Induction of Labor
There are many medical indications for induction. The baby may be measuring small. The amniotic fluid level may be low. The bag of water may have broken without the onset of contractions. The due date may have come and gone a week ago, or even two weeks ago. Elective inductions before 39 weeks are not allowed in most states, as it’s generally considered safer for the baby to stay inside until labor spontaneously begins. However, not uncommonly, situations arise in the weeks surrounding your due date (sometimes prior to 39 weeks) that require medical intervention as the safest way forward for you and the baby. Be sure to ask for as much information about the reason for your induction as you see fit. It is your right to know the details.
There are many ways to encourage the body to go into labor by using non-medical methods such as intercourse, light exercise, acupuncture and homeopathy. However, this is not the purpose of this article. Here, I will address the medical techniques most commonly used today for induction in a hospital setting.
Your induction date may or may not be scheduled. You may be asked to go to the hospital after a regular prenatal visit because your OB/GYN or Midwife has decided that it’s safer for the baby to be on the outside than on the inside at this point. Or perhaps your provider told you to come in to the hospital exactly 1 week to date if labor has not started spontaneously. If your induction is scheduled in a scenario such as this, you’ll likely be requested to come to the hospital in the evening hours, around 8pm or 9pm. Remember to take your time in either scenario as there’s no reason to rush or worry. If your provider were concerned about your immediate health or the baby’s, you would not be given induction, you’d be a candidate for an emergency cesarean delivery.
There are four main methods for inducing labor medically. I’ll outline them here in the order they are generally used. Hospitals vary in their protocol. Some medications have different names. Be sure to ask your provider about what methods he/she prefers and for any pertinent hospital protocol. This specific information will help you mentally prepare for your induction.
Stretch and sweep:
A stretch and sweep is generally performed at your provider’s office during one of your prenatal visits. Your OB/GYN or Midwife will first examine your cervix. They will determine if your cervix is starting to get ready for labor. A stretch and sweep cannot be performed unless your body has started this labor preparation. If the conditions are favorable, meaning that the cervix has started softening, dilating and moving forward, then the provider may begin the stretch and sweep. This involves one or more finger being inserted into your cervix—this is the stretch portion. Once the finger(s) are inside, he/she will locate the amniotic sac and sweep his/her fingers along the side of it, effectively separating the sac from the uterine wall—this is the sweep portion. This can be somewhat uncomfortable. Just remember to breathe and try to relax around your provider’s fingers even though it can be unpleasant. It lasts generally no more than 30 seconds. You may have a scant amount of bleeding after this. It’s best to wear a pad. You may or may not begin feeling a menstrual-like cramping shortly after this. Sometimes it can take a few hours for the cramping to begin. The point of the stretch and sweep is to initiate this cramping. This means that your uterus has been successfully agitated in such a way that labor might ensue. Note*: Very infrequently, your water may break from this procedure due to the handling of the membranes of the amniotic sac.
Prostaglandins are hormones that cause your cervix to soften. Semen contains prostaglandins, which is one of the reasons intercourse is recommended as a more natural method for bringing on labor. What you will be administered in the hospital will be a synthetic form of a prostaglandin. The two most common medications are Cytotec (or misoprostol), or Cervadil (or dinoprostone). Cytotec is a pill, or a small portion of a pill, and Cervadil has the appearance of a tampon with the medication contained within. Both are inserted vaginally and placed as close as possible to the cervix. Generally, if you are already contracting occasionally, you will not be a candidate for this induction method.
Because the main effect of prostaglandin medication is to soften your cervix, it may or may not cause contractions. The onset of contractions usually is delayed at least an hour or two after insertion of the prostaglandin. If by 4 hours there are no contractions and your cervix is not yet softening/thinning or beginning to dilate, you may be given a second dose of Cytotec or Cervadil. After this second administration, you will be given another 4-hour window of time for your cervix to soften, dilate and for contractions to begin. You will be on continuous fetal monitoring during this time so that your medical team can be assured of your baby’s wellbeing.
Sometimes just one administration of the Cervadil/Cytotec will be all that is needed to jumpstart labor. Your body may have been on the cusp of going into labor already and this medication may just kick things into gear. If this is the case, you may not require other medications to keep contractions going and labor will continue on until you give birth to your baby.
