Inducing labor

Labor also called childbirth is the process of your baby leaving the uterus (womb). Labor usually starts naturally on its own, but sometimes it needs to be started artificially. This is called induced labor. Inducing labor also called labor induction is when your health care provider gives you medicine or uses other methods to make labor start – the stimulation of uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth. Most women will go into labor naturally by 42 weeks, but sometimes it may be best to induce labor. Your health care provider might recommend inducing labor for various reasons, primarily when there’s concern for a mother’s health or a baby’s health.

Inducing labor can include breaking your water (amniotic sac), to make your labor start. The amniotic sac also called bag of waters is the sac inside your uterus (womb) that holds your growing baby. The sac is filled with amniotic fluid. Contractions are when the muscles of your uterus get tight and then relax. Contractions help push your baby out of your uterus.

Your doctor may recommend inducing labor if your health or your baby’s health is at risk or if you’re 2 weeks or more past your due date. For some women, inducing labor is the best way to keep mom and baby healthy.

If there are medical reasons to schedule induction, talk to your doctor about waiting until at least 39 weeks of pregnancy. This gives your baby the time she needs to grow and develop before birth. Inducing labor should be for medical reasons only.

Inducing labor can take a few hours or a few days. It depends on how your body responds to your treatment.

Are there any reasons why I wouldn’t be offered a labor induction?

Labor induction isn’t appropriate for everyone. Labor induction might not be an option if:

• You’ve had a prior Cesarean section or C-section with a classical incision or major uterine surgery
• The placenta is blocking your cervix (placenta previa)
• Your baby is lying buttocks first (breech) or sideways (transverse lie)
• You have an active genital herpes infection
• The umbilical cord slips into your vagina before delivery (umbilical cord prolapse)

If you’ve had a prior C-section and have labor induced, your health care provider will avoid certain medications to reduce the risk of uterine rupture.

Your baby is breech

If your baby is breech and you want to deliver vaginally, it’s important that your labor progresses steadily, so induction isn’t usually recommended. Instead, you’ll be offered an emergency cesarean if there are any issues during labor.

You’ve had a fast labor before

If you’ve given birth quickly before also known as precipitate labor, you may be tempted to ask for an induction if you’re worried you may give birth before a midwife reaches you. But it’s unlikely you’ll be offered an induction for this reason. Also, there’s no evidence that induction will prevent your labor from being fast.

Your baby is big

Unless there are any other issues, your healthcare professional won’t induce you because they suspect your baby is large for their gestational age. This is because accurately assessing your unborn baby’s weight is difficult.

Intrauterine growth restriction

If your unborn baby has intrauterine growth restriction (also known as fetal growth restriction) induction isn’t recommended. This is because there is a risk that the baby may die before or after birth.

Why would I need labor induction?

Your doctor might recommend inducing labor for various reasons, primarily when there’s concern for a mother’s health or a baby’s health. For example:

• You’re approaching two weeks beyond your due date, and labor hasn’t started naturally (postterm pregnancy)
• Your water has broken, but labor hasn’t begun (prelabor rupture of membranes)
• You have an infection in your uterus (chorioamnionitis)
• Your baby has stopped growing at the expected pace (fetal growth restriction)
• There’s not enough amniotic fluid surrounding the baby (oligohydramnios)
• You have diabetes
• You have a high blood pressure disorder
• Your placenta peels away from the inner wall of the uterus before delivery — either partially or completely (placental abruption)
• You have a medical condition such as kidney disease or obesity.

Can I wait for labor to begin naturally?

Nature typically prepares the cervix for delivery in the most efficient, comfortable way. However, if your health care provider is concerned about your health or your baby’s health or your pregnancy continues two weeks past your due date, inducing labor might be the best option.

Why the concern after two weeks? When a pregnancy lasts longer than 42 weeks, amniotic fluid might begin to decrease and there’s an increased risk of having a baby significantly larger than average (fetal macrosomia). There’s also an increased risk of C-section, fetal inhalation of fecal waste (meconium aspiration) and stillbirth.

Can I request an elective labor induction?

