Labour Induction
There will likely be a conversation about labour induction toward the end of pregnancy. This blog is the tip of the iceberg on this topic, but it will aim to give you some information to help you navigate that conversation and make an informed decision about whether or not an induction is a good choice for you.
What is an induction of labour?
Induction of labour is using medical means to get the uterus to contract before labour begins on its own. The main reason to induce labour is concern for the health of the baby or the health of the pregnant person. If a healthcare professional suggests labour induction, it should be because the benefits outweigh the risks. However, inductions for non-medical reasons have been on the rise around the world over the last 30 years (Little, 2017). Knowing why and how labour induction is done can help you prepare if you're pregnant.
Going past your estimated due date is not a medical reason for induction! There are many scenarios where healthcare providers will suggest induction for going past one's estimated due date, like Gestational Diabetes or Advanced Maternal Age. You can learn more about Induction for Due Dates in this article by Evidence Based Birth - Evidence on: Inducing for Due Dates
What are the different methods of induction?
Stretch & Sweep: You may be offered a "Stretch and Sweep" or a "Sweep" in the last weeks of pregnancy. It is often presented as routine, harmless and risk-free, but that's not entirely true. It is a form of induction. A health care provider inserts their fingure(s) into the cervix and stretches the cervix, trying to widen the opening. They then try to run their finger(s) between the bag of waters and the uterus to separate the connection and "stir things up."
The benefits: It may help "stir things up" and put you into labour, but there's no guarantee! Some people see a direct result of a Stretch & Sweep leading to labour; others have several, and still nothing happens.
• It can be done in your healthcare provider's office/ clinic and doesn't require hospital admittance.
• It doesn't involve medication or an IV.
The Risks: Aside from the possibility that it may not work, there are a few other downsides to having a Stretch and Sweep.
• It is very invasive and can be very uncomfortable for many people.
• It can cause an "irritable uterus" that is crampy and uncomfortable sometimes for days before labour finds a pattern, and this can be exhausting.
• The baby may not be ready for labour and not in an ideal position, which can create a very intense but slow-progressing labour pattern. Similar to the irritable uterus but more intense. Or it could cause start and stop/ prodromal labour.
• One's bag of waters could accidentally break during the procedure or within a few hours. If this happens, there may be a need to take steps to get labour going with medications. If the waters break and labour doesn't start on its own, you could find yourself in an induction situation.
As a note, a Stretch & Sweep differs from a cervical check. Cervical checks are also offered in the late weeks of pregnancy and are often presented as routine. A cervical check is like a snapshot. It only tells us what the cervix is doing at that moment and can not predict when labour will start. The cervix can change very quickly or remain the same for weeks! You do not need to have a prenatal cervical check, especially if the information may make you feel anxious.
There are only two reasons for a cervical check before labour starts: 1) your curiosity, and 2) to assess what method of the induction process the healthcare provider would suggest starting with.
Get the video recap here: more on STRETCH & SWEEPS
Other types of induction and the various steps that may follow.
Prostaglandin gel or oral prostaglandin: If the cervix is very firm and not showing much "ripeness," a gel may be inserted into it to help it soften and change. This is usually done in a hospital setting, and then the pregnant person is sent home for about 12 hours to try and get some sleep before returning for another cervical assessment and the next steps.
With oral prostaglandin (typically a low dose of misoprostol), a pregnant person is usually admitted and monitored while being given doses every two to four hours. Once the medication is given, it can not be taken out of the body's system; only time will allow it to wear off.
Prostaglandins help create a change in the cervix, sometimes resulting in regular contractions/ surges and a labour pattern. Most of the time, more induction steps are needed.
Foley "balloon" catheter: This is the most common way to start an induction in Toronto. It is typically done in triage at the hospital; however, some midwifery practices will offer this in their clinic. It requires that the cervix be soft enough and possibly slightly dilated to insert the foley. A thin, flexible tube is inserted into the cervix, and the internal end is filled with saline to keep it in place. A tiny bit of traction is put on the foley to create pressure on the cervix from the inside. The external end is taped to the inside of the pregnant's thigh. Following the insertion, thirty minutes of monitoring the baby happens. If all is well, the pregnant person is sent home for about 12 hours to try and get some sleep before returning to have it removed, another cervical assessment and next steps. The hope is that the foley will help dilate the cervix to about 3 cm and mimic the effects of early labour. Occasionally, this may create a labour pattern that continues independently, but more steps are often needed.
Breaking the Bag of Waters: Breaking the bag of waters is not usually done before the cervix is at least 3 cm dilated. This is commonly the next step after a foley catheter is removed. The hope is that by breaking the waters, the baby's head will apply more direct pressure on the cervix and may even begin some contractions/ surges from the oxytocin release that pressure produces. Breaking water can be used in home or hospital births when there is a want or a need to augment labour (create more change), too.
Synthetic Oxytocin: This medication is given by IV and requires continuous monitoring of the baby's heart rate and contractions/ surges because it introduces risks. It is usually the last step of induction when other steps have not created a significant labour pattern strong enough to birth a baby. While it's molecularly the same as our body's natural oxytocin hormone, it does not cross the blood-brain barrier or produce the endorphins that natural oxytocin does. One advantage of this medication is that it can be easily removed from the body's system by turning it off, unlike prostaglandin gel or oral medication.
Synthetic oxytocin is also used in other scenarios to help progress labour. It is often used to aid in the delivery of the placenta or postpartum hemorrhaging - but those are topics for another day!
Get the video recap here: more on INDUCTIONS
An induction of labour is rarely just one of the methods listed above. Each method/ step has its own benefits and risks to be considered carefully. The process is often lengthy, lasting several days in many cases.
As you near your estimated due date, it is essential to inform yourself about inductions and, if you are being suggested an induction, to ask why! Is there a medical reason? How do you know the difference between a valid medical reason and a doctor's suggestion?
What are the benefits and risks of elective induction for birthers and babies before ones estimated due date? What about after you've passed your estimated due date—is there a point where the risks of continuing the pregnancy significantly increase?
Do your goals of care and preferences for their birth matter? (the answer to this is, YES!)
Have you got questions about induction? Do you want to discuss all your options? Do you need help deciding if induction is a good choice for you, and how can you advocate for your preferences? Be in touch!
