After what seems like at least a year of waiting and pregnancy reaches the final few weeks, many women find themselves facing this potentially difficult question. On the one hand, a women is very likely fatigued-physically and emotionally-and ready for the pregnancy to end. On the other hand, there are risks to consider with induction of labor and the number one priority is the delivery of a healthy baby.
Below are some key questions to consider if you find yourself considering induction of labor for a non-medical or “Social” reason (see below). As is so often the case, it is critical that you have a detailed discussion(s) with your physician about these issues. Make certain that you fully understand the particulars of your condition and that your physician spends the necessary time to explain all of your options and why he/she feels one option is better than another. Again, this discussion relates to the decision to have or not to have labor induced at the end of pregnancy for some non-medical reason. Inducing labor for medical reasons such as high blood pressure, diabetes, or problems with the baby’s growth is an altogether different topic.
What are the most common reasons to have labor induced?
The most common reason to have labor induced in the Fort Wayne area is simply to end the pregnancy. Once a patient has reached 39 weeks of pregnancy many physicians offer and/or many patients request what is known as a, “Social induction of labor.” That is, there is no medical reason to induce the labor; it is simply done as a matter of convenience.
Certainly, there are medical reasons related to the health of the baby and/or the mother than may lead us to suggest induction of labor. These include elevations of the mother’s blood pressure, problems with the baby’s growth (too much or too little), medical problems or conditions with the mother such as diabetes, rupture of the membranes without the onset of labor, changes of the baby’s heart rate that suggest the baby would be more safe outside of the womb, and pregnancy that has continued beyond the 41st week (a condition known as “Postdates pregnancy”), just to name a few.
What are the potential risks of labor induction?
After the pregnancy has reached 39 weeks of gestation, by far the greatest risk to consider is that the induction process will fail and therefore lead to a c-section that perhaps would not have been necessary if induction had not be attempted. This can occur as a complication of the induction efforts, or more commonly, when there has been no progress made after several hours effort and all involved resolve themselves to proceed with a c-section.
While cesarean sections are among the most common surgeries performed and are generally very safe, one cannot ignore that the risks to a mother and her baby are many times greater when compared to vaginal delivery. The specific risks of the surgery include that of bleeding, infection, injury to other structures such as the bowel or bladder requiring further and more extensive surgery, and injury to the baby. Several studies over the years have linked induction of labor to increased infection rates, increased need for antibiotics, and a greater likelihood an infant will require admission to the neonatal intensive care unit (NICU). These risks are in addition to the risk of cesarean section.
The risk of a failed induction and the subsequent risk of c-section are for the most part tied to the degree to which the patient’s cervix is ready for labor, or “Ripe” as it is sometimes said. That is, when the cervix is “Ripe,” induction of labor is much more likely to be successful. This “Ripeness” is assessed by a pelvic examination. The examiner determines the softness and thickness of the cervix, the degree to which the cervix is dilated (opened), and the position of the baby’s head in the mother’s pelvis, among other things. He/she then determines a numeric score, known as the Bishop’s Score, based on those findings. Simply stated the closer the score to 10 the greater the degree of ripeness and subsequently the greater likelihood of successful induction. A score of 7 or better is considered, “Ripe.”
What are the potential benefits to labor induction?
The benefits include:
- One can plan the place and time of delivery, allowing family members and friends to be a present
- A patient can be assured that her physician will be available for the delivery
- Avoiding the fear that some women experience related to the spontaneous onset of labor
- Ending of the pregnancy potentially two or three weeks earlier than awaiting spontaneous onset of labor
- The physician can better time delivery for a time that is more manageable and practical
What are the potential benefits to awaiting the spontaneous onset of labor?
Many would argue that a women’s body is brilliantly (even, “intelligently”) designed and that design includes the timing of labor and birth. Simply stated, nature knows best when labor should start. In fact, we still know precious little about the mechanisms that begin labor. It happens when it happens and that is most typically between 38 and 42 weeks of pregnancy. When labor begins naturally it allows all of the natural processes to proceed as designed. Labor typically begins slowly and then gradually progresses with contractions increasing in frequency and intensity over time. This natural progression can allow a woman to better cope with the discomforts of labor—something that is particularly important if she hopes to avoid using or minimizing the use of pain medications during labor.
Many patients tell me how exciting it was to experience the natural onset of labor. Many of those same patients have experienced both spontaneous onset of labor and induction of labor, comparing the two and favoring the spontaneous onset over artificial induction of labor. From a purely medical standpoint, the greatest advantage to avoiding induction of labor is the opportunity to avoid (or at least minimize) the main risk of induction: cesarean section and all that goes with it.
What are the more common methods used to induce labor?
The drug pitocin is used for the vast majority of labor inductions. Pitocin causes the uterus to contract and when given in a very carefully managed method can mimic natural labor contractions leading to delivery. In many cases, the cervix requires some degree of preparation or ripening in an effort to make the pitocin more effective. In these cases, medications such as cytotec and cervidil are often used. A balloon device may also be used to gently dilate the cervix in preparation for pitocin induction in some cases.
If the cervix is dilated sufficiently, it may be possible to rupture the amniotic membranes, also known as, “breaking the bag of water.” This can be done to assist with labor induction using pitocin and/or it can be the sole induction method used. Much has been written in the research journals about artificial rupture of membranes and whether it contributes to failed induction of labor and subsequent c-section. My perspective on this complex topic is this: if labor has begun, artificial rupture of membranes probably speeds the process along, at best, and has no effect, at worse. However, if labor has not yet begun and artificial rupture of membranes is performed, simply stated, there is no turning back; the patient is committed to delivery. Artificial rupture of membranes commits the patient to delivery, vaginal or cesarean, whereas prior to rupture of membranes it is possible to discontinue induction efforts and rethink one’s plan.
There are other less commonly used methods to induce labor such as the use of castor oil, and enemas, among others, but pitocin, cytotec, and rupture of membranes are by far the most commonly utilized methods.
So what are the most important take away points when considering induction of labor vs. awaiting spontaneous onset of labor?
- Understand why you are being induced. Is it for a medical indication or is it merely out of convenience?
- There is nothing inherently wrong with social induction of labor after 39 weeks given a “ripe” cervix and a well-informed patient.
- There are risks with induction of labor. The greatest risk is that a cesarean section will become necessary.
- If awaiting the spontaneous onset of labor is important to you, discuss it with your physician. Ask if he/she is willing to come in for your delivery even if not on-call that particular day or night. If not, what arrangements can be made for you to meet the physician(s) who cover for your physician when he/she is not on-call?
- Don’t feel pressured into a social induction of labor by well-meaning friends and family members. No matter how convenient it may seem, trying to force labor always has its downside.
- Discuss this and other important issues early and often during your pregnancy with your physician. You must play a critical role in managing your pregnancy and your healthcare. Your physician must be someone with whom you can partner to get the very best outcome for you and your baby.