Ep 183: Labor Induction – Updated!


On today’s episode you’re going to learn about labor induction. I covered this topic 3 years ago and there is new information in this updated episode. I get a lot of requests to talk about this and I get why. It’s one of those topics that makes a lot of pregnant people nervous. You may have heard horror stories about induction and pitocin. Plus there’s concern about the cascade of interventions or increasing the risk for c-section - so I get it. And on today’s episode I will answer your questions and shed some light on what labor induction is all about!

In this Episode, You’ll Learn About:

  • What labor induction is
  • Why labor may be induced (you’ll be surprised to hear that there are only 2 reasons)
  • When induction is NOT appropriate
  • How labor is induced and the efficacy of different methods
  • What constitutes a failed induction
  • Which questions to ask before being induced

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Transcript

Dr. Nicole (00:00): Today's episode is an updated episode on a topic I get a lot of questions about and that causes a lot of anxiety, labor induction. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now, let's get to it.

(00:54): Hello there. Welcome to another episode of the podcast. This is episode number 183. Thank you for being here with me today. In today's episode, you're going to learn about labor induction. I get lots of questions about that topic and I get it. It's one of those topics that makes pregnant folks nervous. You may have heard horror stories about induction and Pitocin. There's concern about the cascade of interventions increasing risk of C-section. So I get it, and in this episode I hope to answer all your questions, shed some light on what labor induction really is all about. I first did this episode three years ago. I can't believe it's been that long, and I've added some things since that first episode. So in this episode, you are going to learn, of course, what labor induction is, why labor may be induced. You will be surprised to hear that there really are only two reasons for labor induction. When labor induction is not appropriate, how labor is induced, what constitutes a failed induction, meaning that it's time for a cesarean birth, and then what questions you should ask before you get induced.

(02:11): Now, of course, labor induction is one of the things you may want to know about before birth, but there are a lot more things you need to know going into your labor and birth, like how to push, how to manage pain, how to reduce the risk of vaginal tears, and you can learn about all of that and so much more in my online childbirth education class, the Birth Preparation Course, through my beautiful birth prep process, it's a five step process. You will get calm, confident, and empowered to have the most beautiful birth that you deserve. It starts with setting the tone for your birth because mindset is so important. And then you learn all of the details of labor and birth, including my insider knowledge as an OBGYN who's been in practice for nearly 20 years. You learn about possible things that could happen so that you can manage the unpredictability of birth, and then you get some tips to help you get off to a great start postpartum too.

(03:04): And then how to make birth wishes that actually work to help you have the birth that you want. Birth wishes are also known as a birth plan. And let me share with you what one student said after she went through the course. She said, If you're looking for an in-depth description of what giving birth is like, this is an amazing course. I learned so many things that I felt knowledgeable about my birth and felt confident in talking with my doctor. I actually trusted his advice because I understood what he was talking about. There is a lot of information that I like being prepared and knowing as much as I can about such an amazing experience in my life. Thank you for helping me feel more prepared for my birth, especially offering an online option. I still have to experience birth myself to truly understand it, but I feel a lot more confident and calm about it.

(03:51): You too can feel that way. Check out all the details of the Birth Preparation Course at drnicolerankins.com/enroll, and I'm going to let you in on a secret that you are getting here on the podcast. First, the course will be going on sale for Black Friday. It's gonna be a big discount for Black Friday through Cyber Monday. So if you're thinking about it, stay tuned. Follow me on Instagram @drnicolerankins or join my email list, drnicolerankins.com/email. So you'll be the first to know about the big sale. This is the biggest sale I'll offer of the year, so you are getting it here first. If you're interested in childbirth education and the Birth Preparation Course, do check out that sale that's coming on Black Friday. And in the meantime, just peek at the details, drnicolerankins.com/enroll. All right, let's get into this episode on labor induction.

