Ep 70: Labor Induction: What to Know and What Questions to Ask

I have received so many requests for an episode about labor induction, so I am excited to be sharing this information with you today! I think it is incredibly important for you to be informed about what induction is and what the process is like, whether you are planning an elective induction or are being induced for a medical reason.

In this episode I'm talking about the common medical and non-medical reasons for inducing labor and the step-by-step process of being induced. I also cover what you can expect from different methods and medications that may be used in the induction and share some key questions you can ask (and your provider should be able to answer) if they are suggesting an induction for you.

I will also tell you a bit about the research on inductions and cesareans (C-sections) and why most babies will do great in the outside world once they've hit the 39 week mark.

In this Episode, You’ll Learn About:

What labor induction is and the two main reasons for being induced
Common medical and non-medical reasons for having labor induced
What the ARRIVE study is and why you should not be induced for any non-medical reasons before 39 weeks of pregnancy
Why it is perfectly within your rights to choose an elective induction if you've passed 39 weeks of pregnancy
How labor can be induced and what to know about the different methods
What a failed induction looks like and why you shouldn't feel pressured to go into labor within a certain amount of time
What to know about pitocin, when it is used and how much should be used
Key questions to ask if your medical provider suggests a labor induction

Links Mentioned in the Episode

How To Make A Birth Plan That Works - Free Online Class!
The Birth Preparation Course
Ep 34: Everything You Need to Know about Having a "Big" Baby
The ARRIVE Trial (a breakdown by Evidence Based Birth)
A video of demonstrating how a cervix thins and dilates in labor https://www.youtube.com/watch?v=URyEZusnjBI
Join my email list here!

Keywords

ARRIVE study, hospital birth, labor induction, medical induction, non-medical induction, pitocin, pregnancy

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Transcript

All About Pregnancy & Birth Podcast Transcript

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Speaker 1: I've gotten so many requests for this topic, so I am finally talking about labor induction.

Speaker 2: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN who's had the privilege of helping hundreds of moms bring their babies into this world. I'm here to help you be knowledgeable, prepared, 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 www.ncrcoaching.com/disclaimer. Now let's get to it.

Speaker 1: Well hello there. Welcome to another episode of the podcast. This is episode number 70. Thank you, thank you, thank you for being here with me today. On today's episode I am talking about labor induction. I've gotten a lot of requests to talk about labor induction and I totally get why. Induction is one of those topics that makes a lot of pregnant people nervous. You may have heard horror stories about induction and Pitocin. There's concern about the cascade of interventions, which I'll talk about later, so I get why you want to hear about labor induction. So on today's episode I hope to really help answer your questions about induction and shed some light on what labor induction is all about. So in this episode you are going to learn what labor induction is, why labor may be induced. You will be surprised to hear that there are only two reasons I'll talk about how labor is induced, what constitutes a failed labor induction.

Speaker 1: It's important to understand that, and then what questions you should ask before you get induced. Now of course, labor induction is one of the things that you definitely want to know about before you give birth, but there are also lots of other things that you need to know like what labor is 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, you will be knowledgeable, prepared, confident and empowered to have a beautiful birth. My Beautiful Birth Prep Process is unlike any other childbirth education. It's a uniquely designed method that starts with setting the tone for your birth because before you learn anything about what labor is like, you need to learn how to get in the right mindset, how to have the right support.

Speaker 1: You also get all the details of labor including my insider knowledge about the process as an OB GYN who's been in practice for nearly 15 years. Of course you learn about the things that could happen like shoulder dystocia or meconium so that you can manage the unpredictability of birth and I get you off to a good start for the post partum period and then also cover some things that typically aren't covered at all in childbirth education like placenta encapsulation and circumcision. Let me just share what a student had to say after she went through The Birth Preparation Course.

: "If you are 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 trusted his advice because I actually understood what he was talking about. There is a lot of information, but 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 when I couldn't go in person. I still have to experience birth myself to truly understand it, but I feel a lot more confident and calm about it." And right now to keep the course accessible, The Birth Preparation Course is discounted over 40% off. So you can go to www.ncrcoaching.com/enroll to learn more about The Birth Preparation Course.