Elective labor induction is the initiation of labor for convenience in a person with a term pregnancy who doesn’t medically need the intervention. For example, if you live far from the hospital or birthing center or you have a history of rapid deliveries, a scheduled induction might help you avoid an unattended delivery. In such cases, your health care provider will confirm that your baby’s gestational age is at least 39 weeks or older before induction to reduce the risk of health problems for your baby.

Can I do anything to trigger labor on my own?

Probably not. Techniques such as exercising or having sex to induce labor aren’t backed by scientific evidence. Also, avoid herbal supplements, which could harm your baby.

Is labor induction painful?

No, the induction process itself is not painful, but you might feel some slight discomfort. You may be kept in hospital if you have prostaglandins (although some hospitals may offer you to go home), and you will be kept in if you’re having your waters broken.

Your birth partner may be able to stay with you , although this depends on hospital policy and your birth partner may need to leave for a while. You could bring a book, magazine or iPad with you to pass the time. When you pack your hospital bag to come in for an induction, pack it as you would for the birth of the baby.

Induced labors can be more painful than labors that start on their own. But you should have access to the same pain relief as you would with a natural labor.

What if the labor induction doesn’t work?

If you don’t go into labor after an induction, your doctor or midwife will talk to you about your options. You may be offered another induction or a cesarean section.

How do I decide if I want a labor induction?

It is up to you whether you have the labor induction or not and you should be supported in whatever decision you make.

Before you are offered the labor induction procedure, you should be offered a membrane sweep. This makes it more likely that you’ll go into labor naturally and won’t need an induction.

To help you decide, your doctor or midwife should give you more information about:

• why you’re being offered an induction
• when, where and how the induction will be carried out
• what support and pain relief is available
• what other options are available
• what the risks and benefits are
• what your options are if induction doesn’t work.

Don’t be afraid to ask any questions and take some time to think about your options. You may find it helpful to talk to your partner, family or trusted friends before making a decision.

Ways to induce labor

Your health care provider uses one or more of these treatments to induce labor:

• Separating the amniotic sac from the wall of the uterus also called membrane stripping or sweeping the membranes. Your doctor gently puts a gloved finger through your cervix and separates the amniotic sac from your uterus. The cervix is the opening to the uterus that sits at the top of the vagina. You can have this procedure done in your doctor’s office. You may have some cramping or spotting. Membrane stripping releases endogenous prostaglandins, which can induce labor, and by doing so, eliminate the need for formal induction. To perform membrane stripping, the clinician performs a vaginal exam and places a finger into cervical os in a circular movement to separate the inferior portion of membranes from the lower uterine segment. A Cochrane review ¹⁾ found that membrane stripping results in an increased number of women entering spontaneous labor within 48 hours and decreases the need for induction. There was no difference in risk of maternal or neonatal infection. Potential side effects include patient discomfort during the procedure, vaginal bleeding, rupture of membranes and contractions following the procedure.
• Ripening the cervix. Your doctor gives you medicine called prostaglandins to help soften and thin your cervix so it will open during labor. You may get the medicine by mouth or it may be put in your vagina. You get the medicine at a hospital. Your doctor also may use a medicine called laminaria in your vagina. It absorbs moisture and expands to help open the cervix. Or your doctor may use an instrument called a Foley bulb. This is a thin tube with a balloon at the end. Your doctor inserts it in the vagina to widen the cervix.
• Giving you medicines to start contractions. Doctors often use a medicine called oxytocin to induce labor. This medicine is the man-made form of a hormone that helps start contractions. At the hospital, your provider gives you oxytocin through an IV (a needle into a vein). It may make you have really strong contractions. Ask your doctor about pain medicine you may want to have during labor. Contractions begin after 3 to 5 minutes, and oxytocin reaches a steady level in plasma by 40 minutes. Oxytocin side effects include uterine tachysystole and fetal heart rate abnormalities ²⁾. Fetal heart rate and contractions should be monitored during oxytocin administration ³⁾. A Cochrane review ⁴⁾ compared the effectiveness of low versus high-dose oxytocin for induction of labor. There was no difference in time to delivery or cesarean delivery rate between the two groups. There was a significant increase in uterine tachysystole in the high-dose group, but the consequences of this were not clearly identified. The review was unable to recommend either a low or high-dose protocol over the other. An oxytocin checklist was developed for oxytocin administration focusing on uterine contractions and fetal heart rate rather than specific infusion rates or dosing. Outcomes were compared before and after initiation of the checklist protocol. The maximum infusion rate of oxytocin was lower in the checklist protocol group. There was no difference in time in labor between groups. Furthermore, the cesarean delivery rate was lower and newborn outcomes improved in the checklist protocol group ⁵⁾.
• Breaking your water also called rupturing the membranes or amniotomy. Your doctor uses a small hook that looks like a knitting needle to break the amniotic sac that holds your baby. This shouldn’t be painful, but you may feel a warm gush of fluid. A Cochrane review ⁶⁾ found that there was not sufficient data regarding amniotomy as a method for labor induction to draw a conclusion on its safety and efficacy.

