No one ever expects that they will be told by their midwife (of all people!) that they will need to be induced. It is important to consider the information in this article in case this is something that needs to happen for you to have a healthy mom and baby.

Most common reasons for Induction:

• 41-42 weeks gestation (you will hear this called, ‘post dates’)
• Pre-eclampsia
• IUGR (intrauterine growth restriction)
• Prolonged rupture of membranes

There are other reasons why women may need to be induced but the above are the most common.

We do everything that we can to make inductions as gentle as possible and try to make them mimic a normal labor. When we consider induction we always consult our back up obstetricians and weigh the benefits of the baby being born vs the risk of the baby staying inside the uterus. We assess the cervix and determine if the cervix “ripe” and ready for labor.  A bishop’s score is a score that assesses your body’s readiness for labor.  The bishops score assesses dilation, effacement, softness of the cervix, position of the cervix in your pelvis and how low your baby is in your pelvis.

When cervices are not ripe or ready for labor (the bishop score is under 6) then we discuss ripening agents to help prepare the cervix for labor.  In our practice, if the cervix is slightly dialated,  we like to use a Cook Catheter or Foley Catheter which is basically a water balloon that we put into the cervix over night (usually 12 hours).  The Cook Catheter allows us to put 80cc in the cervix and 80cc vaginally and can often dilate the cervix to 4-5 cm in 12 hours.  The Foley Catheter allows 30cc and usually a woman will dilate to 2-3 cm in 12 hours.  The risk with the Cook Catheter can be urinary retention so we advise women to let the nurse know immediately if they are unable to urinate and we can then remove some of the water from the catheter. Cramping is not an uncommon side affect.  We will offer women medication to help them sleep during the night should they need this.  Rarely, but on occasion, the catheter alone will put people into labor.

The other ripening agent that we will use is called Cervidil. This is a medication that inserts similar to a tampon with a string attached.  It sits behind the cervix and has a slow release of prostaglandin.   This is a prostaglandin that can work overnight and help the cervix soften, thin and dilate.  Occasionally Cervidil will put people into labor.  If contractions become very close together with this medication we will pull in out prior to 12 hours.

Usually the Cook Catheter, Foley Catheter and Cervidil are followed by Pitocin use the following morning.  (See Pitocin below)

Sweeping Membranes. If the cervix has a good bishop’s score and is considered ready for labor we will sometimes try to sweep the membranes. This is done only if a women’s GBS status is negative. Sweeping membranes is basically a vaginal exam where by the midwife goes into the cervix with her fingers and moves the membranes away from the inside of the cervix gently and carefully. Occasionally this will cause rupture of membranes but usually the bag of water is strong enough to stay intact through this procedure. This can often cause the women to release hormones to begin labor if the body is ready for labor.

Acupuncture. Acupuncture is another method to induce labor and can be very effective for some women. We often recommend acupuncture and membrane sweeping on the same day. We give referrals to local acupuncturists and now refer women to the community acupuncture clinic in the Boulder Birth Community Classroom in an attempt to lower out of pocket cost.

Castor Oil. Castor oil is sometimes recommended prior to pitocin use. Castor oil can be extremely effective if the body is ready for labor. Castor oil causes intestinal cramping, loose stools and usually diarrhea. The body has a vagal response where the uterus then begins contracting too. If used in recommended dosages Castor Oil should not cause dehydration or incontinence of stool. There is some thought that it may increase the incidence of meconium stained fluid. I have not seen this correlation with my practice but it is in some of the literature. I think it is hard to determine if the meconium is caused by a deteriorating placenta or Castor Oil ingestion.

Pitocin.  We will occasionally use pitocin to get women into labor. We give women just enough pitocin to achieve regular uterine contraction. Pitocin is administered through a pump so that we give small but adequate amounts of this drug.  Sometimes we need to use an IUPC (Intrauterine Pressure Catheter) in order to know precisely how strong the uterus is contracting.  The IUPC measures the uterine muscle in mm of mercury.  We can then titrate the amount of pitocin we give so that it is not too much or too little.  With pitocin women need to be on continuous monitoring but fortunately Boulder Community Hospital has telemetry monitoring so that women can have good mobility.  The telemetry monitoring is also water proof so women can be in the jacuzzi tub while on pitocin.

Breaking the water. When a woman’s body is extremely ready for labor and the head is low in the pelvis sometime AROM (artificial rupture of membranes or breaking the water) will be enough of an intervention to get someone into active labor.  If the baby is not low in the pelvis this would not be advised due to the risk of cord prolapse or the possibility of the baby settling down in the pelvis in a less than optimal position.

Our practice does see natural childbirth when induction is needed but know that if you want epidural anesthesia, we can call an anesthesiologist in at any time.  The other pain management option is Fentanyl IV.  This IV pain medication can help contractions feel less painful and can “take the edge off” the contractions.

If you should need to be induced, remember the goal is to have a healthy mom and baby.  C-Section risk does increase slightly with induction of labor.  Remember that we are lucky to live in a day and age where Cesarean Section is an option for birth when it is necessary.  Our Cesarean Section rate in 2011 was 11%.  The World Health Organization recognizes this as a healthy rate.  This is how some babies need to be born!

I also tell women and their families that induction can often take several days and this can be mentally challenging.  If attempts for induction are not successful after the first day we often stop and allow for food and rest.  On rare occasions we will stop attempts of induction and send people home for a few days to allow more time as long as there is no immediate health risk to the mom or baby.