: But in the meantime, let's go ahead and talk about labor induction. So what is labor induction? 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 I want to be clear that the goal of labor induction is a vaginal delivery when we start out with inducing labor. The goal is to get a vaginal delivery. Now as far as how many labors are induced, roughly a little less than 25% of all labors are induced in the United States. That number has gone up. It's about twice what it was in 1890 so definitely increased over time. Now overall, most labor inductions do result in a vaginal delivery. The success can be influenced by a number of factors, but to be clear, most labor induction does result in a vaginal delivery so you can feel confident in that, that if your labor is induced, most likely it is going to result in a vaginal delivery. There are a few key things though to make sure that that happens and I'll talk about that in a minute.

: So why might labor be induced? And I mentioned earlier that there really are only two major reasons and I'll unpack a little bit under those reasons, but really at the top level, high level, there are two major reasons for labor induction.

Speaker 1: The first one is there's a medical reason, meaning that we believe it's beneficial for your health or it's beneficial for your baby's health to induce labor. And then the second reason is 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, then induction is for a nonmedical reason. That's it. So either we're inducing your labor because we think it's beneficial to your health or your baby's health or we're inducing your labor because of other reasons. And I'll talk about what those reasons are, but it's a nonmedical reason, meaning there's no threat to your health or your baby's health. Just choosing to induce labor.

: So some common medical reasons an induction may be recommended are things like high blood pressure or diabetes that's developed either during pregnancy or was there before pregnancy. There's some conditions with the baby where we may recommend labor induction like growth restriction where the baby is no longer growing appropriately inside your body. If the fluid is low, that can be a sign that a baby is in distress. We may recommend labor induction under certain circumstances. With that, there could be issues with blood flow to the placenta that we see on ultrasound. We're concerned that baby is not getting enough nutrition and oxygenation. And in that case we may recommend labor induction. Some other reasons that you may see labor induction being recommended are like a suspected large baby that is sometimes cited as a reason for induction, but it actually is not a recommended medical reason for induction. I talk about what to do when you have a suspected big baby in episode 34 of the podcast and I will link it to that in the show notes. So that's not again a reason to induce labor. Also going past your due date as a common reason that labor induction is recommended, but it's usually offered early than is really necessary.

Speaker 1: Now the timing for inducing your labor because of medical reasons really varies depending on what the issue is with your pregnancy. But for the most part it tends to be between 37 and 40 weeks, rarely past your due date and not usually before what's considered full term, which is 37 weeks. So usually medical induction is recommended anywhere between 37 to 40 weeks for conditions like high blood pressure, diabetes, low fluids, so forth and so on. Sometimes it's earlier, but again, most of the time, 37 to 40 weeks now, why are we inducing, well, the big bad outcome that we're really looking to prevent is stillbirth. That is something that we want to obviously prevent. It's not something that happens commonly, but when we look at all of the information and the, and we say, okay, is it better for baby to stay inside or is it better for baby to be on the outside?

Speaker 1: Then for the most part, for these conditions, we come to the conclusion that it's better for baby to be on the outside. Baby's pretty much done with the growing. If baby needs a little bit of support after birth, usually it's minimal, whereas the risk of baby staying inside with some of those conditions, again, that big bad thing that we're looking to prevent is stillbirth. There's some other things that we want to prevent like development of preeclampsia or the placenta, just looking bad or baby suffering from a chronic lack of oxygen, but stillbirth is the awful thing that we always want to prevent. Okay, so let's talk about some nonmedical reasons for induction. So this would be what are considered more elective reasons for induction. One is distance from the hospital. If you happen to live, say two hours away and you have a history of really rapid labors, that's technically a nonmedical reason for induction, but still a perfectly reasonable choice or or reason behind why you would have an induction if you live a long distance from the hospital.

Speaker 1: If you have a military spouse and or partner and that person is going to be deployed or will only be available for a certain amount of time, then it's certainly reasonable to induce labor in that instance. Again, it's not a medical reason but a reason. It may be the doctor's schedule. Suppose that you definitely want to know that you have a certain doctor or midwife there for your delivery. You may choose to be induced when you know that person can be available and then finally, some women just want to be induced early. Some women are tired of being pregnant. They are ready to be done with it. Family's coming in town. Sometimes that's not as prevalent now of course because of COVID, but sometimes people have family coming in town who's going to help and they're trying to schedule things. So some women want to be induced early, which are not early, I should say.