There’s no guarantee that an induction will work. There’s also some evidence that if your labor is induced, you may be slightly more likely to need instruments such as forceps or ventouse to help your baby to be born safely.

How to induce labor naturally

Although none of these methods have been backed up by research, some women have tried these ideas when they’ve been past their due date:

• Sex. Your partner’s semen contains natural prostaglandins that may stimulate labor. Don’t worry, having sex during pregnancy is safe and will not make you go into labor early. But don’t have sex if your waters have broken because there’s an increased risk of infection.
• Stimulating your nipples. Nipple or breast stimulation stimulates uterine contractions, likely by increasing oxytocin levels. A Cochrane review ⁷⁾ found that when compared to no intervention, more women entered labor by 72 hours with nipple stimulation; however, this was only significant for women who had a favorable cervix initially. Additionally, there was a decrease in post-partum hemorrhage among women who performed nipple stimulation. There were no cases of uterine tachysystole. However, a trend towards an increase in perinatal death amongst women who used nipple stimulation was noted. More information is needed regarding the safety of this method before recommendations about its use can be endorsed.
  
• Keeping active with lots of walking.

Don’t listen to anyone who tells you that castor oil will help – it won’t. It will just make you feel sick and may give you diarrhea and stomach cramps that aren’t labor pains.

What are medical reasons for inducing labor?

To determine if labor induction is necessary, your doctor will evaluate several factors, including your health, your baby’s health, your baby’s gestational age, weight and size, your baby’s position in the uterus, and the status of your cervix.

Your doctor may recommend inducing labor if:

• Your pregnancy lasts longer than 41 to 42 weeks (postterm pregnancy). After 42 weeks, the placenta may not work as well as it did earlier in pregnancy. The placenta grows in your uterus (womb) and supplies your baby with food and oxygen through the umbilical cord.
• Your placenta is separating from your uterus (placental abruption).
• Your water breaks before labor begins. This is called premature rupture of membranes also called PROM.
• You have health problems, like diabetes, high blood pressure or preeclampsia or problems with your heart, lungs or kidneys. Gestational diabetes is when your body has too much sugar (called glucose) in your blood that develops during pregnancy. This can damage organs in your body, including blood vessels, nerves, eyes and kidneys. High blood pressure is when the force of blood against the walls of the blood vessels is too high and stresses your heart. Preeclampsia is a serious blood pressure condition that can happen after the 20th week of pregnancy or after giving birth also called postpartum preeclampsia.
• Your baby has a stopped growing (fetal growth restriction). The estimated weight of your baby is less than the 10th percentile for gestational age.
• Your baby has oligohydramnios. This means your baby doesn’t have enough amniotic fluid.
• You have Rhesus disease (Rh disease) and it causes problems with your baby’s blood.
• You have an infection in your uterus (chorioamnionitis).

