Let’s Get It Started! Common Labor Induction Methods
An induction of labor is a medical intervention used to bring on labor before it begins naturally. Induction can be recommended for various reasons including underlying medical concerns for mother or baby, pregnancy that has extended beyond 40 weeks, complications of pregnancy such as high blood pressure, or patient preference. Inductions are common in the United States, used in around 22% of all deliveries, and may be more common among high-risk pregnancies. Described in this post are the common medications and interventions used during an induction of labor. Understanding the options available for induction will help you have an informed discussion with your provider and choose the best plan for your birth.
Considering an Induction of labor?
Pros
Causes labor when delivery is medically beneficial for mother or baby. Induction can be a life saving intervention when continuing pregnancy is unsafe for mother or baby. An example of this is when a pregnant person develops severe pre-eclampsia.
Can help coordinate delivery timing. Being able to plan your delivery timing may be very beneficial if specialty medical teams need to be present for your delivery, or if you have to coordinate travel or childcare for your delivery.
Can expedite delivery if you have reached your due date and are really ready to not be pregnant anymore!
Induction of labor at 39 weeks or after is not associated with an increased risk of cesarean section.
Cons
Induction of labor will likely be a longer labor process compared to going into labor spontaneously, especially with your first baby. You are likely to spend more time in the hospital.
Induction of labor requires more interventions such as medication, breaking of water, and continuous fetal monitoring. This may not be a good fit for people who desire a low intervention birth process.
Induction of labor often consists of two parts. The first part is cervical ripening, which softens and prepares your cervix for labor. The second part is induction of labor contractions. Your provider will check your cervix to determine how to begin your induction process.
Cervical Ripening
If your cervix is closed or one centimeter dilated at the start of your induction, you will likely need cervical ripening. Cervical ripening is the process of softening and thinning your cervix so that it will better respond to labor contractions. There are medication and mechanical options for cervical ripening. What option your provider recommends may depend on what is available at the hospital you are delivering at, your medical history and pregnancy course, their clinical preference and expertise, and your preferences.
Medication: Medications used for cervical ripening are called prostaglandins. Prostaglandins help soften and thin the cervix. Prostaglandin medications may be avoided if you have had a previous cesarean section or uterine surgery.
Misoprostol: Misoprostol, also called Cytotec, can be administered as a pill you swallow, a pill you let dissolve in your cheek, or a pill that is placed into your vagina by your provider. Misoprostol can be administered every four hours and you may receive multiple doses before moving on to the next step of the induction process. Misoprostol may make you feel cramps or light contractions. Your nurse will monitor the baby’s heart rate prior to and after administering the misoprostol. You may be able to come off fetal monitoring after a normal fetal heart rate is seen. Misoprostol can be administered in the hospital or in an outpatient setting where you can go home after. Misoprostol is not given to cause true labor, but in some cases- it might bring on the real deal!
Cervidil: Cervidil, also called dinoprostone, is a vaginal insert that looks similar to a flat tampon. It is inserted in the vagina by your provider and placed close to your cervix. The placement of a Cervidil will feel very similar to a cervical exam. It releases medication slowly over a period or time to help ripen the cervix. Cervidil is often kept in place for 12 hours but it can be removed sooner if necessary. Cervidil may make you feel cramps or light contractions. When Cervidil is being used, your provider will likely want your baby’s heart rate to be continuously monitored and therefore you will stay in the hospital the whole time. Like misoprostol, Cerdivil is not given to cause labor, but occasionally that may occur. Cervidil is a more expensive medication than misoprostol and therefore is not as readily available.
Mechanical: Mechanical methods of cervical ripening use pressure on the cervix itself to slowly open the cervix a few centimeters. These methods may be avoided if your water is broken.
Dilapan: Dilapan osmotic dilators are small rods that are inserted into the cervical canal by your provider. These small rods absorb fluid from your vagina and slowly expand, gently dilating the cervix. The pressure of the dilapan on your cervix triggers the release of your body’s own prostaglandins, further helping the process of thinning and softening your cervix. The rods typically remain in place for 12-24 hours, after which time your provider will remove the rods by doing a cervical exam and gently pulling them out. If a rod falls out on its own, that is okay! Just make note of the number of rods that fell out and let your provider know. The most common side effect of Dilapan is discomfort, pressure, or cramping during insertion. To insert the dilapan, your provider will position you into a lithotomy position with your feet in stirrups and a vaginal speculum will be used to allow them to visualize your cervix and place the dilapan correctly. After the dilators are placed, you may feel cramping and have light spotting. Your care team will likely check your baby’s heart rate before and sometimes after placing the rods. Some people are sent home with Dilapan in place and return the next day to continue their induction while others stay in the hospital.