Speaker 1: Some women want to be induced, which is perfectly reasonable under certain circumstances. There's certainly nothing at all wrong with that. Now when we talk about elective induction, meaning it's not for a medical reason for your baby's health or for your health, and there are some things that we need to be mindful of. Number one, your labor should never be induced before 39 completed weeks of pregnancy without a medical reason. 39 weeks is when data has shown that babies do well, like the vast majority of babies born at 39 weeks are going to be healthy, will go home with mom. We used to induce elective inductions even earlier, but we found that every day up to 39 weeks counts and helps to get babies ready. And then we found that after 39 weeks, there's not necessarily a whole lot of benefit in the sense that outcomes don't improve for moms and babies.

Speaker 1: 39 weeks has turned out based on research to be sort of this golden magic ish time when we know that babies are well and the risk of complications is low. So for an elective induction is, should not be before 39 completed weeks. Ideally you should have a favorable cervix and I'll talk about what a favorable cervix is in a moment based on the Bishop's score and also regarding elective induction, you shouldn't feel pressured, you shouldn't feel like it's something that you have to do. Actually you shouldn't feel pressured about induction period. You should feel really comfortable with the decision and understand why induction is being offered. And finally you shouldn't feel guilty. Like you shouldn't feel guilty if you decide that, hey, I'm 39 weeks and some change and I'm just tired of being pregnant and my cervix is already three or four centimeters dilated, which is considered favorable.

Speaker 1: I just want to be induced. There's nothing wrong with that. So don't feel guilty if you decide that you want to be induced. That's perfectly within your right. I do want to take a minute and talk about elective induction at 39 weeks based on the arrive study. The ARRIVE study is a randomized controlled trial that's the gold standard of scientific study where women are assigned to a group randomly to get one intervention or not and women were randomly assigned to labor induction versus expectant management. This is women who were having their first baby with no complications and they were assigned to either, again wait for labor to come on or induction. And inducing labor at 39 weeks didn't improve any outcomes of death or serious complications for babies. So it didn't make a difference for babies. But for mothers, induction at 39 weeks was linked to a slightly lower rate of cesarean delivery.

Speaker 1: So 19% cesarean rate for women who were induced versus 22% and then also our lower chance of developing pregnancy induced high blood pressure. So 9% if you were induced and 14% if you waited. I've seen a lot of OB GYN who are offering and even recommending induction at 39 weeks based on this one study. I don't think that that's the right thing to do. I think it's a reason to say like if you want to be induced that's fine, but if you don't, then that's also fine. It only slightly decreases the risk of cesarean, and there are other things that can reduce the risk of cesarean. And for example, continuous labor support from a doula can reduce the C section rate by 25% so this one study isn't enough to routinely recommend induction. I think it's enough to say if you want to do it, fine and present the evidence.

Speaker 1: But if you don't want to do it then that's perfectly fine as well. I've also seen OB apply this study to women who don't actually fit the patient population. So it actually doesn't apply to women who've had a baby before cause that's not who was in the study. So just be careful if you hear your OB GYN talk about the ARRIVE study as a reason for recommending induction. It's not necessarily needed or should be recommended just based on this one study.

: So let's move on and talk about how is labor induced. So the first part of induction is actually cervical ripening. Now cervical ripening is the process of softening, thinning and slowly dilating the cervix. It's a remodeling of the cervix where the cervix goes from a firm to soft. It goes from long to thin and short. And this is a really important part of labor.

Speaker 1: When cervical ripening is done, then the chances for a successful induction are really, really, really increased. There is a YouTube video of a balloon and a ping pong ball that shows what cervical ripening or how the cervic shortens during labor. It's a good example of that. I'm going to link to that video in the show notes. Now, cervical ripening is definitely needed when the cervix is considered unfavorable by a Bishop score. Okay. A Bishop score assigns points from zero to three for each of five measurements of your cervical exam. So how dilated your cervix is, how open it is, how affaced it is, whether it's longer, shorter, how faced it is this station, which is the position of the baby in your pelvis, the consistency of your cervix, whether your cervix feels soft or firm. As you get closer to going into labor, your cervix softens significantly and then the position of your cervix and when you're not in labor, the cervix sits back in the vagina, can sit what we call very posterior.

