Induction Options

Knowing your choices can lower your risk

Maximize freedom of movement to lower your risk

Common Induction Options & Medications

Within the induction process, there are many options. We will explore those and discuss their history, risks, and benefits. There is not a one-size-fits-all option and we can choose the path that best meets our individual birth needs and goals. If we want to reduce the incidence of intervention or the likelihood of having a cesarean we can target labor induction options that may help with this. We might choose one option over another or we might choose an option but deviate from it's standard dose and administration. We should feel empowered to make the decisions that we feel are right for us.

Being able to choose the day that you meet your baby can feel exciting and tempting when you are uncomfortable and ready. It is important to weigh all of the factors to reduce the chance for feeling regret over a decision of this magnitude. There are important questions to answer:

Is an induction risk free?

If not, what are the risks?

Are there ways to mitigate those risks if I feel an induction is absolutely medically indicated?

We will answer these questions and explore the grey areas for induction. Many care providers will err on the side of induction, because it reduces their liability. At the end of the day, it is the parents who will take home the results and it is their life that is most impacted by the induction process. It is up to them to weigh the evidence-based research pertaining to the recommendation made. We will explore the risks of intervening, because some women only here one side from their provider and it is often incomplete information. Here is a study that explains the benefits of waiting for labor to begin on it's own:

How to Enhance the Environment

The first intervention is leaving your home. The more you are able to recreate and reestablish the feel of home in your new environment, the more easily you will be able to help your labor hormones flow freely. Bring as many things from home as you can that bring you comfort. A blanket that smells like home, that is soft and warm, and is one that you do not mind parting with if it becomes soiled. More importantly, bring a pillow, or two, because this is something that hospitals often lack and when they do have them, they are often flat and uncomfortable. Bring your own slippers and find a pair that you feel enhance your comfort. Bring battery candles, essential oils, music, your rebozo, a tens unit, tennis ball for massage, and anything else that has been part of your labor plan and practice.

Cervidil

Cervidil is a cervical ripening agent that is inserted to ripen the cervix. It is the only cervical ripening agent insert that is approved by the FDA for use in pregnant women.

 

"It has been relied upon by doctors for over 20 years"

 

It contains a synthetic prostaglandin that signals to your body to begin the labor process. Some mothers begin contractions after it is inserted. Generally, the mom will lie down for 2 hours following it's insertion. It may cause a rapid fetal heart rate and uterine hyperstimulation. This occurred alone or together in less than 1 in 20 women who were given Cervidil in clinical trials. Less than 1 in 100 had fever, nausea, vomiting, diarrhea and abdominal pain. There are other risks that can be read here:

Foley Catheter

An often underused method for beginning the induction process, is to use a foley catheter bulb. This method has no medication and is a very low risk option. Your care provider would insert a tube with a small inflatable balloon on the end into your cervix. If the cervix is completely closed, prostaglandins may be used prior to the foley catheter bulb, but if there is a very small amount of dilation, then the bulb may be used. Once the bulb has been inserted, it is inflated with a saline solution. The bulb often stays in for a few hours at least and may stay in longer. The mother will most likely dilate a few centimeters and contractions may begin on their own in some cases. The foley catheter bulb is associated with lower rates of cesarean delivery and less fetal heart rate changes (page 17 in link below).

"A meta-analysis that included these new data was then conducted by the researchers; it confirmed that induction of labor with the Foley catheter produces a vaginal delivery rate similar to that of prostaglandin E2 gel and significantly reduces the rates of uterine hyperstimulation and postpartum hemorrhage. This finding is in line with another recent meta-analysis."

Pitocin and Alternatives

Pitocin is associated with lower APGAR scores and a higher risk for NICU admission for full-term babies. There are many risks for the mother as well. It may cause the contractions to be experienced as more painful than normal labor and the mother may be more likely to ask for pain medication. Even if the mother has an epidural and experiences relief from the pitocin, the baby is continuing to experience the unnatural tightening with little break in between. A mother can ask for less of the drug to be sent through the IV. For example, she can arrange with her care provider to receive half the dose with double the space between to give her body time to catch up. She can use nipple stimulation, concentrated Red Raspberry Leaf Tea, acupressure, clary sage essential oil, movement, rebozo sifting, dancing and more to help her body work together with the synthetic oxytocin while she is building her own oxytocin. The partner can facilitate all of these efforts and add in massage and counter-pressure. There are providers whose standard of care is to use less pitocin, but even if this is the case or if an arrangement were made, the nurse, whose shift changes every 12 hours, could easily go into auto-pilot and give more than the mother wanted. Individualized care is challenging for many hospitals, but we can give reminders and our birth team can monitor the actions of the staff. If less pitocin is used, the baby may be at less risk. Pitocin can also be turned off if the baby goes into distress or if the mother experiences any problems.