(04:44): So what is labor induction? Well, labor induction quite simply is the process of using medications or other methods to make labor start before labor has started on its own. And the frequency of labor induction really has increased very significantly over the years. In 1990, about 9.5% of labors were induced, in 2020, that number was 31.4%. So it really is like more than triple what it was in 1990, and there are a lot of reasons for that. Honestly, we're not as healthy as we used to be. They're more complications and issues with pregnancy. There have also been more of a push for induction in some instances, but in general, yes, labor induction has gone up. Almost a third of labors are induced for whatever reason. Now, the goal of labor induction is vaginal birth. I want to be clear about that. The goal of labor induction really truly is a vaginal birth and all those suc, the success or the likelihood of having that vaginal birth or having a successful labor induction is influenced by a lot of factors.

(05:55): I want you to know that overall, most of them do result in a vaginal birth. About 80% of labor inductions will result in a vaginal birth. So most likely if your labor is induced, you will have a vaginal birth. You just have to be patient with the process. As you will find, I'll talk about that several times in the episode that the key to a successful labor induction is really being patient with the process. So why might labor be induced? Well there are really only two major reasons. Two major reasons, two big categories. One, there's a medical reason to induce your labor, meaning that it's for the benefit of your health or it's for the benefit of your baby's health. Or the second reason, it's an elective induction, meaning that there's not a threat to your health, there's not a threat to your baby's health.

(06:44): There's no medical reason to do the induction. So really that's it. It's either a medical reason or it's an elective induction. Now, underneath that medical reason, there are a lot of things that can fall under that. For example, conditions that affect moms or things like high blood pressure or preeclampsia, diabetes that has developed either during pregnancy or existed prior to pregnancy. Something like cholestasis of pregnancy would be a reason to do labor induction, for conditions that affect babies growth restriction, low fluid issues with concern about blood flow to the placenta, are all valid reasons to do labor induction. Some things that you see are not valid reasons. A suspected large baby is sometimes cited as a reason for labor induction, but actually is not a reason for labor induction and being past due date is a reason, but usually it's offered earlier than needed. You really don't need to be induced for being post-term until you get to 42 weeks.

(07:48): Most often induction is labor is offered a lot earlier than that for being past due date. But past your due date, getting post-term 42 weeks is a reason to offer labor induction. Now, the timing of induction varies for medical induction, meaning there's a reason for your health or your baby's health. Typically, that's gonna be between 37 to 40 weeks. It's generally never before 37 weeks unless it's some severe circumstances like severe preeclampsia may be a reason to induce before 37 weeks. But in general, it's gonna be between 37 and 40 weeks. And the thing that we're looking to prevent is stillbirth. Really, we're looking to prevent stillbirth when there's a medical reason for induction. Then really we're saying that we have the tools, the capability to either have better health for you or for the baby's benefit. We believe that the baby's going to be better outside than in that we have better things to support the baby outside rather than in. Now some non-medical or elective reasons for labor induction or if you live a long distance away from the hospital.

(08:55): So say you live two or three hours away from the hospital, that is actually a possibility in some rural places, especially as more maternity units are closing that people can leave quite live quite a distance away from the hospital. Also, if you have a military spouse and your spouse will be deployed or that your spouse will be in town for a certain period of time, that's certainly a valid reason for labor induction. Sometimes it's patient preference. Some folks just get tired of being pregnant. That is totally fine. It's something that happens if you want to be induced. There's nothing wrong with you being induced. Sometimes you have family coming into town and you wanna coordinate your family being able to be there to help you and support you. So that may be part of a patient preference. Sometimes it may be because of the doctor's schedule.

(09:43): Now, if it's because of the doctor's schedule, it may be that she's going out of town and it should be offering like, Hey, I'm going out of town. If you want me to be there for your birth, then we can consider labor induction. It shouldn't be that, Hey, I'm going out of town. So you have to be induced. It really should be because there's a discussion and a conversation, but maybe your doctor's gonna be out of town and you want to make sure you have that opportunity to be with your doctor. So it could be the doctor's schedule that leads to an elective induction. Now, if it's an elective induction, you should never be induced before 39 weeks, all right? Unless there's a reason to do so. 39 weeks for elective induction before that should not be done. We shouldn't induce labor before 39 weeks again, unless there's a reason to do so, and I think we've gotten very good about that.