Speaker 1: As you start to go into labor, as your body gets prepared for labor, your cervix starts to rotate forward becomes more anterior. Now, the most important element in the Bishop score is dilation. You can almost certainly expect to have cervical ripening if your dilation is two centimeters or less, regardless of what the other points are. Now, a favorable Bishop score is a score that is eight or greater. Your chances for a vaginal delivery are good. Your cervix is thought to be favorable. If your Bishop score is eight or more, if it's six or less than the chances are lower and you need to have more cervical ripening. For sure. So I don't want you to think that if the Bishop score is low, that that automatically means that you're not going to have a successful induction. That's not the case. It just may mean that it's going to be a longer process.

Speaker 1: Okay. And I will put a chart of what constitutes the Bishop's score or what goes into the Bishop score into the show notes. So the way cervical ripening is done is by one of two methods. One is a medication called prostoglandins and the other is using something called a mechanical dilator. Both methods are about equally effective and our prostoglandins 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 the contraction and relaxation of smooth muscle like the muscles in the uterus. There are a couple different types of prostaglandins. One is dynapro stone that comes into different forms. A gel called Prepadel, or an insert called Cervidil. Both are placed in the vagina. I've never actually used the gel. A lot of people do. I have used Cervidil. I don't use it at the current hospital I'm at anymore just because it's expensive.

Speaker 1: So it's been taken off the formulary, but a lot of places do use Cervidil. Now Cervidil has the advantage, it looks like a, it's also called a tape. It looks like a piece of long string tape and the advantage of it is that it's the only prostaglandin and that can be easily reversed. You can just remove it from the vagina if the baby is showing some signs of distress from the prostaglandin and you can't do that with the gel. So that's one of the main advantages of Cervidil over the other forms of prostaglandin. And both the gel and the insert are FDA approved for use in pregnancy. Now the other prostaglandin in misaprostil or Cytotec. This one is a little bit controversial. It was initially developed to treat peptic ulcers. It's not FDA approved for use in pregnancy and I don't think the company will ever seek FDA approval to use it in pregnancy.

Speaker 1: There's no advantage to that because it's already used in pregnancy actually quite widely. So there's no incentive for the company to go through that process because it's not going to help them financially to get FDA approved, but there are lots and lots and lots of studies showing that Cytotec is safe and also effective in helping induce labor in pregnancy. We also use it to help stop bleeding in pregnancy as well, so for cervical ripening, Cytotec can be given vaginally, it can be given orally or it can be given bucally which is put inside your cheek and allowed to dissolve. Now one of the side effects or issues with Cytotec is that there's an increased risk of negative effects like too many contractions. That's something called tackysystoli. There's also an increased risk of meconium and an increased risk of uterine rupture.

Speaker 1: All of those incidents of bad things happening are low and when the medication is used appropriately, that means in the lower doses that are spaced out in reasonable intervals like every four to six hours, then Cytotec is very, very safe. I've used this many, many, many times to induce labor and it is quite effective and quite safely used an added advantage of Cytotec is that it is very, very inexpensive. I mean the cost of Cytotec versus Cervidil, it's, is probably, oh my gosh, 10 to 20 times at least more expensive than Cytotec. It means the prostaglandin is very, very inexpensive. So that's it for the prostoglandins. There's Cytotec and then there's Cervidil, either the gel or the vaginal insert.

: Now the second option for cervical ripening is mechanical dilators. And what mechanical dilators do is they work by applying gentle pressure to slowly dilate your cervix. And there are two types. One is a Foley catheter. A Foley catheter is a type of catheter that's typically used to drain the bladder or there's a special type of balloon catheter called a double balloon catheter that is specifically for cervical ripening in inducing labor. Now the advantage of these is that they are low cost. They have very low side effects. They can even be done at home. Like you can have a balloon catheter placed in your cervix and then you can go home overnight and then come back in the morning to start the labor induction. I'll put a couple of pictures of what these look like. Basically what it is is that for the single balloon, it's a balloon that's blown up or inflated with sterile saline anywhere between 40 that even up to 80 cc's of fluid and it just sits inside your cervix and we place a little gentle traction on it so we tape it to your leg so it has a little bit of traction on it and over time, just that little bit of constant pressure helps slowly dilate your cervix.