Your baby is late

Usually, babies arrive anywhere between 37 and 42 weeks of pregnancy. But if your baby is very late (if you are pregnant for more than 42 weeks), the placenta may not be working as well as it used to and the risk of stillbirth increases. In this case, you’ll be offered an induction between 41 and 42 weeks of pregnancy. Being overdue (also known as a prolonged pregnancy) is the most common reason for an induction.

Your labor doesn’t start after your waters break

You may be offered an induction if you’re more than 34 weeks pregnant and your waters break, but labor doesn’t start on its own after 24 hours. This is because your waters breaking increases your baby’s risk of infection.

If your pregnancy is uncomplicated, you may also be offered expectant management. This is when your midwife or doctor monitor you and your baby, and your pregnancy progresses naturally as long as it is safe.

If you’re more than 37 weeks pregnant, you may be offered an induction within 24 hours of your waters breaking. If you don’t want an induction, your midwife will put together a plan for monitoring you.

If your waters break before 34 weeks, you’ll only be offered an induction if there are other factors that suggest it’s the best thing to do. For example, if you have an infection or there are concerns about the baby’s health. If your baby is born earlier than 37 weeks, they may be at risk of problems related to being premature.

You or your baby has a health problem

You may be offered an induction if you have a condition that means it’ll be safer to have your baby sooner. This could include:

• type 1 or type 2 diabetes
• gestational diabetes
• pre-eclampsia
• intrahepatic cholestasis of pregnancy (ICP)
• pregnancy-induced hypertension.

If your healthcare professional thinks that being induced is the best option for you and your baby, they should talk to you about this. They can help you assess the benefits and any potential risks so you can make an informed decision.

What are the risks of inducing labor?

Labor induction isn’t for everyone. For example, it might not be an option if you have had a prior C-section with a classical incision or major uterine surgery, your placenta is blocking your cervix (placenta previa), or your baby is lying buttocks first (breech) or sideways (transverse lie) in your uterus.

Inducing labor also carries various risks, including:

• Your due date may not be exactly right. Sometimes it’s hard to know exactly when you got pregnant. If you schedule an induction and your due date is off, your baby may be born too early. If your pregnancy is healthy, wait for labor to begin on its own. If you need to schedule an induction for medical reasons, ask your provider if you can wait until at least 39 weeks.
• Oxytocin and medicines that ripen the cervix can cause abnormal or excessive contractionss, which can diminish your baby’s oxygen supply and lower your baby’s heart rate. This can lower your baby’s heart rate. Your doctor carefully monitors your baby’s heart rate when inducing labor. If your baby’s heart rate changes, your doctor may stop or reduce the amount of medicine you’re getting.
• You and your baby are at higher risk of infection. The amniotic sac normally protects your baby and your uterus from infection. If labor takes a while to start after your membranes rupture, infections are more likely. Some methods of labor induction, such as rupturing your membranes, might increase the risk of infection for both mother and baby.
• There may be problems with the umbilical cord. If the amniotic sac is broken, the cord may slip into the vagina before your baby does. This is called umbilical cord prolapse. It’s more likely to happen if your baby is breech. This is when your baby’s bottom or feet are facing down before birth instead of being head-down. Umbilical cord prolapse can cause the umbilical cord to get squeezed during birth. If this happens, your baby doesn’t get enough oxygen, which can be life-threatening.
• Failed induction. Induction may not work so you may need a C-section (cesarean birth). C-section is surgery in which your baby is born through a cut that your provider makes in your belly and uterus. About 75 percent of first-time mothers who are induced will have a successful vaginal delivery. This means that about 25 percent of these women, who often start with an unripened cervix, might need a C-section. Your health care provider will discuss with you the possibility of a need for a C-section.
• You may have a uterine rupture. This is when the uterus tears during labor. It happens rarely, but it can cause serious bleeding. If you’ve had a C-section in a prior pregnancy or major uterine surgery, you’re at higher risk of uterine rupture because a C-section leaves a scar in the uterus. An emergency C-section is needed to prevent life-threatening complications. Your uterus might need to be removed.
• You may be at higher risk of serious bleeding after birth called postpartum hemorrhage. Inducing labor increases the chances that your uterine muscles don’t contract the right way after you give birth (uterine atony), which can lead to bleeding after delivery.