(10:36): Ideally, you want to have a favorable cervix, and I'll talk about what favorable means in a minute. But ideally, you want to have a favorable cervix. That is ideal, but it's not required. As you'll see from the arrive study that I'll talk about in just a minute, not everyone in that study, in fact, most people in that study did not have a favorable cervix and induction was still successful. So you ideally wanna have a favorable cervix, but it's not required if your cervix is not favorable and by favorable, it's slightly dilated. Thinned out the position of the baby in the pelvis, something called the bishop score. Again, I'll talk about that in a minute. If it's not favorable, then it is just gonna take longer for the induction. Also, you should never feel pressured for an elective induction. I think there's been a lot of unnecessary and inappropriate pressure on folks to be induced because of this study called the arrive trial.

(11:24): So induction at 39 weeks, and you should never feel pressure to feel induced. And on the flip side, you shouldn't feel guilty if you decide that you want to be induced. There's totally nothing wrong with that as long as the risk, the benefits, what you're getting into. If you wanna be induced, that is totally up to you. All right, so let's talk about the arrive study. This is a study that evaluated planned induction between 39 weeks and 39 weeks and four days versus waiting for labor to happen. It was 6,100 low risk patients having their first baby in the US. It was a randomized controlled trial, which is the strongest level of scientific study that we have. And cause of this study results. And let me go through the results. I've seen a, there's been a shift in the way that we talk about labor induction.

(12:19): So in this study, there was, for those who were induced, for those who were induced, there was a reduced risk of cesarean birth. It was 18.6% if you were induced versus 22.2% if you waited to go into labor. So a slightly decreased risk of cesarean birth. There was a reduced risk of hypertensive disorders of pregnancy, 9.1% versus 14.1%, a reduced risk of neonatal respiratory support, 3% versus 4.2%. And then there wasn't a difference in the risk of perinatal death or severe neonatal complications. Those were the same. All right? And then there were some secondary analysis of the data from the arrive trial. So where they looked at the data and looked at other factors that they weren't initially planning, that weren't part of the initial design of the study, but that they knew they were going to look at. So it found that patients who were induced at 39 weeks had fewer antipartum visits, test and treatments. They had a longer duration on labor and delivery, which you might expect by approximately six to seven hours. That number seems low to me, but that's what this study showed. They had shorter postpartum, maternal and neonatal hospital duration, similar total cost, which I also thought was surprising given that if you have a labor induction, it typically involves more cost.

(13:49): Yeah, so that was it. So lots of benefits that were found with labor induction. This study really kind of flipped everything on its head because for so long, data has shown that labor induction leads to an increased risk of cesarean birth. But this was the first randomized control trial. There are a few caveats about this study. It's in low risk women, it's also in women having their first baby. They also had strict protocols and things that they had to follow. Now, because of this study, a lot of OB GYNs have started recommending induction at 39 weeks, and I think that's strong. I don't think it needs to be recommended. I do think it should be offered if you want to have induction at 39 weeks. And I think I see most OB GYNs falling in that offer category. We can talk about induction at 39 weeks, but it really doesn't have to happen.

(14:43): In fact, ACOG says, and I'm gonna read their statement, ACOG is the American College of Obstetricians and Gynecologists. They help set standards for O B GY N practice. And what they said about the arrive study is based on the findings demonstrated in this trial, it is reasonable for obstetricians and healthcare facilities to offer elective induction of labor to low risk NEIS women at 39 weeks gestation. So that's first baby. However, consideration for enactment of this elective induction of labor intervention should not only take into account the trial findings, but that this recommendation may be conditional upon the values and preferences of the pregnant woman, the resources available, including personnel, and the setting in which the intervention will be implemented. A collaborative discussion with shared decision making should take place with the pregnant woman. So it really should be a discussion, not a recommendation that you should do.

(15:45): It should be offered, okay, it should be offered. And I also should say that this isn't the only thing that can reduce the rate of C-section. Also, continuous labor support from something like a doula can reduce the risk of C-section by 25%. Now, I will say that that evidence is a lower quality of evidence, its considered low quality evidence that shows that. But that is important to know that having a doula can also reduce your risk of C-section. Also, being able to get up and move around, having mobility, all of those things can help as well. So labor induction as is not the only thing that will reduce your risk of C-section. And also it didn't reduce it by a huge, huge amount. Yes, it did but not like by overwhelming numbers 18.6 versus 22.2%. So don't feel pressured to be induced at 39 weeks its perfectly reasonable if you don't want to.

