Having an induction (or in medical shorthand IOL – induction of labour) isn’t as simple as having a small amount of drugs and labour will instantly start. Labour is a complex system of hormones released by mother and baby which work together to get the process going. Not only do you need the labour hormone, oxytocin to be circulating in your body, but your uterus also needs oxytocin receptors to be activated, something which happens once labour is established. Because your body may not be ready for labour, high amounts of artificial oxytocin may be needed to get labour going. And that in itself poses risks to you and your baby which is often conveniently left out by your carer.
It’s important to be aware that labour induction doesn’t always work every single time; some inductions become ‘failed inductions’ and will require a rescheduled induction or for some, a caesarean section. A midwife from a large Melbourne hospital recently confided that they see many women come in for inductions where both mother and baby are well, but sadly somewhere between 50-75% of first time mothers being induced are ending up with caesareans.
An induction has only one advantage. When given for medical reasons, it may potentially save the life of a mother and / or her baby. Of course, if it means saving a life, we are all going to choose the option to induce – there is no argument an induction would then be beneficial. Just like a caesarean, they definitely have a place in life threatening situations – and for that we are very grateful.
However in the case of an induction for social reasons or convenience, I encourage you to seriously think twice. An induction only introduces real risks to what could have been a perfectly normal birth. It greatly increases the likelihood for further interventions, from pain relief to caesareans or several of these procedures in one birth.
Inform Yourself About the Facts of Induction
It’s important to research, research, research – find out if the reason for your induction is warranted and what other mother’s stories are in the same situation. Question everything. Get yourself informed and empowered about the effects of an induction for both mother and baby during labour and post-birth, not only on a medical level but also physiologically – induction can even interfere with endorphin (hormone of pleasure and transcendence) production. The following few paragraphs are exerts from Dr Sarah Buckley’s article,
Ecstatic Birth (references to evidence and text can be found in the article as linked).
NB. references to Pitocin is similar to Syntocinon in Australia:
“Synthetic oxytocin (oxytocin is the labour hormone) administered in labor does not act like the body’s own oxytocin. First, Pitocin-induced contractions are different from natural contractions, and these differences can have significant effects on the baby. For example, waves can occur almost on top of each other when too high a dose of Pitocin is given, and it also causes the resting tone of the uterus to increase.
Such over-stimulation (hyperstimulation) can deprive the baby from the necessary supplies of blood and oxygen, and so produce abnormal FHR (fetal heart rate) patterns, fetal distress (leading to cesarean section), and even uterine rupture.
Birth activist Doris Haire describes the effects of Pitocin on the baby:
“The situation is analogous to holding an infant under the surface of the water, allowing the infant to come to the surface to gasp for air, but not to breathe.”
These effects may be partly due to the high blood levels of oxytocin that are reached when a woman labors with Pitocin. Theobald calculated that, at average levels used for induction or augmentation/acceleration, a woman’s oxytocin levels will be
130 to 570 times higher than she would naturally produce in labor. Direct measurements do not concur, but blood oxytocin levels are difficult to measure. Other researchers have suggested that continuous administration of this drug by iv infusion, which is very different to its natural pulsatile release, may also account for some of these problems.
Second, oxytocin, synthetic or not, cannot cross from the body to the brain through the blood-brain barrier. This means that Pitocin, introduced into the body by injection or drip, does not act as the hormone of love. However, it can interfere with oxytocin’s natural effects. For example, we know that women with synthetic oxytocin infusions are at higher risk of major bleeding after the birth and that, in this situation, the numbers of oxytocin receptors in the laboring woman’s uterus actually decreases, and so her uterus becomes unresponsive to the postpartum oxytocin peak that prevents bleeding. But we do not know the psychological effects of interference with the natural oxytocin that nature prescribes for all mammalian species.
‘The Doula Book’, written by Klaus, Kennell & Kennell, contains a study on Doulas and induced labour in Cleveland, USA. The overall epidural rate for those who were induced was
81% and caesarean rate
43%. This includes women who had professional support people with them and others without.
Being Offered An Induction
A very important thing to consider when being offered a medical induction is risks vs benefits. Ask yourself this:
‘What risks am I happy to accept in relation to the benefits?’ This is a very personal question and there is no right or wrong answer for YOU.
