Induction – How is it done?
- 7 days ago
- 6 min read
Updated: 6 days ago
The views and opinions expressed are those of the author and should not be considered medical advice. Always consult your OB or midwife for the most appropriate treatment.
What Is Induction?
Induction is the use of medications or other methods to bring about labor. It’s usually a two-step process that jump-starts cervical ripening and stimulates labor contractions. Inducing labor can take anywhere from a few hours to a few days, depending on your body’s response and whether it’s your first pregnancy.
Induction of labor is not an uncommon procedure. Often, there are medical reasons to induce, for example, when someone has high blood pressure or is reaching 42 weeks. At other times, the procedure is elective, i.e., you are choosing it without a medical indication rather than waiting for labor to start on its own. See Except When Medically Necessary: Making informed choices about induction of labor for more information.
Whether induced or spontaneous, the goal of labor is the same: a healthy vaginal delivery. Getting familiar with the induction process ahead of time better informs your birth plan.
The Two Stages of Induction
Stage 1: Cervical Ripening
In early labor, your body is working to ripen the cervix so it can open (dilate). The cervix is designed to soften, thin, and move forward (known as cervical ripening) on its own, but when waiting for labor to start is not the plan, it needs a little help.
In the first stage of an induction, your doctor will recommend a medication, device, or procedure—or a combination of these—to begin cervical ripening. It’s your body and ultimately your decision, so discuss these options with your doctor:
Stripping the Membranes
A procedure performed by your OB or midwife that involves gently separating the membrane of the amniotic sac from the wall of the uterus around the cervical area. This triggers the release of prostaglandins that help ripen the cervix. While this procedure is often done during a prenatal visit, it is a form of inducing. Some research shows that a membrane sweep can avoid a more formal induction later on. A membrane sweep
In 9% of people, it may cause their water to break prematurely. Group B Strep International suggests that membranes should never be stripped because GBS status can change. More than 60% of early-onset GBS cases have occurred among infants born to a parent who had a negative prenatal GBS culture screen.
Balloon Catheter
A device with one or two small inflatable balloons that apply pressure on the cervix so it softens and thins. It also irritates the cervix, which, like a membrane sweep, releases prostaglandins.
Some people find the insertion of the balloon painful, and they may desire some pain medication like nitrous or Fentanyl, but it is mostly well-tolerated. This procedure is also often done outpatient, meaning that after the balloon catheter is placed, someone goes home for 12-24 hrs, depending on the situation. If staying at the hospital, it can mean some time spent there waiting. Prepare accordingly, and bring things to do! Make sure to get sleep overnight and ask for sleep medication if desired. It is really important not to go into the rest of your induction with a lack of sleep.
Pill (Cytotec®/misoprostol)
A medication that is typically given orally, though it can be given vaginally as well. This medication helps ripen the cervix with contractions that range from mild to intense. Sometimes this is enough to help someone into active labor, but not commonly. This medication is contraindicated to be used in a TOLAC. Pitocin is then often used at a low dose over a certain amount of time.
Some people use the tub or nitrous oxide if the contractions become intense. This does not mean that the contractions will remain this way. The medication has a 2-hour half-life, meaning that after 2 hours, the concentration or amount of the drug in the body is reduced by one-half. Knowing this may help you from one dose to the next. Needing pain management when using misoprostol also does not mean that you will need pain medication later on. Contractions caused by this drug are different and not physiological.
Evidence shows that combining misoprostol and the balloon at some point has a better effect than using only one of the two methods.
Stage 2: Stimulating Contractions
When your cervix is sufficiently ripe and dilated, your OB or midwife will begin the second step—inducing labor. This stage involves stimulating the body to produce contractions (if they haven’t started on their own). Sometimes, people start here if their cervix has already ripened and dilated to 3-4 cm on its own.
Depending on your situation, there are two ways to do this:
IV Drip (Pitocin®/oxytocin)
A medication, similar to the hormone oxytocin, is used to encourage contractions. An IV with a small dose is administered initially, then the dose is gradually increased until contractions are strong and frequent enough to deliver. Pitocin can also be turned down when contractions become too frequent, or stopped altogether if your body is laboring on its own.
Keep your birth plan in mind if you hope to avoid an epidural. Not everyone needs the same pattern of contractions to fully dilate, and turning the Pitocin down for a short while, if needed and an available option, does not mean that you are losing momentum. Our bodies naturally do this in labor, and ideally, an induction mimics natural labor. Rest can have an amazing impact. It will pick up again.
Amniotomy
A procedure performed using a small hook to rupture the amniotic sac (break your water) to produce (more) contractions. The procedure itself is not painful, as there are no pain receptors in the bag, but it is like a cervical exam, and that can be uncomfortable in labor. Like the membrane sweep, an amniotomy releases prostaglandins, which keep ripening the cervix and therefore help it dilate.
Often, rupturing the bag of water is a normal part of an induction after having been on Pitocin for a while. Some OBs or midwives offer to perform both at the same time, an hour or so after the balloon is out. There is moderate evidence that this accelerates labor without increasing the cesarean section rate. It is a more aggressive route, however, and it is good to consider your birth plan concerning pain medication when evaluating your options.
The bag of water can also break on its own at some point, and some prefer to wait for this, hoping for some normalcy in the process. This is a valid wish!
There is an increased risk of infection over time, the longer your bag of water is broken. Also, cervical exams are typically done more frequently in inductions to make sure there is progress, and this can also increase the risk of an infection. It can be a good idea to wait till you are in active labor before having your bag ruptured, since the time of being in labor will be shorter generally from then on.
Usually, breaking the water is only done when a baby’s head is very low (-2 station or less) and well-applied on the cervix, making the procedure safe, but in very rare circumstances, the cord falls in front of the baby’s head (prolapses), and a C-section needs to be done immediately. Ask for your baby’s station and whether waiting for a lower baby is appropriate.
Lastly, discuss with your OB or midwife if cervical exams are painful or traumatic for you, and know that you can use pain medication like nitrous, Fentanyl, or topical lidocaine to make them more tolerable.
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This is a lot of information, but I hope it helps you make decisions, adjust your birth plan, and have realistic expectations of the process.
Some questions to ask your OB or midwife ahead of time:
Is induction medically necessary at this time?
How will it help contribute to a safer delivery of my baby?
How ripe does my cervix need to be before starting Pitocin?
If I need the balloon first, can I go home when it is inserted?
How does the balloon come out, and how long is it OK to wait for it to come out?
What options are available to me to help support the best possible outcome?
What risks are associated with induction?
What if my baby does not tolerate Pitocin?
What if my body does not respond well to the induction?
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