(16:38): Perfectly reasonable if you do. Okay. So there are some circumstances when labor induction is not appropriate. If you've had a prior classical cesarean. And a classical cesarean is when the incision on the uterus goes through the muscular part of the uterus, that greatly increases the risk of uterine rupture. So if there's a prior classical cesarean induction is not appropriate. Actually labor is not appropriate. And actually in all of these, labor is not appropriate. So also induction is not appropriate. So having a prior uterine rupture, you should not be induced, active herpes infection, you should not be induced or labor, placenta previa where placenta is over the opening of the cervix. And I talked about that in a recent episode on the placenta, if you've had a lot of uterine surgery, including in the muscular part of the uterus, you should not labor or be induced, if the baby is laying cross crossways.

(17:32): I don't know if that's the word or I made that up, whether if the lay the baby's laying across in your uterus called a transverse lie, then you shouldn't be induced or labor, cuz if the baby's going across, it's not gonna come out of your vagina. And then I wanna talk about before we get into how labor is induced, a few factors that may influence labor induction. Really there's no good way to predict whether an induction will be successful. There are a couple of online calculators. I find them completely useless because it doesn't really help you to say you have a 20% chance or a 30% chance or a 90% chance. Either it's gonna happen or it isn't. And those calculators aren't good at predicting that. I think calculators in general for this, for vback, are all trash. So don't look at any calculators.

(18:18): There's no good way to predict whether or not it will be successful. Really the key for it to be successful is just patience, patience, patience, patience. The early part of labor, the latent phase of labor is longer in induction. It can be days. I've seen inductions last on the longest, probably the longest labor induction I've seen is seven or eight days. Yes, seven or eight days. So you really have to be patient with the process. Typical, I would say for a first time mom is gonna be a couple days, two days, two to three days, a couple days, usually a couple days, okay? One thing I will say is that an early epidural does not influence induction success. So if you get an epidural, then that is not going to influence your chances of having a successful vaginal birth. All righty. So let's move on and talk about how labor is induced.

(19:11): First thing I'm gonna talk about is cervical ripening. So cervical ripening is the process of softening, thinning, slowly dilating the cervix. It's a remodeling process of the cervix where the cervix goes from firm to soft, long to thin, and it's a really important part of labor. So during pregnancy, the cervix is really hard. It's pretty firm. In order to protect the pregnancy, protect the baby. And then as you get closer to labor, it softens. It opens. So the baby come out. And when cervical ripening is done, the chances of a successful induction are greatly increased. And it's really important to do it when the cervix is considered unfavorable by a bishop score. And what is the bishop score? So the bishop score is a score that assigns points from zero to three for each of five measurements of your cervical exam: dilation, how open the cervix is effacement, how thin the cervix is, the station which is the position of the baby in your pelvis, the consistency of your cervix, whether it's soft or firm and the position of your cervix.

(20:18): The cervix normally sits back in the vagina, it's posterior, it rotates forward and becomes more anterior as you go into labor. The most important element and the bishop score is dilation. Okay? And if your dilation is two centimeters or less, regardless of what the other things are, then you can expect to undergo some cervical ripening. And there are a couple ways that cervical ripening is done. One is with prostaglandins, that's a medication, and I'll talk about that. And the other is with mechanical dilators. Both methods are about equally effective. So let's first talk about prostaglandins. Prostaglandins are a group of hormone like substances. They actually have a lot of functions in the body, including controlling inflammation, body temperature, blood pressure, and they also control the contraction and relaxation of smooth muscle, like the muscles in the uterus. And there are a couple types of prostaglandins.

(21:20): One is dinoprostone. This one comes in a gel called propadil. It also comes in an insert called cervidil. Sometimes it's that cervidil is called a tape because it kind of looks like a tape. Both of those are placed in the vagina. I have never actually been in a hospital where they had prepadil, but many doctors do use the gel. I have used cervidil many times. However, it is increasingly less to use because it's super expensive. It does have the advantage that it's the only prostaglandin that can be easily removed. The cervidil tape, okay? If you have too many contractions with it, which is a potential side effect of prostaglandin, you can just pull the tape out. Whereas with the propadil, you can't do that. And cytotek, which I'll talk about in a second, you can't reverse that. It's either reverse that either I should say.