Speaker 1: The double balloon catheter is different in that it has two balloons. One balloon sits just inside your uterus and then the other, once it's in your vagina to apply pressure to your cervix. In a similar way, there's still a risk to the balloon catheters. There's a risk of bleeding. It can potentially break your water, which isn't necessarily a problem, but it can. And probably the biggest thing is that it can be uncomfortable depending on how much fluid is in the balloons. It's just kind of a different sensation having this catheter inside your body. Now the key about cervical ripening is that it can take time. Okay. It could be 12 hours, it can be 24 hours, it can be even longer for cervical ripening, and the more unfavorable your cervix is at the start, the longer it may take. So if you're starting your labor induction and you're completely closed, you're not dilated at all or you're one centimeter, then it's probably going to be a longer process.

Speaker 1: Be prepared for that. So cervical ripening can take some time, 12 to 24 hours or even longer. Sometimes we do one method. If that doesn't work, then we go to another method. Sometimes we do the Cytotec or Cervidil first, and then we may go to a mechanical dilator after that to even get a little bit more ripening in place. So just be prepared for that early part of cervical ripening can take time. Now once your cervix is ripened and we believe that it's dilated, thinned out some, then this is where we use Pitocin and the reason we do this is Pitocin doesn't work as well to help ripe in the cervix. It really helps to work or it really works. Once the cervix is ripen and it gets the contractions going to help get those contractions stronger, closer together to take the process one further into the active part of labor.

Speaker 1: So Pitocin is synthetic oxytocin and that causes contractions. Oxytocin is the natural occurring hormone in the body that causes contractions. Pitocin is actually one of the most commonly used drugs in the United States. It's not necessarily just because of a labor induction. We also give it to prevent postpartum hemorrhage. So almost every woman who gives birth in the hospital in the United States gets Pitocin after birth in order to help prevent postpartum hemorrhage. Now one of the big issues with Pitocin is something called the cascade of interventions. And let me take a second and explain what that means.

: So what happens is when you get Pitocin, you have to have an IV because it's an IV medication. Also because Pitocin has risk with it, you have to be continuously monitored. When you're continuously monitored, you may be connected to a machine and may have less mobility, so you may not be able to move around as much in order to help manage the discomfort from the contractions, and Pitocin can often cause more painful contractions then naturally occurring contractions.

Speaker 1: A lot of doctors don't believe that. I believe it to be true. I'm just going to be honest that I think Pitocin causes contractions that are more painful than naturally occurring contractions. Not saying that they can't be managed, but the truth is I do think they are a bit more painful. So what happens is because they're more painful and then you may not be able to move as much to help manage that discomfort because you have an IV or you're being continuously monitored, then women may opt for an epidural to help manage pain. Then you have the epidural and the Pitocin and then if there are changes in the heart rate because of the Pitocin, then that can potentially lead to an increased risk of cesarean. Now, I'm not saying that this cascade of interventions always happens or is even likely to happen, but that's just a description of what the cascade of interventions entails.

Speaker 1: So because of that, women are understandably nervous about Pitocin, especially if you intend to have an unmedicated birth. If you plan to have an epidural anyway, then I don't think it's a problem, I guess so to speak. But if you plan to have an unmedicated birth, then yes, this cascade of interventions can be problematic. But again, it's not that it is always going to happen or is even likely to happen, but it is a possibility. Now, as far as some of the risk of Pitocin, the most common one is tachysystole, which is a fancy word for saying too many contractions back to back when there are too many contractions back to back. What contractions are, is that the uterus is squeezing, is literally squeezing, trying to squeeze the baby out. And when that happens, it can sometimes compress the cord, which can cut off blood supply to the baby and the baby needs a little bit of a chance to recover.

Speaker 1: So if you have too many contractions back to back, that squeezing is constantly happening and there's not a chance for the core to get not compressed or for the baby to just kind of recover from that squeezing. Now that tachysystole is completely related to how much Pitocin is given. So if you give too much Pitocin that you can get tachysystole if you turn back the Pitocin, then the tachysystole goes away. So there are some other rare complications of Pitocin. These happen in less than 1% of women who receive Pitocin. Things like low five minute Apgar scores, amniotic fluid embolism, which is when the amniotic fluid goes to a woman's lungs, it's actually quite dangerous, jaundice in the babies. All of those things are very rare that they happen. Now, as I said, the issues with Pitocin are completely dose-related. That means that the more you get then the more risk of having problems.