You are most likely to be offered an induction if you are post-dates (remembering that it’s considered a full-term pregnancy between 38-42 weeks), if your Ob ‘thinks’ you have a big baby / small pelvis or if there are health issues detrimental to either mother or baby. If all is well, there may be several reasons why baby hasn’t come yet. Your baby simply may not be ready – the due date may have been miscalculated by mother or machine.
Ultrasounds are notoriously inaccurate for pinpointing the day of birth (around 3-5% of babies are born on their ‘due date’). They acknowledge that they are plus or minus 7 to 10 days either side of the estimated due dates. This is because they calculate these dates based on mathematics and averages, not your own baby and the unique rate at which he or she grows. Even first trimester ultrasound can be inaccurate by 5 days either side.
Babies can be born from inductions unexpectedly premature (i.e. were not as advanced for dates as ultrasound detected) based on miscalculated due dates and then may have breathing problems resulting in artificial breathing assistance which is not a pleasant experience for all involved. They may also be more prone to infection.
Another reason baby might not have arrived on time is that occasionally the problem is anxiety or stress in the mother resulting in the slow onset of labour. Adrenaline in the system is not helpful to oxytocin production. You might be familiar with the ‘flight or fight’ response we have as humans. If we don’t feel safe, our bodies don’t want our babies to come until we are in a safe place and can ‘let go’.
The below information on reasons for induction was compiled by Midwife, Brenda Manning.
Doctors may suggest an induction for any of the following:
- Post-dates (which varies, most doctors will recommend an induction at around 7-14 days past your due date according to their own opinions and/or beliefs)
- Where continuing the pregnancy poses a threat to the mothers health (mental or physical)
- Pre-Eclampsia / high blood pressure
- Diabetes
- Multiple pregnancy
- Blood group incompatibility
- Fetal and / or maternal compromise
- IUGR (inter uterine growth restriction) or a very small for dates infant
- Fetal abnormality
- Diabetes
- Chronic renal disease
- Polyhydramnios
- Abnormal liver function tests
- Blood dyscrasias
- Previous stillbirth
- Fetal death in utero
- Poor past obstetric history (complications and/or lost or damaged babies)
- Membranes rupture but no labour after 72 hours, less if you are GBS positive (this time frame differs between hospitals)
- Where continuing the pregnancy is detrimental to the baby i.e. isn’t growing or is unwell & would be safer out than in.
- Antepartum haemorrhage (not placenta praevia)
- Large for dates infant
- Placental insufficiency
Cases where an induction is not clinically advisable:
- Abnormal presentation (e.g. transverse)
- Fetal distress
- Placenta praevia
- Cord prolapse
- Vasa praevia
- Social reasons
- Obstructed labour
Reasons induction of labour may be requested but is inappropriate:
- Social – i.e. convenience or just wanting to know the date baby is coming
- Because it is your caregivers ‘standard management’
- For hospital convenience (unless lack of anaesthetic cover is a consideration)
- Mother being “over it” or sick of waiting
- Doctor / Midwife going on holiday / golf / conference / disruption to consulting sessions
- Partner going on holiday
- Family staying from out of town and needing to return home
- Wanting baby born on a specific date
- Wanting a smaller baby (unless medical indication)
- ‘9-5 obstetrics’ – some hospitals, mainly private ones, have a 90% induction rate termed 9am to 5pm obstetrics, so the care-giver is not woken overnight to attend births.
Methods of Induction
There are several ways your labour can be induced, dependant upon your cervix and if it is deemed to be ‘favourable/ripe’ which is slightly open, or ‘unfavourable/unripe’ which is a closed, long cervix. A midwife or doctor will examine you to determine this.
Some of the risks listed in this section your doctor may not tell you and it may seem very worrying or disturbing, however if you were to be given a packet of the drugs used for the induction, that’s what you’ll get on the included drug information with relation to it’s use and effects. It is not intended to scare anyone, but to help you make a balanced, informed decision as to what the risks versus benefits are. Of course, when used for life saving benefits, there is no risk we wouldn’t take. But if yours or the baby’s life is not in danger, it is worth considering if it’s worth the risks to you and your baby.