(22:08): I feel like I'm talking pretty fast this episode, like I'm high energy today. So, forgive me if I'm, I'm talking too fast. You can just slow it down if you need to. All right. So both forms of the dinoprostone are FDA approved for use in pregnancy. Now, the other prostaglandin is misoprostol or cytotek. Cytotek is a bit controversial. It was initially developed to treat peptic ulcers actually, and then somehow it was discovered that it can help start labor. It is not FDA approved for use in pregnancy. I say that a lot because people will say that the internet streets will talk about that a lot, how we're using this medication. It's not FDA approved in pregnancy. No, it is not. Okay? And the reason that it's not FDA approved is because the company has zero incentive to go through that process and pay for that process of it being FDA approved because it's already used, like it's already used very commonly in pregnancy.

(23:05): So there's no incentive for them to do so. However, there are multiple, multiple, multiple studies showing the safety and effectiveness of cytotek. So don't let that throw you off that because it's not FDA approved, that it's not safe in pregnancy. It's been studied quite extensively and has been shown to be safe if used appropriately. It can be given vaginally, it can be given orally, or you can put it inside of your cheek. It's called buly and let it dissolve. Now, there are some increased risk of cytotek, like too many contractions. That's called tachisystally. There's also an increased risk of meconium, stained amniotic fluid, and there's an increased risk of uterine rupture with misoprostol. And for that reason, it's not used if there is a prior cesarean birth. But when used appropriately when giving in low, given in low doses and spaced apart, it is safe.

(24:02): It also has the added advantage of being very inexpensive, like cytoteck is really cheap. All right. Second option for cervical ripening is mechanical dilators and mechanical dilators work by applying pressure to the cervix. And that pressure slowly opens. The cervix slowly dilates the cervix. And there are three types of mechanical dilators. One is a Foley catheter, and that's actually a catheter that is used, typically used to drain the bladder, or you can use a double balloon catheter that's called a cook catheter. They're fairly low cost. The Foley catheter is pretty cheap. The double balloon catheter, the cook catheter is a bit more expensive, but they're not terribly expensive. And there's a reduced risk of tachisystally having too many contractions. It's just applying pressure to the cervix, so it doesn't really cause contractions. It can also be done at home for low risk folks. Usually it can get put in the office if for people who do it at home, not all doctors will do it at home.

(25:07): But if your doctor does do it, usually it's put in at the end of the day in the office, and then you come into labor and delivery the next morning. So you stay home, sleep at home come to labor and delivery the next day to start the induction. There are still some risk. There's a risk of bleeding. It can break your water. That can also be uncomfortable. If they're uncomfortable, we can decrease the amount of fluid in them. But typically they're very well tolerated and they work very well to help ripen the cervix. And then the third option is something called a hydroscopic dilator. And there are two types of hydroscopic dilators. And what hydroscopic means is that it absorbs moisture from your cervix and then gradually expands with the moisture. And as it expands in the cervical canal, it opens the cervix. So there are two types. One is made from seaweed, it's called laminaria. The other one is a synthetic product, something called diliphan. I have used laminaria way, way, way, way, way back when I've never used diliphan. But these are also things that can be done at home as well. They're very safe and they're as effective as the other agents. They tend to be more used in pregnancy termination, particularly like second trimester pregnancy termination. But they can be used for term pregnancy, labor, cervical ripening as well.

(26:32): Now again, cervical ripening takes time. It could be 12 hours, 24 hours, even longer. Sometimes we have to do one and then go to the other. We may start with cytotek for 24 hours and then do a cooked catheter for another 12 hours. So sometimes it can take longer, and the more unfavorable your cervix is, the longer that it's going to take. So you really have to be patient. We have to be patient with that cervical ripening process. All right? Now, once your cervix is ripened, then we move on to the induction part, and that's where we use Pitocin. Pitocin is synthetic oxytocin. So is it is a synthetic version of the natural hormone that causes contractions. And actually Pitocin is one of the most commonly used drugs in the United States, but not just because of labor induction. It is also given routinely to prevent postpartum hemorrhage.