Speaker 1: So the way that that needs to be addressed is that there really should be strict protocols for using Pitocin stopping Pitocin, decreasing the dose, there should be pumps so that it can be precisely administered. Where obstetricians get into trouble with Pitocin is using too much of it. There is a misconception among OB doctors and I think this tends to be especially among doctors who are older that the more Pitocin the better. Like you just got to keep giving more and more and more Pitocin and that is not true. There should only be enough Pitocin to get contractions that they are strong enough and every two to three minutes apart. When that point is reached, you do not need to increase the rate of Pitocin and that point where that happens is going to be different for every woman. For some women I've seen it happen at very low levels of Pitocin.

Speaker 1: I was going to say the numbers, but the numbers don't mean anything to you. But for some women that can happen at low levels of Pitocin, for some women it takes more. But the point is you don't just need to keep cranking it up just because. So there should be strict protocols in place for using Pitocin and that is how you stay out of trouble. All right. Now the other thing that we can do in terms of helping move labor along, once your cervix is ripened is breaking the water. That's called amniotomy. Amnio is like the amniotic sac. Amniotomy is a breaking it or making a hole in it. So amniotomy and that's where we artificially rupture the membranes, break the membranes that are surrounding the baby, we do that by using a long hook that nicks a hole in the amniotic sac.

Speaker 1: Water's gonna break eventually during birth. Very rarely it happens at the very, very end. Most of the time it breaks at some point before that. So we're not doing anything that isn't already going to happen. We just may be doing it in earlier time. Sometimes it's done in addition to Pitocin. So those two things are done together. It can be done by itself, just breaking your water. It's just that the impact is unpredictable and once it's done, it's done. We have a little bit more control, a lot more control actually over how Pitocin is used. Now the risk of breaking your water, the longer your water's broken, the more your baby is exposed to the bacteria that we normally have in our vaginas, and that can increase the risk of infection around the baby. So the longer the water's broken, particularly more than 18 to 24 hours, when that infection risk goes up, if the water's broken too early and your baby is not low enough in your pelvis, the umbilical cord could fall in front of the baby's head.

Speaker 1: That's something called a prolapsed umbilical cord. That is a true emergency because it'll cut off the blood flow through the placenta. So that means a stat C-section, like true, true emergency C-section. So those are the biggest risks.

: Okay. So that is it for the typical ways that labor is induced. There's actually not a lot in our toolbox that we have in terms of traditional labor induction. So there's the prostoglandins that I talked about Cytotec and then dynapro stone that comes in those two forms, the Cervidil or the Prepadil, and then there's the mechanical dilators or there is Pitocin and breaking your water. That's pretty much it. That's what we have for labor induction. Now there are some methods that aren't as commonly used, and I'm gonna tell you bit about those. So stripping your membranes is something that your Dr. may offer. It's not really a method for induction, but it may help you go into labor sooner on your own.

Speaker 1: Like it may help stimulate natural labor. It really shouldn't be offered before 38 39 weeks because again, 39 weeks is that magical number where we know that babies do well. Nobody should be stripping your membranes at 37 weeks and 38 weeks I think is even iffy. If it's 38 weeks closer to 39 weeks, then fine anytime after 39 weeks. And totally fine and what stripping membranes is a finger is inserted in your cervix, so you have to be somewhat dilated for this to happen because the finger has to get inside the cervix so that your membranes can be swept, so it's like sweeping your membranes around in a circle to separate the membranes from the lower part of the uterus and that may stimulate labor. The thing that can happen with this, increased bleeding is a risk. Also, it's uncomfortable. It is not comfortable to have your membranes stripped.

Speaker 1: Many women tolerate it just fine, but lots of women report that it is uncomfortable. I think one of the biggest problems that I've seen in stripping membranes is that some doctors do it without consent at all, which is absolutely positively, unequivocally wrong. They'll say like, well, I was just there or I've just stripped your membranes. That should not happen without your consent, so there should be a discussion about it. First I personally, you know, I would offer when I was in the office and practice, I will offer stripping membranes. But I didn't feel like strongly about it either way because again, I have seen how for a lot of women it's quite uncomfortable. Now some other things that may stimulate labor are nipple stimulation. Nipple stimulation causes oxytocin to be released. This will happen even after your birth. The issue with nipple stimulation is we don't really have a standard technique.

