Inductions, inductions, inductions… some people want them, others would like to avoid them. Many expecting women who hear the word induction immediately think negative thoughts and that in the end, it is just another avenue for a C-Section. It is not, but depending where you are when the induction takes place (are you effaced, dilated, etc.) has a big impact on how long the process could take. With my first pregnancy, I went into labor on my own, but had such severe back labor when I went into the hospital (at 2 cm), that I asked the on-call OB for an induction. That I would rather take my chance then deal with this pain for another minute. With my second pregnancy, I had an amniotic fluid level of 5, which was right on the cusp of being low. I was 90% effaced and 1 cm dilated at 38 weeks and was given the option for an induction at 39 weeks. I went for it. Both pregnancies ended up in a healthy vaginal delivery. This isn't the case for all though, and definitely feel that an already softened cervix and dilation (if you can get that lucky) is a huge advantage when being induced.
So, let us talk inductions. An induction is the use of medications or other methods to start labor contractions of the uterus for a vaginal birth. Inductions are recommended if the health of the mother or fetus may be at risk, or if labor has not started on its own. According to ACOG, new research suggests that induction for healthy women at 39 weeks in their first full-term pregnancy may reduce the risk of a C-Section. Healthy women whose labor is induced at 39 weeks may have lower rates of preeclampsia and gestational hypertension than woman who do not have an induction at 39 weeks.
There are different options for starting the induction process and much of it depends on where your cervix is – are you thinned/effaced and dilated is a big factor. For women, whose cervix is high and hard, your doctor is going to want to soften the cervix before starting synthetic oxytocin. Some common ways to soften the cervix are cervical ripening and sweeping of the membranes:
Cervical Ripening - process by which the cervix is prepared to undergo induction. There are several different methods of cervical ripening. Before labor begins, your cervix is generally closed and long, like the appearance of a closed fist. As you go through labor, your cervix thins out like a sheet of paper and dilates to 10 centimeters. Cervical ripening is the initial process to help your cervix dilate and efface (thin out). It is done to improve the likelihood of success of your induction. It is not uncommon for the cervical ripening to take up to 24-36 hours and can be an exceptionally long process. You may even be sent home for the night and asked to come back. The cervical ripening process in not considered labor but the “prep work” to get you into labor. If all goes well, you will be ready for the second stage of your induction, which is the administration of Pitocin.
Different types of cervical ripening:
Cervidil – A vaginal insert of prostaglandin (hormone like substance that softens the cervix so it can dilate) that stays in the vagina for up to 12 hours
Cytotec – A medication that is inserted in the vagina every 4-6 hours
Foley Catheter – A balloon tipped catheter that is inserted into the cervix and inflated to slowly stretch the cervix
Prostaglandin gel – A variety of gels used to soften the cervix
Stripping of the membranes - is done when you are partially dilated. This action is done by using a gloved finger to sweep over the membranes that connect the amniotic sac to the wall of the uterus. The hopes of doing this is that it will cause your body to release natural prostaglandins, which softens the cervix further and may cause contractions.
Once your cervix has softened and dilated the second stage in the induction process is the start of Pitocin or synthetic oxytocin. Pitocin starts the contractions and can begin as early as 30 minutes after being administered through an IV. During this phase, your OB will artificially rupture your amniotic sac, or better known as “breaking your water” with an amnio hook.
AROM has its advantages and disadvantages.
AROM Advantages:
· that labor may be shortened by an hour
· the fluid can be examined for meconium, which may be a sign of fetal distress
· the baby's heart rate can be monitored directly on the scalp.
AROM Disadvantages:
· prolapsed cord
· Increase your chance of infection.
Some (but not all) reasons you may be induced:
· Your water breaks, but you are not having any contractions
· You have high blood pressure
· You have an infection in your uterus
· You have diabetes
· You have low amniotic fluid
· Your baby has stopped growing
Risks of an induction. (Like anything in life, an induction is a risk):
· The uterus can become overstimulated, causing it to contract too often. When this happens, it can cause changes to the fetal heartrate.