Cervical Balloon: To use a cervical balloon, your provider will insert a small plastic catheter through your cervical canal. Once the catheter is through your cervix and in the bottom or your uterus, a balloon at the top of the catheter is inflated with saline. This balloon puts downward pressure on your cervix. If your provider uses a specific brand of balloon called a Cook Balloon, they also have the option to inflate a second balloon in your vagina. This puts upward pressure on your cervix at the same time. The pressure on your cervix causes your body to release its own prostaglandins which soften your cervix while the balloon mechanically dilates your cervix slowly. The balloon can be kept in place for 6-12 hours, after which time your provider will deflate the balloon and remove it. In some cases, the cervix opens enough that the balloon falls out on its own. This is not concerning and just means things are moving along! To place the balloon your provider will likely position you into a lithotomy position and may use a vaginal speculum to better visualize your cervix. It is common to feel uncomfortable pressure and cramping during the insertion which usually is a fast process, lasting 15 minutes or less. The cramping and pressure tends to get better once the balloon is in place. If you are concerned about pain, talk to your provider about pain management options such as nitrous oxide gas or IV pain medications prior to placement. Since the balloon is attached to a catheter, the catheter will extend out of your vagina while the balloon is in place. This can be secured to your inner thigh with a small piece of tape. You will be able to use the bathroom regularly with the balloon in place. Your care team will monitor the baby’s heart rate before and sometimes after placing the balloon. Some people are sent home with a balloon in place and return the next day to continue their induction while others stay in the hospital.
Combining Methods
Medication and mechanical methods can be combined to speed up the cervical ripening process. For example, a cervical balloon may be used while also administering misoprostol or pitocin. More than one method of cervical ripening may be necessary to prepare the cervix for labor.
Induction of Contractions: After cervical ripening, your cervix will be softer, more thinned (also called effaced) and hopefully two or more centimeters dilated. Your cervix is now ready for the next part of induction: labor contractions. If your cervix is already two or more centimeters at the start of your induction, your provider may recommend skipping right to this part!
Pitocin: Pitocin is a synthetic form of the hormone oxytocin that causes labor contractions. During a contraction, the uterine muscle contracts, pushing your baby’s head down onto your cervix. The pressure of the baby’s head on your cervix causes your cervix to open or dilate. Pitocin is administered through an IV. It is started at a low dose, and titrated up to a dose that causes regular uterine contractions. Your nurse will increase or decrease the amount of pitocin you are receiving to reach a goal of having a contraction every two to three minutes. The dose at which this contraction pattern is achieved will be different for everybody. If you are receiving pitocin, your baby’s heart rate will be monitored continuously and you will be staying in the hospital. Since pitocin causes labor contractions, your pain level may increase over time as your contractions get closer together and more intense. If you are planning for pain management such as nitrous oxide or an epidural, talk with your nurse about timing for utilizing these interventions. If you are planning a non-medicated birth, this will be a good time to plan for increased labor support such as breathing techniques, position changes, and counter pressure. Pitocin will likely continue running throughout your entire labor process until your cervix is ten centimeters dilated and you are able to start pushing and deliver your baby. If your provider is ever concerned that your baby’s heart rate is showing signs of distress in labor, the pitocin will be decreased or turned off to decrease the intensity of your contractions.
Artificial Rupture of Membranes: Artificial rupture of membranes (AROM) is the medical term for breaking your water. Breaking the bag of water around the baby will allow the release of the amniotic fluid surrounding the baby. This helps to induce labor and is used on its own or in conjunction with pitocin. To break your water, your provider will check your cervix and use a small plastic hook to tear a small hole in the amniotic sac, releasing the amniotic fluid. This will feel like a cervical exam, you will not feel the plastic hook. You will feel warm fluid coming out of your vagina once your water is broken. Your baby will continue to make more amniotic fluid so you will continue to feel fluid leaking until your baby is born. For some people, contractions get more intense after their water is broken. If you have had a baby before, breaking your bag of water is very effective at causing or speeding up labor and is sometimes the only intervention needed. To safely break your water, your cervix must be a few centimeters dilated and your baby’s head must be low, pressing down on your cervix. Not everyone needs their water broken by a provider during an induction as your water could break on its own at any time.
TAKE AWAY:
During an induction of labor medications and other medical interventions are used to cause contractions and cervical dilation. Understanding the options available for induction will help you have an informed discussion with your provider and choose the best plan for your birth.