1. Sweeping Membranes / Stretch & Sweep
If you have a ‘favourable’ cervix this may be offered to you in the first instance as a ‘drug-free’ induction with less side effects and risks compared to other methods. It’s not usually painful but may be uncomfortable and result in some bleeding afterwards. Sweeping the membranes involves a vaginal exam, your doctor or midwife will place his / her finger inside your cervix and ‘sweep’ the membranes in order to separate it from your cervix. It is said to be quite effective, often within 48 hours of the sweep. A ‘stretch and sweep’ is the same sort of procedure, only your cervix is also stretched at the same time.
2. ARM (Artificial Rupture of Membranes)
Should your cervix be favourable and your baby in the pelvis, this option may be given to you for an induction. The waters will be broken in the hope this will lead to labour, however often you are given a very short space of time for contractions to establish – sometimes only an hour or two – before being put onto an i/v (intravenous) oxytocin drip. Of course, once the membranes have been ruptured, you are also on a time line as your chance of contracting an infection is increased. Some midwives have also noticed that the early rupturing of the membranes can result in more posterior or malpositioned babies.
If your labour is not progressing after the membrane rupture, you will likely have a syntocinon drip put up (which you can consent to or not consent to – it is your body and your choice), possibly followed by pain relief and depending on the option you choose for pain relief, you may require assistance by the way of an instrumental delivery. All this is called a ‘cascade of intervention’ where one intervention leads to another and another and so on. However some women will go on to labour well and not require all these things – it’s just something to bear in mind from both sides.
3. Artificial Oxytocin (Syntocinon)
Syntocinon is administered via an intravenous drip and may be used if your waters have broken but there are no contractions, or if contractions don’t start up on their own. Because you are having this drug, you will be required to be monitored continuously as your doctor will need to know what effect this is having on the baby. So if you planned on having an active labour and moving around freely, this could leave you confined to the bed. Being restricted to the bed, reclining or semi-reclining during labour works against gravity and are not particularly helpful to the normal processes of labour. It also means that you won’t be able to use a bath and probably a shower for pain relief too. You can still use a bath and shower for pain relief with intermittent monitoring, it’s just more awkward so it will depend on the hospital and staff on at the time.
It may be argued that you will be induced starting at a low dose which may bring you some comfort at the time. But this ‘low dose’ will be continually increased during your labour, usually every half an hour the dose will be doubled – so you can imagine how quickly this builds up until you start labouring at the rate required and so your labour keeps progressing. Once you are on an oxytocin drip, most doctors will say that unless your baby becomes distressed, they will want the drip on until your baby is born, so your labour doesn’t stop. So if you decide you don’t want it after an hour or so, or it gets too much, know that you do have the choice and power to have it turned down or turned off – however if your labour slows or stops they will want it back up again. Sometimes it just takes a little syntocinon to get labour going, however by accepting an induction in this way you do run the risk of requiring the drip for the whole labour.
An example of a dose you might have prescribed is as follows:
10u of Syntocinon added to 1000mls of fluid. The drip rate is usually started at somewhere between 15-30mls per hour. It is then increased by somewhere between 15-30mls per hour every 30 minutes.
So if we were to start with 30mls per hour, after 30 minutes the rate would be increased to 60mls per hour, and after 1 hour the rate would increase to 90mls per hour.
Side effects include:
- Hypotension (low blood pressure)
- Water intoxication
- Hypertonic uterus
- Uterine rupture
- Uterine inversion
- Stillbirth
- Tachycardia
- Heart abnormalities
- Nausea
- Vomiting
- Diarrhoea
- Because it acts on the smooth muscles asthma could be a problem
This is taken from the packaging of Syntocinon which has been recently updated:
“ADVERSE REACTIONS
The following adverse reactions have been reported in the mother: Anaphylactic reaction, Postpartum hemorrhage, Cardiac arrhythmia, Fatal afibrinogenemia, Nausea, Vomiting, Premature ventricular contractions, and Pelvic hematoma.
Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.
The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug.
Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.
The following adverse reactions have been reported in the fetus or infant:
Due to induced uterine motility: Bradycardia, Premature ventricular contractions and other arrhythmias, Permanent CNS or brain damage, and Fetal death.
Due to use of oxytocin in the mother: Low Apgar scores at 5 minutes. Neonatal jaundice, and Neonatal retinal hemorrhage.”
4. Prostaglandins
If your cervix is not ripe or favourable, prostaglandins will likely be used in an attempt to soften and open your cervix. Should this be effective and your cervix becomes at least slightly open, your waters will then be broken (ARM as per above). Prostaglandins may need several doses to work, so you may be asked to come in for extra doses. There are a few different prostaglandins being used in hospitals, the most common two which are in gel and pessary form as described below.