(27:28): Now, Pitocin is where the cascade of interventions comes into play. So let me tell you what the cascade of interventions is, Okay? So that is when, all right, you're being induced and you need to get Pitocin. In order to get Pitocin, you need to get an iv. You also need to have continuous monitoring where we're monitoring the baby all the time to make sure that the baby's heart rate is tolerating, that the baby's tolerating the Pitocin. Now, because of the continuous monitoring, because of the IV with typical monitors and IVs, that means you have less mobility, less mobility, and Pitocin causes more painful contractions. I have been doing this for a long time, almost 20 years, and I will tell you, I believe Pitocin causes more painful contractions than natural contractions, okay? A lot of doctors don't believe that. I personally think that that is true.

(28:34): And for women who've done both, I've heard them say that they believe that it is true that Pitocin causes more painful contractions. Not that they're like, you're gonna die, but yes, they're more painful. Okay? So you got the iv, you get Pitocin, you're on the monitor, you can't move as much, you're having more painful contractions. And then it's like, Okay, F it, I'm just gonna get epidural because of that, because this is a lot. All right? And then also from the epidural, and then maybe changes in the heart rate from Pitocin, especially if people don't use Pitocin appropriately, then that can lead to an increased chance of risk of cesarean. So that's that sort of cascade of interventions. Cause of that, women are understandably nervous about Pitocin, especially if you intend to have an unmedicated birth. But it can be done. You can have an unmedicated birth and be induced and use Pitocin.

(29:35): All right? So it's not that it can't be done, but we have to be careful with using Pitocin. I talk about this more inside the Birth Preparation Course. Okay, so what are some of the risk of Pitocin? The most common risk is something called tacitly. I said what tacitly is before it's too many contractions in a row, and that is directly dose related. So what that means is that you're getting too much Pitocin. So all you have to do is turn it back and the contractions will decrease. All right? That's the good thing about Pitocin is that the effects can be reversed pretty quickly. You can just turn it down, turn it off, and the side effects will go away. There are also some rare complications that happen less than 1% of the time, low five minute Apgar score, jaundice low sodium. Also, there's a tiny risk, increased risk of amniotic fluid embolism, which I've never seen.

(30:28): All right? Now, because the issues with Pitocin are dose related, there should be strict protocols in place for using Pitocin. And when to stop Pitocin, it should be on a pump. So it is given very precisely. Where obstetricians get into trouble is using too much Pitocin. There's a misconception that more is better. Crank the pit, crank the pit, and you really should not do that. You just need to give enough Pitocin to get strong contractions that are two to three minutes apart. That's it. Once it gets to that point, there's no point in increasing the Pitocin beyond that, it's not gonna do anything. It's not necessary, all right? It should not be increased. So there really should be strict protocols in place to get an effective labor pattern. Leave it there. We're also stop it if it looks like the baby is having some issues.

(31:19): So that's it for Pitocin. Now, the other thing we can do for induction is amniotomy, which is artificially breaking the water. Your water's gonna break on its own. So we're not doing anything that isn't gonna happen during the course of labor. But artificial rupture of membranes can be a way to help stimulate labor. It can be done by itself, but it tends to work better with Pitocin when it's done by itself. The effects can be unpredictable about when labor will actually start. And the way we do it is using a long hook. It looks like a crochet hook in order to break a hole into the amniotic sac. Okay? All right, so amnio, there are some risk of amniotomy if it's done too early. You can have a prolapsed umbilical cord where the cord falls through the cervix first. That is on us to make sure we're not doing it too early before the baby's head is nice and well applied to the cervix.

(32:18): Also, it can cause umbilical cord compression where the umbilical cord is compressed, and that can lead to changes in the heart rate. So we have to be careful about that. And then there's an increased risk of infection, triple eye intra amniotic infection, also known as choreoamnionitis, because once the water breaks in general, that's gonna increase the risk of infection. There's not a clock. There should not be a clock in place once your water breaks. In terms of labor induction, we just have to be mindful that once your water's broken after 24 hours, that does increase the risk of infection. So that's it for the typical ways that labor is induced. There really aren't that many. Okay, there's cytotek, Cervidil, propadil. There's Pitocin, there's the cook catheter balloon or a Foley catheter balloon. And there's amniotomy, like that's it there. Those are the tools that we have in our tool bag for labor induction, the typical tools, tools.

