Inductions: The Why, How and Can Anything Be Done to Prevent Them?
*NOTE: some quotes use gendered language. Let us remember that women are not the only birth givers. Trans men, non binary folks and anyone with a uterus can be a birthing person.*
This is always a hot topic with pregnant folks. Especially when your due date is nearing and maybe either you or your healthcare provider are eager to get things started!
Let's dive a little deeper into what conditions are needed for the optimal birthing scenario, ways to encourage labour to begin, when inductions may be useful and how they are done!
First, let's discuss Optimal Birth!
"Labor progress and prevention of dystocia depend on harmonious interactions among a variety of psycho-emotional, interpersonal, physical and physiologic factors...when a birthing person feels safe, respected, cared for. When she can remain active, mobile and upright; and when her pain is adequately and safely managed."
The Labor Progress Handbook
For labour to begin and continue, an incredible cocktail of hormones need to be present.
Those hormones are:
Oxytocin: Our love hormone. This one contributes to uterine contractions, our urge to push, reduces pain perception AND our memory of aversive experiences (Helloooooooo, this one is clearly needed if we are going to have more than one baby!)
Endorphins: These have a morphine like quality and increase with pain, exertion, stress and fear. They contribute to the "birth high". They can contribute to a trance like state, an otherworldly like feeling and the inward focus needed to manage active labour.
Catecholamines: These are stress hormones. Having high levels of these present during prelabor or early labor can counteract the effects of Oxytocin and Endorphins but in the second stage of labor (Pushing out baby stage!), these are super useful to boost our strength, focus and effort!
Prolactin: This is our nesting hormone. It has mood elevating and calming effects on the pregnant/birthing person.
Prostaglandins: Promote changes that soften the cervix. (Which we know is an essential early part of labour beginning!)
In recent years, studies have "identified two proteins in a fetus' lungs responsible for initiating the labor process. They discovered that the proteins SRC-1 and SRC-2 activate genes inside the fetus' lungs near full term, leading to an inflammatory response in the mother's uterus that initiates labor." (UT Southwestern Medical Center)
Science is so cool! So, now we can see that hormones play a huge part in when labour starts!
So what are some practical tools for encouraging the ideal hormones to flow?
The first thing that is absolutely essential and often overlooked, is creating the optimal environment for birth.
Have you ever seen another animal give birth?
Some common elements for mammal birth:
Safe (space and people)
The ability to move freely in a variety of positions and movements.
Some ways to encourage contractions and/or cervical ripening:
Movement and Positioning
Immersion in Warm Water
Nipple Stimulation: "Compared to placebo or no intervention, breast stimulation significantly reduced the number of women not in labor 72 hours later IF cervix was favorable when started. Also, there was less postpartum hemorrhage. Safe for low risk women."
The Labor Progress Handbook
Acupressure/Acupuncture (This is best avoided until full term) Some research (regarding acupressure) has shown a shorter first stage of labor but more is needed.
Mollart et al. 2015
Eating Dates: "One randomized trial of dates to ripen the cervix, one group ate 6 dates per day for 4 weeks; the others ate none. Results: the date group had more spontaneous onset of labor, greater dilation on admission, less use of synthetic oxytocin; shorter mean latent phase labor. All these differences were statistically significant. Birth outcomes were not significantly different."
Al-Kuran et al 2011
Now let's look at the hot topic: Inductions!! Why they are done, how they are done and when is it necessary?
So, HOW are inductions done?
There are several commonly used methods here to induce labour.
Membrane Sweep: This is done by your health care practitioner inserting their fingers into your cervical opening and "sweeping" the outer lining of the amniotic sac from the cervix and uterine wall. This can only be done if your cervix is already showing signs of "ripeness" (ie: effacing or dilating)
Cervical Ripening: This can be done chemically or mechanically. It is often performed with the insertion of a cervical ripening agents. Many birthing folks are sent home to rest, relax and wait after this procedure.
Artifical Rupturing of the Membranes (Breaking the waters): This is usually only done once labour has started and some cervical effacement and dilation has occurred. Often offered as a way to "speed things up".
Synthetic Oxytocin: Remember we talked about ways to encourage the flow of oxytocin naturally? Well, this can also be administered intravenously using synthetic oxytocin, often called Pitocin.