Speaker 1: Often we use a breast pump and just do one breast at a time and rest in between. There is a little bit of evidence that it works within 72 hours. For women who have a favorable cervix, I can say that hospitals, doctors don't feel as comfortable with it just because we don't know how to use it very well. We haven't been trained on it. It's not something that we know how to use well. There is a risk of having too many contractions with nipple stimulation. And that's been shown in the little bit of studies that it's been done. So there is a little bit of a risk to it. Some other things that may help with inducing labor. Acupuncture is mixed evidence. It may help with cervical ripening. There's not a lot of data. However, it's generally considered safe for women who are low risk as long as it's done with someone who is licensed and knows what they're doing.

Speaker 1: Castor oil is something that I think actually works fairly well in order to induce labor, and I'm just saying that from my clinical, like my anecdotal, just seeing it in practice. There are some studies, small studies that have shown that it's probably effective. What castor oil is, it is a powerful laxative. It stimulates the intestines and then in turn when the intestines are stimulated and the intestines of course surround the uterus, we have like 18 feet of intestines in our belly so that intestines get stimulated. They're moving all over the place and it's thought that all of that movement may help stimulate the uterus. There is some evidence that it may also stimulate the uterus directly. Again, it's probably safe for low risk women, it tastes disgusting. The vast majority of women will have nausea. So you can do it in a smoothie, just like a tablespoon.

Speaker 1: You can do it in peanut butter, you can do it in eggs. You have to mix it in something because it tastes really gross. And then finally, sex may help bring on labor. Semen has a very high prostoglandin content to it, so maybe full term, there's something about the combination of full term or prostoglandins that may bring on labor because we know that sex during other points in pregnancy doesn't bring on labor, but there's something about being at the end and sex may bring it on. It's possible that the release of oxytocin helps as possible. That orgasm helps. The evidence is really mixed. It definitely doesn't appear to be harmful if there's no reason why you shouldn't be having sex. So you can certainly give it a try. Okay, so that's it for all of the different methods of induction.

: Let's talk about how you know if induction has failed, in which case there will be a cesarean birth. Now this is really important to understand when induction has failed because it's really important to help prevent that first cesarean. We know that the C-section rate in this country is unacceptably high and once you have that first cesarean you're more likely to have another. So really preventing that first cesarean is important. And then in addition to that, the most common reason for C-section is that labor isn't progressing. So we need to have a very clear definition of when induction has failed. So women aren't getting cesarean too early. So ACOG, the American College of Obstetricians and Gynecologists, that's the organization that sets practice guidelines and standards for obstetricians in the US, they have a document called Safe Prevention of Primary Cesarean delivery. And the definition of failed induction in that document is if the maternal and fetal status allow cesarean deliveries for field induction of labor in the latent phase.

Speaker 1: So that's the early phase of labor from zero to four centimeters. So cesarean induction can be avoided by allowing longer durations of the latent phase up to 24 hours or longer, and requiring that oxytocin be administered for at least 12 to 18 hours after membrane rupture before deeming the induction a failure. So that's latent phase, which is the first part, zero to four centimeters is considered the latent phase of labor that needs to last 24 hours or longer. And then once you're in the more active phase and your water's broken, then you need to be getting oxytocin or Pitocin for at least 12 to 18 hours after that. So that means that induction can last two or three days. As long as you're healthy, your baby's healthy, we should keep going with induction that may be longer if you're not dilated at the start or if it's your first baby.

Speaker 1: The longest induction I've seen is probably five days. That was a long induction. It may be almost stretched into six days, but she had a successful vaginal delivery at the end, and mom and baby looked fine the entire time. So it was a success, but it was a long induction. Even mentally that can be long, but it definitely shouldn't be this start induction at eight o'clock and then by five o'clock if something isn't happening, then say it's a failed induction. That is not appropriate at all, and unfortunately I've heard women share those types of stories. Again, induction can last two or three days. It's not usually a long process for most people. If you've had a baby before, it's probably going to be within 24 hours. Even first first baby, it will be within 24 to 48 hours, but it can be longer, so just be prepared for that possibility. Sometimes we take breaks, folks eat, they shower, they walk around. Just be prepared to let it go on a little bit longer and discuss it with your doctor that, Hey, I want to give this a really good go before we decide that this is a failed induction.