Once the prostaglandin has been administered, you will be advised to lie down and rest for around half an hour. A midwife will monitor the baby’s heart rate (CTG) as well as check your blood pressure and pulse regularly before and after administration. You will also have a further vaginal exam to check your cervix.
Some rare side effects include nausea, vomiting or diarrhoea. Following the prostaglandin application, if all is well occasionally you may go home whist awaiting its effects.
Prostin gel – Prostin gel is placed in the vagina near the cervix during a vaginal exam. It works by softening and dilating the neck of the womb and stimulating contractions. A second vaginal exam will be performed to check your cervix. If your cervix has opened the doctor or a midwife may be able to break your waters. You may be required to have another dose if there has been no or little movement. Prostin Gel may result in ‘prostin-pains’ once applied, which isn’t established labour and may be quite uncomfortable. Uterine Hyperstimulation can occur with gel, in which case the gel is wiped out with gauze and the vagina washed out with saline.
Because prostin acts on smooth muscle it can also affect cardiovascular, hepatic and renal systems. It can induce asthma, epilepsy and glaucoma.
Side effects include:
- Hypertonic uterus
- Stillbirth
- Postpartum haemorrhage
- Uterine rupture
- Amniotic fluid embolism
- Nausea
- Vomiting
- Diarrhoea
Cervadil Slow Release Pessary – Cervadil is inserted into the vagina and placed behind the cervix in the form of a pessary, which is similar to a tampon – it has a tape that hangs down for removal.
The pessary will be removed if:
- Hyperstimulation occurs
- Your waters break
- Labour establishes
- 12-18 hours has passed
Following its removal you may then be recommended to have your waters broken if they haven’t already and / or be put on a Syntocinon drip.
Side effects include:
- Hypertonic uterus
- Stillbirth
- Uterine rupture
- Nausea
- Vomiting
- Diarrhoea
Still not sure what to do? Well imagine if your baby could make the decision for you. Would he / she like to go through a harder induced labour over a natural one? Would you like to go through a harder, induced labour than a natural one? An induced labour makes the uterus work very hard, producing long, strong contractions. While some mothers feel that their induced labour was no different to a normal labour, many mothers who have had both induced labours and non-induced labours feel that their induced labour felt like they were completely out of control, which resulted in pain relief when they didn’t want any. One mother said:
“My daughter (first born) was born vaginally without drugs or induction. It was a 7 hour labour and I look back on it with so much pride. I can recall moments throughout the entire labour and it was one of the best and most joyful things I have ever done. My son was born 18 months later and I was induced at 38 weeks due to my Obstetrician thinking was my son was “huge‿. He wasn’t huge at all and it turns out that the induction was, in hindsight, totally unnecessary. My labour with my son was only 2 hours: too fast. I can’t remember much about it, because the pain and the speed were all way too much. I certainly adore my son, but regret the induction, as whilst it did him no harm, I feel like we were robbed of the natural birthing rhythm.”
And another mother:
“I wish those contemplating a social induction only realised the pain involved in a medicated induction. It is just SO much worse than labouring naturally. I have NEVER felt so out of control as I did when I was augmented. Seriously, the pain and intensity of the pain and contractions after syntocinon is unreal. I really thought my heart would stop from the pain. I knew that I could deliver without drugs, I’d done it twice before, but that synto had me agreeing to an epidural…”
And finally:
“Soon after having the syntocinon drip to augment (speed up) my labour, I was having very strong contractions – much more so than earlier contractions which were at 5cms dilation. They were on top of each other and I can remember screaming at the top of my lungs for it to stop and I said that I was going to die – in some very choice words which was unlike me. I couldn’t open my eyes, I tightened up against the pain, I was bawling and felt like I was having a bizarre out of body experience. At that point, I realised that my longed for drug-free birth was out the window.