Inducing labor is a serious decision. Work with your health care provider to make the best choice for you and your baby.

What are the risks of scheduling labor induction for non-medical reasons?

Scheduling labor induction also called elective labor induction, is the initiation of labor for convenience in a person with a term pregnancy who doesn’t medically need the intervention. Elective labor inductions might be appropriate in some instances. For example, if you live far from the hospital or birthing center or you have a history of rapid deliveries, a scheduled induction might help you avoid an unattended delivery. In such cases, your health care provider will confirm that your baby’s gestational age is at least 39 weeks or older before induction to reduce the risk of health problems for your baby.

Scheduling labor induction may cause problems for you and your baby because your due date may not be exactly right. Sometimes it’s hard to know exactly when you got pregnant. If you schedule labor induction and your due date is off by a week or 2, your baby may be born too early. Babies born early (called premature babies) may have more health problems at birth and later in life than babies born on time. This is why it’s important to wait until at least 39 weeks to induce labor.

If your pregnancy is healthy, it’s best to let labor begin on its own. If your provider talks to you about inducing labor, ask if you can wait until at least 39 weeks to be induced. This gives your baby’s lungs and brain all the time they need to fully grow and develop before he’s born.

If there are problems with your pregnancy or your baby’s health, you may need to have your baby earlier than 39 weeks. In these cases, your provider may recommend an early birth because the benefits outweigh the risks. Inducing labor before 39 weeks of pregnancy is recommended only if there are health problems that affect you and your baby.

If your doctor recommends inducing labor, ask these questions:

• Why do you need to induce my labor?
• Is there a problem with my health or the health of my baby that may make inducing labor necessary before 39 weeks? Can I wait to have my baby closer to 39 weeks?
• How will you induce my labor?
• What can I expect when you induce labor?
• Will inducing labor increase the chance that I’ll need to have a c-section?
• What are my options for pain medicine?

Labor induction process

Labor induction is done in a hospital or birthing center, where you and your baby can be monitored and labor and delivery services are readily available. However, some steps might be taken prior to admission.

Labor induction procedure

There are various methods for inducing labor. Depending on the circumstances, your health care provider might:

• Ripen your cervix. Sometimes synthetic prostaglandins, which are typically placed inside the vagina, are used to thin or soften (ripen) the cervix. After prostaglandin use, your contractions and your baby’s heart rate will be monitored. In other cases, a small tube (catheter) with an inflatable balloon on the end is inserted into the cervix. Filling the balloon with saline and resting it against the inside of the cervix helps ripen the cervix.
• Rupture the amniotic sac. With this technique, also known as an amniotomy, your health care provider makes a small opening in the amniotic sac with a plastic hook. You might feel a warm gush of fluid when the sac opens, also known as your water breaking. An amniotomy is done only if the cervix is partially dilated and thinned and the baby’s head is deep in the pelvis. Your baby’s heart rate will be monitored before and after the procedure. Your health care provider will examine the amniotic fluid for traces of fecal waste (meconium).
• Use an intravenous medication. In the hospital, your health care provider might intravenously give you a synthetic version of oxytocin (Pitocin) — a hormone that causes the uterus to contract. Oxytocin is more effective at speeding up (augmenting) labor that has already begun than it is as a cervical ripening agent. Your contractions and your baby’s heart rate will be continuously monitored.

Keep in mind that your doctor might also use a combination of these methods to induce labor.

How long it takes for labor to start depends on how ripe your cervix is when your induction starts, the induction techniques used and how your body responds to them. If your cervix needs time to ripen, it might take days before labor begins. If you simply need a little push, you might be holding your baby in your arms in a matter of hours.

After the labor induction procedure

In most cases, labor induction leads to a successful vaginal birth. If labor induction fails, you might need to try another induction or have a C-section.

If you have a successful vaginal delivery after induction, there might be no implications for future pregnancies. If the induction leads to a C-section, your health care provider can help you decide whether to attempt a vaginal delivery with a subsequent pregnancy or to schedule a repeat C-section.