: Now the final thing I want to tell you is the questions you should ask or have the answers to before you are induced. I've been surprised at how many women have encountered and it's like, Oh yeah, my first labor was induced and it's like, well, why were you induced, like, I don't know. My doctor just said I had to be induced. You should really know why you're being induced, so asked why am I being induced? I actually had somebody just reach out to me not that long ago and said, my doctor's just automatically scheduled me for an induction. Didn't really talk about it or tell me why. You should understand exactly why you're being induced.

: Then you want to know what are the benefits of being induced. They should be able to clearly say like what are the benefits? It may be a decreased risk of cesarean. It may be a decreased risk of stillbirth depending on what is going on with your pregnancy, but they should be able to say what are the benefits. Also, what are the risks? Everything has risk and benefits and some of the risks may be some of the risks of the medication and how it affects your baby. There's a risk of course of cesarean section with induction as well. Then if you don't want to be induced, what are the alternatives to induction? So what can you do in the meantime? A good example of this is being near your due date or going past your due day.

Speaker 1: And you can have monitoring where you put on the monitor, check the baby's heart rate, check the fluid around the baby twice a week. If that looks reassuring, then you can certainly wait longer to see if you can go into labor on your own. So you can ask if there are alternatives to induction. And then finally, what are the risks of waiting? So if you decide I want to wait, then what are the risks of waiting if I don't want to be induced? Oh, and then, sorry, one more, one more question. What method are they going to use for induction? Are they gonna use Cytotec? Are they going to use the mechanical dilator? And what are the risks and benefits of each. Every doctor has their own specific things that they try, don't try or can or can't do based on their hospital. But they should be able to tell you about what method they recommend for induction in your specific case and what are the risks associated with that, how the process is going to go.

Speaker 1: Whew. Okay. So that is it for this episode. I know that was a lot of information and just to recap, induction is making labor happen before it happens on its own. There are two reasons for induction. Either there's a medical reason that benefits your health or your baby's health or it's an elective induction where there's no medical reason to do so. The induction methods are not that many. There are prostoglandins either the gel or the vaginal insert or Cytotec. They're mechanical dilators, Pitocin and breaking your water. That's it. Some of the methods like castor oil, acupuncture and sex are low risk. So if you want to try those as well, you can. Induction can take some time. It is not typically going to take this long, but it can be two to three days or longer. And then finally make sure you understand exactly what's going on with your induction.

Speaker 1: And I'm not saying like put that burden on you in the sense that you need to understand, what I'm saying is that go ahead and ask those questions. If your doctor is not explaining things to you, then ask the questions so you understand what's going on, what's going to happen. As I've said before, and will continue to say again, when you're equipped with information and you're just more prepared, you're more able to advocate for yourself, you're more able to assess things and still really have that birth experience that you want, that beautiful birth that you want. Okay, so that's it for this episode. Be sure to subscribe to the podcast in Apple podcast or wherever you're listening to my voice right now, Spotify, Google Play. Of course, I'd love it if you leave a review, particularly an Apple podcast. That is the best way to help other women find the show and to help the show to grow.

Speaker 1: And then of course do not forget to check out The Birth Preparation Course, my online childbirth education class that ensures you are knowledgeable, prepared, confident and empowered to have a beautiful birth. It is currently heavily discounted right now, so super affordable. You have nothing to lose by enrolling, there's a 30 day money back guarantee. You also get lifetime access to it so you enroll once and you have it for every pregnancy going forward. With all the updates and everything that I'll do as I update along the way, you can check out the course at www.ncrcoaching.com/enroll. Next week on the podcast, it is a birth story episode, so do come on back next week and until then I wish you a beautiful pregnancy and birth.

: Thanks so much for listening to this episode of the all about pregnancy and birth podcast. Head to my website at ww.ncrcoaching.com to get even more great info including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on how to make a birth plan as well as everything you need to know about The Birth Preparation Course. Again, that's www.ncrcoaching.com and I will see you next week.

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