Cytotec

Concerns

Cytotec (Misoprostol) is not approved for use in pregnant women by the FDA. It is an ulcer drug that is used off label, therefore it's use in pregnant women is experimental.

 

It is associated with an increased risk of torn uterus, severe bleeding, hysterectomy and death of the mother and baby.

 

It is also associated with tectonic contractions. It is given in a pill form. Since the pill is difficult to cut consistently, it is often given in an uncertain dose and may react differently in each mom. Also, since it is in pill form, once it has dissolved, it is gone. It cannot be turned off, like pitocin, which is given in IV form. Many mothers decline cytotec for these reasons. 

Read More Here: 

Reasons to Induce Labor

There are a wide variety of care providers, and the recommendation from one care provider to another will not always be consistent. It is important that we advocate for ourselves and learn some of the common reasons for an induction and discover the research and statistics for ourselves. With this complete picture, we can evaluate the choices before us and decide what is best for our individual needs.

Grey Areas for an Induction 

Your Baby is Large

This is a common reason given for an induction, yet the ultrasound measurements may be inaccurate by up to 2lb either way. Many women give birth easily to 10lb babies or larger. In the absence of uncontrolled gestational diabetes, the mother's body will grow a baby that is the perfect size for her to birth. The most important consideration is the space, flexibility and elasticity that she creates with her positioning preparation, with tailor sitting, ball sitting, posture and squats.

ACOG has re-evaluated many of their practices:

Suspected Fetal Macrosomia


Suspected fetal macrosomia is not an indication for delivery and rarely is an indication for cesarean delivery. To avoid potential birth trauma, the College recommends that cesarean delivery be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes Table 3 99. This recommendation is based on estimations of the number needed to treat from a study that modeled the potential risks and benefits from a scheduled, nonmedically indicated cesarean delivery for suspected fetal macrosomia, including shoulder dystocias and permanent brachial plexus injuries 100. The prevalence of birth weight of 5,000 g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise Table 3. Even when these thresholds are not reached, screening ultrasonography performed late in pregnancy has been associated with the unintended consequence of increased cesarean delivery with no evidence of neonatal benefit 101. Thus, ultrasonography for estimated fetal weight in the third trimester should be used sparingly and with clear indications.

Concerns over Meconium

It is very normal for babies to make a poop in the womb and if they are older babies it may be more common. The care provider might site the increased "risk" of a baby making a poop in the womb with increased gestational age, but they might not mention that meconium is only dangerous if the baby aspirates (breathes in) and interventions, like inductions increase the chance of aspiration. It is extremely rare: "around 2-5% of the 15-20% who had meconium stained amniotic fluid will actually aspirate and of that very low percent, only 3-5% will not survive, which translates to 0.06%.

Gestational Diabetes

This is only a concern if the condition is not well managed. If gestational diabetes is well managed without insulin, then the concern should be removed

It is After Your Due Date

When a mother is told that there is an increased risk of stillbirth, it might feel terrifying, but when we have the statistics, the theoretical fear might be lessened. There is an incredibly small increase in the incidence of stillborn babies between 41 weeks (4/10,000) and 42 weeks (6/10,000). Each mother should evaluate her personal health and that of her pregnancy. 

You Have Low Fluid

Fluid measurements can be inaccurate and should not be used alone to decide to induce labor. Research supports this.

Your Baby is Small

The baby can be monitored with non-stress tests for signs of distress. This method compared with induction does not show a difference in outcomes.

Advanced Maternal Age

Each mother should evaluate her personal health

Valid Absolute Medical Indications

  • Decreased placental functioning or baby's heart rate is abnormal

  • Pre-eclampsia diagnosed with consistent high blood pressure and protein in the urine

  • Other clear medical indications that the baby and mother would both benefit from ending the pregnancy, like fever or heavy bleeding

Does An Induction Have Risks

  • Pitocin contractions may stress out the baby, leading to a cesarean

  • Pitocin has been connected with adverse effects on neonatal outcomes including lower APGAR scores and longer NICU stays

  • If the mother's cervix is not ripe (with a low Bishop Score) then a cesarean is more likely

  • Pitocin contractions may be more intense which may lead to interventions which have risks of their own

It is important to know the scientific evidence and to carefully consider the recommendations made by an individual health care provider, because there are unfortunately many who either do not know or do not practice the latest evidence-based medicine, who may err on the side of protecting their own liability when it is a grey area and the United States has some of the worst maternal and infant outcomes to show for it.

We must advocate for ourselves.

TEL: 202-441-6771 chava@birthingwithjoy.com