What do the studies show?
One of the most thorough and accessible websites for information regarding this topic is Evidence Based Birth!
Excerpt from Evidence Based Birth
"The Bottom Line
Current research evidence has found that elective induction at 39 weeks does not make a difference in the rate of death or serious complications for babies. For mothers, induction at 39-weeks was linked to a small decrease in the rate of Cesarean compared to those assigned to wait for labor (19% Cesarean rate versus 22%).
We have heard from people who are surprised at this finding, since for so long elective induction was thought to increase the Cesarean rate. It’s largely a matter of the new research using the appropriate comparison group for elective induction (now including medical inductions in the expectant management group). It would be interesting to see secondary analyses published on who actually was induced versus who actually had spontaneous labor for every study (like we saw with the Hannah Post-Term trial). But from a decision-making perspective, it is most helpful to consider the results according to original group assignment (active versus expectant management), since spontaneous labor is not a guarantee with expectant management.
It’s important to keep in mind that there are plenty of alternatives for people or facilities seeking lower risks of Cesarean that don’t involve elective inductions.
Elective induction at 41 weeks and 0 to 2 days could help to reduce stillbirths and poor health outcomes for babies, especially among first-time mothers.
Importantly, two large randomized, controlled trials published in 2019 both found benefits to elective induction at 41 weeks instead of continuing to wait for labor until 42 weeks. One of the studies found fewer perinatal deaths with 41-week induction and the other found fewer poor health outcomes for babies (e.g., intensive care unit admission, low Apgar scores) with 41-week induction.
Neither trial found an increase in the risk of Cesarean or forceps/vacuum during birth with 41-week induction compared to continuing to wait for labor until 42 weeks. Both of these trials took place in countries that follow the Midwifery Model of Care, and the overall Cesarean rates were low (only 10-11%).
An earlier study called the Hannah Post-Term study found that waiting for labor after 41 weeks greatly increased the risk of Cesarean for people who ended up needing an induction for medical reasons, but not for people who went into labor on their own.
People can talk with their care providers about the pros and cons of waiting for spontaneous labor or elective induction at 39 weeks and 41-42 weeks. This conversation should take into account the mother’s* preferences, personal birth history, risk factors for stillbirth, chances of a successful induction (how “ripe” the cervix is, also known as the Bishop score”), the facility’s Cesarean rate with induction, and alternatives.
The Bishop score that helps to determine if you are a good candidate for induction is based on five factors:
How dilated (or open) is your cervix?
How effaced (or thin) is your cervix?
How soft is your cervix?
How far forward is your cervix?
How far down the birth canal is your baby’s head?
None of the research evidence looked closely at birthing people’s experiences or preferences. These non-medical factors are very real when it comes to individual decision-making. For example, the experience of being induced (potentially more painful contractions, tethered to wires for monitoring and IV fluids, confined to bed) may not make much of a difference to someone planning a birth with an epidural, but it can make a huge difference to someone planning to use movement and other comfort measures during an unmedicated birth. On the other hand, someone who has experienced miscarriages or stillbirth in the past may have a strong preference for elective induction in order to lower the absolute risk of stillbirth by any means necessary. All of these experiences and preferences are valid."
Some Pros for induction at 39 weeks:
Avoid potential complications of continuing the pregnancy (developing a high blood pressure disorder, large baby)
May reduce risk of potential stillbirth (although the absolute risk remains low until after 41 weeks)
Some Cons for induction at 39 weeks:
Longer time spent in labour
Miss the hormonal benefits of spontaneous labour
Medically induced contractions may increase pain and pharmaceutical pain relief use
Potential for increased medicalization of birth (continuous monitoring, etc)
All this to say: there are pros and cons for inductions are different stages of your pregnancy and obviously based on your individual situation.
The take away is this:
Elective inductions at 39 weeks do NOT show a lot of benefits to either birthing person or babe (UNLESS MEDICALLY INDICATED).
As in all things, YOU are the one who ultimately makes the decisions regarding your care.
Use your BRAIN when discussing options with your care provider!
Benefits: What are they?
Risks: What are they?
Alternatives: What are they?
Intuition: Check in with yours!
Nothing: What happens if we do nothing?
Did you have an induction? How did it go? Feel free to share below or send me a private message!
In solidarity and love,