· Uterine rupture (this is rare, but a serious condition), which is when the uterus tears open along the scar line from a prior C-section or major uterine surgery.
· Bleeding after delivery because your uterine muscles will not contract properly.
Deciding if an induction is necessary for you…. think about and ask yourself:
· What has this pregnancy been like (complications, etc.)?
· Previous deliveries? What were they like (vaginal or C-Section)?
· Do you have health issues (Gestational diabetes, obesity, other health conditions that may impact your ability to handle Pitocin or the induction process)?
Tips to have a successful induction:
· Check into the hospital and REST or SLEEP before things pick up! I know, this sounds absurd, especially with the nerves and excitement but try your best, especially if you're admitted at night for cervical ripening - prostaglandin or a Foley balloon. Many hospitals do this overnight in the hopes you will lay in bed and sleep allowing the medication to work it's magic.
· Keep moving!! Move, move, move! Once the Pitocin starts, walk those hospital halls as much as you can. Try different positions so that the baby continues to move down into your pelvis (a great resource for positions and movement is spinningbabies.com). Get some music on and dance, stretch, try some yoga positions or ask for a labor ball to bounce on…either way, just keep moving!!! 😊
· If possible, hold off on an epidural until it is absolutely needed. Once you receive an epidural, you are confined to a bed, limiting your mobility and movement. I cannot stress how important movement is during labor.
· Keep your water intact for as long as possible. Once the doctor breaks your water, you may be on the clock for a C-Section (depending on your hospital). It also increases your chance of infection. Yes, it is true that breaking the bag of water may jump starts labor, but it very well may not and could just cause more complications and interventions, or worse, put your baby into distress resulting in a trip to the OR. Also, with breaking your water, you are not leaving that hospital without a baby. If you hold off with AROM, and the induction doesn't progress, assuming you and the baby are doing ok, you may have the option to go home (this is absolutely a case by case call and depends on what resulted for an induction to begin with). Weigh the pros and cons of where your labor is at, but most importantly communicate with your nurse, midwife and/or doctor.
· Have faith and stay optimistic that this will be a successful induction!
Additional notes & tips for an induction with a VBAC:
An induction is usually safe and just as effective when a mother wants to try for a VBAC, and the risks associated with TOLAC (trial of labor after cesarean) are the same as those associated with an elective repeat C-Section. I highly suggest that you do your research on your hospital’s stance on VBACS, especially if there could be a reason for an induction. It is so so so important to find a hospital and midwife that supports TOLAC.
Many factors go into whether someone is a good candidate for a VBAC, but mothers who have had a prior C-Section with a low transverse incision should be counseled about VBAC and offered TOLAC (unless otherwise noted). If you are denied a VBAC from a hospital or they refuse to support it, find a hospital or birthing center that will.
If you are going for a TOLAC and find yourself needing an induction, talk with your doctor or midwife about the options that are available and start SLOW AND LOW (doses).
Some gentle and successful ways to induce for a VBAC:
· Stripping of membranes (see above for description)
· Evening primrose oil to soften/ripen the cervix (do not take this during pregnancy)
· Foley bulb induction (must be dilated to 1 cm for this). You can also ask for an outpatient Foley bulb where they send you home and when it falls out you return to the hospital.
· Pitocin – Once your body has been in a regular contraction pattern and you are in active labor, ask for Pitocin to be turned off. Once labor gets going, it often continues without any stimulation. If it is recommended you stay on Pitocin, ask to keep it at a low dose.
· Have 2 birth plans in place - a VBAC birth plan and a C-Section birth plan (just in case).
· Breath and stay calm. There is a 60-80% success rate for women attempting a VBAC. Like I say all the time, knowledge is power. Know your options, know your hospital and doctors/midwife, have a written birth plan for all to read, and stand firm with what you want and do not want. You have a voice and unless you use it to be heard, hospitals are not afraid to take it upon themselves to do unnecessary medical interventions and C-sections because it’s too convenient in today’s healthcare system.
Resources used in this blog:
http://www.aafp.org
http://www.thevbaclink.com