I attended a mama being induced last week, and it reminded me that this post was still waiting to be written. So here it is, finally! I’m discussing medical induction here – if you are interested in ‘natural’ induction, the midwife Aviva Romm wrote an interesting piece last month.
Birth can be induced for all kinds of reasons. Some are medical – baby too small (IUGR), mama’s blood pressure too high. Some are social – dad only has the weekend off work, for example, or a loved or trusted care provider is only available at a particular time. Some reasons are better than others. The March of Dimes has a campaign to encourage parents to wait until at least 39 weeks before attempting an induction, and ACOG says the same thing. One reason is that, while a baby may technically ‘early pre-term’, he or she may not quite be ready for earthside life yet. Both the linked pages above note the increased likelihood of NICU stays for babies born between 37 and 39 weeks. Once a pregnancy reaches 41 weeks, many if not most care-givers prefer to induce, citing an increase in the likelihood of still birth as the key rationale: taken together, various studies have suggested that one still birth will be avoided for every 369 women induced between 41 and 42 weeks. The first key questions, then, when confronted with the option to induce, are ‘why?’ and ‘why now?’
Apart from the need to wait to at least 39 weeks, a factor to consider is that the mama’s body (or rather, the mama-baby partnership) may not quite be ready for labour yet, so that ‘failed induction’ is a big cause of cesarean section, especially in first time moms. If you are confronting a possible induction, it’s a good idea to ask your care provider about your ‘Bishop Score’. The Bishop Score is a number between 0 and 13, calculated by assigning points for cervical position (posterior, middle, anterior), dilation (in centimeters), consistency (firm, medium, soft), effacement, and the extent of your baby’s descent into the pelvis (from -3cm above the ischial spines to +3cm). There is a Bishop Score calculator here. With a score of 8 or higher, an induction is likely to be successful – a doctor or midwife may be able to give you a percentage likelihood. 7 or below means that an induction is unlikely to be successful. If you want to be induced, or are feeling pressure from some source to induce, this information is useful to have. It helps to answer another key question, ‘Will it be likely to work?’ It’s good to know your options if it doesn’t work ahead of time – can you go home, and try again another day (likely not if you have agreed to have your waters broken) or will you be facing a surgical birth?
Once the decision to induce is taken, there are several different options (‘how?’). Some involve causing the cervix to soften (prostaglandins) or dilate (a Foley balloon or certain types of seaweed), while others induce contractions (most commonly Pitocin, an artificial form of the oxytocin that your body naturally produces in labour). Often, artificially rupturing the membranes – breaking the water – is an option. Pitocin and rupturing the membranes can also be used to augment a labour already in progress, usually because it is considered to be going to slowly for some reason. Sometimes, if a mama is very near her time, the merest hint of induction can trigger natural labour: a ‘whiff of Pit’, as it is often known, may be given to set things in motion, but then the mother’s own body takes over and no more Pitocin is needed. For others, a combination of all these factors may be used to try to bring labour: first cervical softeners are applied, then Pitocin is started, then later the membranes are ruptured until finally, hopefully, a good labour pattern is established. Or not. What is your care provider’s preference for you? What is his or her preferred timeline?
What do we need to know about these and other methods of induction and augmentation in order to make our own best decisions? In other words, what information do we need to consider before giving or withholding consent? Please note: I am not a care provider and I have no medical advice (or advice of any other kind) to give. That said, I think we need to have, as best we can, both personal, physiological information (how will my body likely respond?) and provider information (if I dilate to 4cm with a Foley bulb, but contractions do not start, what is your plan?). For example, the cells of the uterus are equipped with oxytocin receptors that cause them to contract when that hormone is present, but they are not switched on until labour is imminent – otherwise you might have contractions every time you make out with your honey. If your labour is not imminent, and those receptors have not been activated, what effect will Pitocin have? Or, if you had plans for an unmedicated labour, but Pitocin causes the intense contractions (and sometimes fetal stress/distress) for which it is well known, how will you manage the resulting
agony discomfort or fear? If you planned to move through labour, but must have continuous fetal monitoring due to Pitocin, and be in or near the bed, what will you do? If your care provider asks you to come in and have your waters broken, with the plan to ‘see what happens’, how will you, in the hospital, inform yourself sufficiently to make your best decisions when subsequent steps are suggested? If you are labouring naturally yourself, but your care provider wants to augment your labour, the same kinds of questions apply. Why do you want to do this? Why do you think I need to do it now? What effect will it likely have on me? And on my baby? What are the risks of doing it? And of not doing it? Are there other options? How long do I have to decide?
Providing yourself with good, evidence based information on options for induction and augmentation may help to make some decisions ahead of time. It may give space and time to think and make decisions. Childbirth Connection has a good article on considerations in induction. Henci Goer wrote a great article on elective induction. Evidence Based Birth has a good one on induction for ‘big baby’. And the now quiet blog ‘Birth Sense’ had an interesting series on due dates and inductions, here (click ‘next’ for the two following posts). Many of these articles have links to medical journal articles where you can read cutting edge research – and sometimes, if you feel you need to, present it to your care provider.