(33:17): Now, let me take a minute and talk about some less commonly used tools or other things that you may hear of that may help with labor induction. So one is stripping membranes. That's not really a method for labor induction, but I'm mentioning it here, But it hel it may help you go into labor sooner, and you won't have to be induced. It really should be offered towards the end of pregnancy, 38, 39 weeks. And the way that works is that a finger is inserted into your cervix and it's swept around quickly in a circle. And the goal is to separate the membranes from the lower part of the uterus, and that may help stimulate labor from the release release of prostaglandins. It can be uncomfortable. It can cause some increased bleeding. The biggest problem that I see with stripping membranes is a lack of informed consent.

(34:10): Sometimes doctors will say, Oh, I can check your cervix. Let me check your cervix routine, cervix check. Which by the way, there's no need for routine cervical exams at the end of pregnancy. They say that they're gonna check you, and they just kind of strip your membranes while they're in there. That is completely inappropriate. Really, it's assault because it was done without consent. So that is the biggest problem that I see is a lack of consent for stripping someone's membranes. It's completely inappropriate to do so. Okay? All right. Some other things that can be used for labor induction are nip nipple stimulation. We know that nipple stimulation causes oxytocin to be released. There really is no standard technique that's been studied for nipple stimulation. Typically, we use a breast pump. We focused on one breast at a time, and then some rest in between. Their different protocols.

(35:03): I've seen 20 minutes, 30 minutes for pumping one breast rest and then press do the other. And this works within 72 hours. For women who have a favorable cervix. The biggest risk of nipple simulation is tachisystally. So having too many contractions. Also, I think some hospitals and doctors are not very comfortable with it because it's just not something that they're familiar with. Midwives are very comfortable with this, but I do see more and more doctors comfortable with trying nipple stimulation. And then the last methods of induction are acupuncture. There's mixed evidence whether or not acupuncture can help. It may help with cervical ripening. There's not a ton of data there, but it is generally considered safe for low risk women, and it's a licensed practitioner who knows what they're doing. So acupuncture is worth a try. Castor oil may help. It's a laxative. We think that it works by stimulating your intestines and your intestines around the uterus, and that helps stimulate the uterus.

(36:08): It may also stimulate the uterus directly. It tastes disgusting. So for everyone, it typically causes some nasi nausea. And the way you take it is it can be mixed in smoothies, peanut butter, eggs that sounds gross to me, but, how you can take it or you can just knock it back like a tablespoon of castor oil. It is safe for low risk women, and it actually probably is effective based on small studies. In my experience, I do think that castor oil is effective. And then finally, sex. Sex semen has high prostaglandins in it, and then maybe orgasm as well can cause a release of oxytocin, and that can help simulate labor. The evidence is mixed as to whether or not it works, but it does not appear to be harmful. All right, so that's it for the different methods of labor induction. Now we're gonna end with how an induction has failed.

(37:07): And then questions to ask before you are induced. Okay, so how do you know if an induction has failed? In which case there will be a cesarean birth. This is really, really, really important in helping prevent the first cesarean. The cesarean rate in our country is unacceptably high, and once you have that first cesarean, you're more likely to have another. So preventing that first one is super duper duper important. And the most common reason for C-section is that labor isn't progressing. So we really need to have a clear definition of when induction has failed. So women are not getting a cesarean birth too early. So I wanna read a statement from acog, and this is from a document called Safe Prevention of Primary Cesarean Delivery. And here's what it says. If the maternal and fetal status allow cesarean deliveries for failed induction of labor in the latent phase can be avoided by allowing longer durations of the latent phase up to 24 hours or longer.

