you don’t respond to the agents we use to induce labor, a decision will need to be made by your clinician about what to do next. Sometimes, the best plan (if you and your baby are medically stable) is to send you home, follow you closely through the office, and try again in a few days or a week. If delivery is necessary for medical reasons and we can’t get you into labor, a cesarean delivery might be needed.
Is induced labor more painful?
Labor is hard work and usually painful whether it starts on its own or is induced. When labor is induced with Pitocin, you need an IV and continuous fetal monitoring of your baby. These interventions may limit your use of some natural means for coping with labor pain and you may choose to rely more on pain-relieving medications. Also, for some women induced labor is quicker so the pain is not spread out over many long hours and this can make it seem worse. Remember – you do not need to experience more pain in labor than you can tolerate, and your OB providers and hospital nurse will help you come up with ways to cope with pain in labor.
What are the risks to inducing labor?
Each way to induce labor has some risks. You should discuss the reasons for induction with your clinician and understand the benefits and risks of the planned procedures.
Some of the risks associated with each method are as follows:
- Pitocin: Pitocin can cause harder, more frequent contractions than a woman might otherwise have. Very strong contractions might be stressful for the fetus. This may require temporarily stopping the Pitocin. Rarely, it leads to an emergency cesarean delivery. Sometimes Pitocin causes contractions, but the cervix does not open.
- Ripening agents: These drugs can cause harder, more frequent uterine contractions than occur naturally. These contractions can usually be stopped with an injectable uterine relaxing drug if necessary. Rarely, these contractions can put stress on the fetus, requiring an emergency cesarean. Other side effects of ripening agents include nausea, vomiting and diarrhea. If you have asthma, be sure to tell your clinician. Some ripening agents may not be the best option for you.
- Amniotomy: If the amniotic membrane is ruptured, the risk of infection for the baby grows greater as the hours pass. If labor does not begin within a few hours of an amniotomy, Pitocin may be given to start labor contractions and reduce the risk of infection to the baby. Very rarely, the umbilical cord can enter the birth canal ahead of the baby after amniotomy and a cesarean is required to prevent harm to the baby.
- All types of induction may cause a long labor, because labor will start before the body is completely ready for it. Or, they may fail to cause labor or birth. If the reason for delivering the baby is important enough for induction, a cesarean birth may be needed.
Ask your clinician about special policies related to induction at your hospital or that may apply to your individual case. Find out when you are expected in labor and delivery. Remember that sometimes you may have to wait for staff and space to start your induction.
A call to labor and delivery before you leave the hospital is often a good idea. How busy the labor floor is changes from hour to hour. Sometimes inductions even have to be rescheduled another day, but only after careful consideration of you and your baby’s needs.