Cervical Foley (Foley balloon):
Your cervix must be dilated slightly to be able to use this method. A Cervical Foley is a long flexible rubber tube with two inflatable areas at its end. This tube is inserted through the cervix into the uterus and will extend from the uterus all the way outside of your vagina about 6 inches or so. The way it is secured inside of you so it does not slip out is by blowing up the inflatable areas with water so that they become small balloons both inside your uterus and just outside of your cervix. The tautness of the water balloons keeps the Foley in place. Think of the shape of a dumbbell, but instead of the two weighted ends are the water balloons, and where you would grasp the dumbbell in between the weights is where your cervix is. So, effectively, what these balloons are doing are mechanically encouraging your cervix to dilate by putting pressure on either side of your cervix.
This may sound uncomfortable and a drastic way of forcing dilation. In fact, neither is the case. Dilation does not occur quickly: many hours are needed to encourage the cervix to change. Any agitation of the cervix can elicit contractions and subsequent dilation, and this is specifically what the balloons are doing. Once you’ve dilated to about 5cm, the Foley balloons will slip out. While it is inside, you will likely require continuous fetal monitoring in order to ascertain how the baby is tolerating the induction. However, you might be given the option for intermittent monitoring—be sure to ask!
Often a Cytotec/Cervadil is administered first with the Cervical Foley being the second (or third if you received a stretch and sweep) line of treatment to induce. However, if you were not given a prostaglandin because you were contracting, you may still be a candidate for the Cervical Foley provided that you have begun dilating. If this is the case, the Foley would potentially be your first line of induction treatment. And it may be the only treatment needed to get labor going. However, if the contractions do not pick up and generate an active labor pattern, as deemed by your provider, it may be recommended that you receive Pitocin to bring on more contractions. Remember, it is the contractions that cause dilation and they will need to increase in intensity for labor to progress and ultimately lead to the birth of your baby.
Oxytocin is a hormone that every human generates. It is produced during our happiest, most content and safe moments. Often called the “hormone of love,” it floods us when we are making love, laughing or beholding our baby for the first time. It is also the hormone that triggers contractions. The synthetic form of oxytocin is called Pitocin and it is a liquid that is administered through an IV. The IV is hooked up to a pump and the Pitocin is given continuously at a specified dose. This dose may be increased or decreased as the provider sees fit. They will generally want to increase the dose in order to generate contractions that are approximately 3-4 minutes apart. They will generally want to decrease the dose if the contractions get too close together: less than 2.5-3 minutes apart. The medication exerts its effect within 5-10 minutes of being initiated. It also has a very short half-life, so when it is decreased or turned off, its intensity is lessened or leaves the body within 5-10 minutes or so. In this way, it is the only induction treatment of the four listed here that can be tightly controlled. During administration, continuous fetal monitoring is required.
The contractions that are caused by Pitocin can be intense and physically challenging. This is mostly because it is not your body that is naturally producing the contractions but instead it is a medication doing so. The body has a way of pacing itself during labor so that you and your baby tolerate this physical transformation of birth in a manageable way. With Pitocin, it is your provider that is effectively pacing your labor by increasing or decreasing the level as needed. Sometimes this can feel as though there is no pacing and that labor has become unmanageable. When this occurs, it is not uncommon for mothers to ask for an epidural. This is not the case for all mothers who receive Pitocin, however. Many mothers who wish not to have an epidural can still manage to tolerate Pitocin.
Pitocin may be given as an induction agent or an augmentation agent. When used for induction purposes, it’s generally started after the administration of Cytotec/Cervadil and a Foley. But it can also be used independently of these other methods provided that the cervix is favorable: starting to dilate, efface, move forward. If Pitocin is used for the augmentation of labor, this means that labor is already ongoing but needs a little bit more steam. A frequent scenario might be that you are contracting approximately every 10 minutes and you are given Pitocin to encourage contractions to come every 3-4 minutes.
I hope you find these explanations useful. They can be used in the order listed above or independently as I’ve described. All except the stretch and sweep are administered within a hospital setting and require continuous external fetal monitoring. Remember that each hospital have their own protocol, so some of what I describe may vary. All these methods can effectively bring on labor so that you have the opportunity to deliver your baby vaginally.