(38:18): So that's for that early phase of labor and requiring that oxytocin be administered for at least 12 to 18 hours after membrane rupture, before deeming the induction a failure. All right, so let me break that down for you. Up to 24 hours or longer for the latent phase of labor, that's up until about five to six centimeters that can take longer. All right? And then an additional 12 to 18 hours after membrane rupture, plus oxytocin during that time before we say the induction is a failure. So it really needs to be, give it a good go before we say induction has failed. And that's why induction can last for two or three days or even longer, Alright? Especially if you're not dilated at the start or if it's your first baby. I used to hear more stories of like, Yeah, my induction started at eight and by five not much was going on.

(39:15): So my doctor just gave me a C-section. I don't hear that as much as I used to, thankfully as we shouldn't be. But there really shouldn't be. Like you started in the morning and by dinner time there wasn't anything going on. So your doctor's like, Let's just do a C-section. No, at minimum, at minimum, as long as you and your baby are doing well, 24 hours at minimum for induction, and really in general, it's going to take longer. Okay? All right. And then the final thing I want to end with is questions you should have answers to before you indu, you are induced. I have seen women who didn't know this, doctors didn't really explain, and they were just kind of trusting of what their doctor said and just kind of showed up. I see that more and more women want to know, are demanding to know information about what's going on, which I think is great.

(40:13): But these are some questions that you want to know and have the answers to before you are induced. So your doctor says, Hey, let's talk about induction. So here are things you wanna know or ask. Why are you recommending or suggesting I be induced? What are the benefits of being induced? What are the risk of being induced? What are the risk of waiting and not being induced? What are the alternatives to induction? Cuz maybe you can continue to get close monitoring. What methods would you recommend for induction in my specific case? And what are the risk associated with those methods? Okay. All right. So that's what you wanna ask. Why are you recommending induction? What are the benefits? What are the risk? What are the risk of waiting? What are the alternatives to induction? And then what methods would you recommend for induction based on my specific case?

(41:17): Okay. All right, so that is it. Just to recap, induction is making labor happen before it happens on its own. There are only two reasons for induction. A medical induction, meaning it's for the benefit of your health or it's for the benefit of your baby's health, or an elective induction, meaning that it is a non-medical reason for the induction. For the induction methods, there are prostaglandins, there's propadil, cervidil, cytotek, the mechanical dilators, pitocin, and then artificial rupture of membranes or amniotomy. Those are the tools in our toolbox. You can also try caster oil, acupuncture, sex. Those are all low risk things that may be effective. And then induction can take some time. It can take some time. If I like, one thing I want people to take away is that it can take some time. And I say that because sometimes it is not just the doctor who's throwing in the towel.

(42:12): Sometimes I have seen the pregnant person get really frustrated with the process and just I'm tired of this. And keep in mind, even though it's two to three days, you should be able to eat. You should be able to shower. You should be able to get up and move around. But yes, it can be mentally exhausting. Oh, sometimes you need to move to another room if it's a long process. But know that it can be a process. But if you stick with it, the most likely outcome is vaginal birth. And then ask those questions so you understand what's going on with your induction. I had someone come in once and she came in at six in the evening. She was thinking the baby was gonna be born by midnight. Know what you're getting into, know what can happen with induction, and then get thoroughly prepared for your birth by joining the Birth Preparation Course, my online childbirth education class that will get you calm, confident, and empowered to have a beautiful birth.

(43:12): Keep in mind, it is going to be on sale for Black Friday. You are getting that information here first. So do check that out. Check out the details of the course at drnicolerankins.com/enroll. So there you have it. Do me a solid share. This podcast with a friend sharing is caring and helps me to reach and serve more pregnant people, which is my passion and purpose in life. Be sure to subscribe to subscribe to the podcast wherever you listen to podcast. I am talking really fast, just have lots of energy, and I'm excited to talk to you today. All right. Be sure to subscribe to the podcast an Apple Podcast or wherever you're listening to me right now. Leave a review on Apple Podcast because I love to hear what you think about the show. Come follow me on the gram. I'm @drnicolerankins. There I post lots of good information on Instagram. You can also follow me on the ticks as I like to tell my children. They tell me that I'm old for calling it the Ticks, but I'm on TikTok at dr Nicole Rankins dot. Well, Dr. Nicole Rankins as well. All right, so that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.

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