I tried gas which was useless and I began screaming for an epidural, over and over as they couldn’t understand what I was saying (as a result of the gas which made everything feel like it was in slow motion, my speech included). Even getting the epidural in was a nightmare, it took three jabs in my spine before it went in all the way as I couldn’t stop writhing through each painful contraction. While the pain stopped with the epidural, I couldn’t feel my baby being born, I had to have a urinary catheter and couldn’t get up after the birth and do much at all. I felt so vulnerable and robbed of what I expected birth to be; I had NO chance against the syntocinon. The labour had kicked into gear in an instant and my body had no opportunity to build up into the harder contractions or have a break from them. I hate it and I know that if I had to have syntocinon again (which I would only ever have if it was in life saving circumstances), I would not be able to cope without pain relief because it is such a powerful drug, so I choose not to be induced.”
Some women are able to have an induction with no pain relief – our uterus’ have unique levels of sensitivity to synthetic oxytocin, however the vast majority soon have pain relief, often epidurals, after an induction or augmentation.
What does induced labour feel like?
Someone once told me how to imagine and compare a normal labour with an induced labour like this:
‘Normal Labour’:
1. Hold your hand out flat, like you would to receive money from someone.
2. Clench your fist and hold it closed for a second
3. Release your fist back into a flat position again.
If you repeat the above over several times, this is how a normal labour would be to the uterus. You can see how it’s not so bad and the circulating blood, hence oxygen, would be restricted but the uterus has time to recover. Now for the ‘induced’ analogy.
‘Induced Labour’:
1. Hold your hand out, clench, out, clench, out clench, out, clench, out, clench, out, clench, out, clench, out, clench, out – keep going for a minute or so – is your fist tired or sore yet? Imagine how this would feel for your uterus to do this for hours on end and what difference this could make during your labour and for your baby.
How will I know if I really need to be induced?
If you are offered an induction or augmentation and the situation is not life threatening, it’s always useful to use B.R.A.N.D.:
- What are the BENEFITS? (of this being done)
- What are the RISKS?
- Are there ALTERNATIVES? (other than this being done)
- Does it need to be done NOW?
- Can we have some privacy to make a DECISION?
Of course its very important to be under the care of a midwife or Obstetrician whom you trust. Hopefully you have been able to include your wishes in regards to inductions in your birth intentions or birth plan (which your carer has read, signed and supported). Alternately or in addition, talking with your midwife or Obstetrician prior to labour may help better communicate your wishes for birth and you can also find out under which circumstances your carer will want to induce labour. If you feel you would need help in situations where you need to make a decision, consider hiring a
Doula who can support you and your partner as well as help you with your birth plan and advocating for you.
Induced labours are not just a full-speed rollercoaster ride for babies. Induction can sometimes result in uterine hyperstimulation – this means contractions which are very strong, close together or on top of each other and longer.
First think this before you make a decision to cave into the lure of an induction: given everything in your pregnancy has been well, you’re lining up at the starting line with the best possible chance for the best possible outcome during birth for both yourself and your baby. Do you really want to make it more likely that you will need intervention, assisted delivery or even a caesarean?
So if you are contemplating an induction, imagine if you could ask your baby what sort of experience they would like as their welcome into the world. You may feel like you’ve had enough of being pregnant now, but how would you feel if your baby was born unexpectedly premature and had problems breathing on it’s own and required assistance? This is a reality of an induction and what it can mean if not thought through properly.
One mother said this about trusting her body and her baby to do what they needed to do, in their own time:
“My pregnancies were all long. My twins were born by induction at 40 weeks and the next baby was born by induction at 42 weeks. By child number 4 I decided on a homebirth – which meant that I would need to go into labour naturally. Finally at 43 weeks and 4 days that happened. It isn’t recommended to go that long, however he was fine, although his skin peeled off everywhere. Baby number 5 was 42 weeks and 3 days, also born at home. I tried acupuncture, I drank gallons of raspberry leaf tea, I had so much sex I was sick of it. I believe that some women naturally have longer pregnancies and some have shorter. The women who spontaneously labour have their babies at 37 weeks fall into the ‘normal’ category and the unlucky women who go longer than 40 weeks unfortunately get landed with all the interventions. Choosing to wait for labour to occur naturally was very hard work as there was a tremendous amount of pressure to agree to an induction, however I believed that my body must eventually labour spontaneously. I did agree to regular monitoring in the last week to check that the baby was OK.”
Letting your baby choose it’s own birth date while all is well is the best gift you can give to your unborn baby. So if you are healthy and baby is healthy, give that gorgeous belly of yours a nice rub and let baby know he or she is welcome into the world whenever natural oxytocin beckons – and when he or she is ready for the world.
