**If you like information in an engaging movie format, check out my Medical Birth Lesson Package, where I cover the content below and much more**

This post has been inspired by conversations I've had with women about their induction experiences. Induction of labour is increasingly common, yet women often seem to be very mis-informed about what it involves, or what was done to them during induction and why. Usually there is zero information given about how an induced labour compares to a spontaneous labour. Women need to be given adequate information to make birth choices; and practitioners need to give adequate information to meet legal requirements. I have written about the risks of induction in a previous post so will not repeat myself here. Instead, this post aims to provide some basic general information about the induction process, what is done and why.

Making the Decision

The decision to undergo an induction of labour is the woman's. The care provider's role is to share evidence-based information and then support (not judge) the woman's decision.

Decision-making framework

I include a decision-making framework in my book Why Induction Matters, the following is an overview of the questions to consider:

Consider the reason that induction is being offered

• Is your situation a complication or a variation?
• What are the complications associated with your situation?
• Will inducing your labour reduce the chance of these complications occurring?

Consider the experience of induction

• What were your thoughts about labour before an induction was offered?
• How will the induction process alter your previous expectations about your labour?
• What are the risks of induction in your situation?
• What are your thoughts about alternative methods of induction?

Consider the alternative options to induction

Waiting for spontaneous labour:

• What are the risks of waiting for spontaneous labour?
• Is there anything you can do to reduce these risks?
• Will additional monitoring help to identify a complication early?
• How do you feel about additional monitoring?
• What are your boundaries and thresholds about waiting?
• What support will you have from family and friends while you wait?

Planned c-section:

In some scenarios (eg, fetal growth restriction) a planned c-section may be an alternative option. This requires a discussion about the risks of surgery vs induction vs waiting.

Before agreeing to induction

There are a few things you need to be clear about before choosing to be induced:

1. You consider the risks involved in continuing the pregnancy greater than those involved in induction (risk is a very personal concept).
2. You are well informed about the process and medication involved (read the patient information leaflets for medication details).
3. You are committed to getting this baby out. Once you start, you can't back out, and a c-section is recommended for a 'failed induction'.
4. You are aware that you are not having a physiological birth. You have intervened, creating risks that require further monitoring and intervention. There is no such thing as a 'natural' induction, vaginal birth maybe, empowering perhaps, but not physiological.

An induced labour is very different to a spontaneous labour, from start to finish. That is why I have an entire lesson comparing induction with spontaneous labour in my Medical Birth Lesson Package. It is important to understand the difference to optimise the experience and outcome of an induced labour.

The Induction Process

Induction of labour involves artificially causing labour to happen, rather than waiting until the baby/body initiate labour. There are three steps to the induction process. You may skip some of the steps along the way, but you should be prepared to buy into the whole package when you embark on induction.

Note: If your waters have broken naturally, the term 'augmentation' rather than 'induction' is used because it is assumed that your body has started the labour process itself. You can read more about this situation here.

The success of an induction is influenced by whether the mother and baby have begun preparing the body to respond to labour hormones. This is more likely closer to term, when the woman would naturally go into labour herself. So, before looking at the three steps of induction, here is a reminder of how the body prepares for labour.

Step 1: Preparing the Cervix

During pregnancy the cervix is closed, firm and tucked into the back of your vagina. This means that you can have contractions without the cervix opening. For the cervix to respond to contractions, it needs to make a number of complex physiological changes. Relaxin and oestrogen initiate these structural changes, and prostaglandin, leucocytes, macrophages, hyaluronic acid and glycoaminoglycans are all involved in softening the cervix ready for labour. You don't need to remember all of this scientific stuff, all you need to know is that it is a complex process, and prostaglandins are only one piece of the puzzle. However, prostaglandins alone are the focus of the induction process. All of the interventions aimed at preparing the cervix for labour (ripening) either stimulate the body to produce prostaglandins, or introduce synthetic prostaglandins. Prostaglandins are part of the body's inflammatory response.

When you are being induced your cervix will be assessed by vaginal examination. If your cervix has already changed and is soft and open enough to get an amnihook in, you can skip straight to Step 2. If your cervix is still firm and closed, attempts will be made to change it so Step 2 is possible. If not, interventions are carried out to ripen the cervix by increasing prostaglandins.

Pharmaceutical methods of cervical ripening

This involves applying artificial prostaglandins (prostin E2 or cervidil) to the cervix as a gel, pessary or sticky tape. Artificial prostaglandins can cause hyperstimulation of the uterus resulting in fetal distress, therefore your baby's heart rate will be monitored by a CTG before and after the prostaglandin is administered. You may also experience 'prostin pains' which are sharp, strong pains, sometimes accompanied by contractions.

Mechanical methods of cervical ripening

Some practitioners offer routine membrane sweeps during pregnancy to induce labour and avoid a prolonged pregnancy. The procedure involves a vaginal examination where the practitioner places a finger into the opening of the cervix and 'sweeps' it around the inside of the lower part of the uterus. The aim is to separate the membranes of the amniotic sac from the lower uterus, which releases prostaglandins. A Cochrane Review into membrane sweeping concluded, "Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects." [1]

Another mechanical method involves inserting a balloon catheter into the cervix and filling it with water, so that you have a water balloon sitting in your lower uterus. This irritates the cervix and releases prostaglandins. It can also push the baby's head upward and increase the risk of cord prolapse or malposition.

Successfully completing Step 1 may take a few attempts with re-inserting prostaglandins or repeating the mechanical methods. This can take hours or days because you must wait hours before re-assessment and re-insertion. If your body is ready to go, you may respond to the prostaglandin by going into labour, therefore skipping the following steps. However, you are still having an induced labour and will usually be treated as 'high risk'.

Step 2: Breaking the Waters

Your waters will be broken once your cervix has softened and is open enough to get an amnihook in. This allows induced contractions to be more effective; the baby's head to press harder on the cervix; and may trigger contractions for some women avoiding Step 3. It can also reduce the risk of amniotic embolism (amniotic fluid getting into the blood system) which is a rare risk associated with induction. There are risks associated with artificially breaking the waters. Once your waters have been broken, you can wait a few hours to see if labour starts, or go straight to Step 3.

NOTE: Step 2 is not always part of the induction process in the US.

Step 3: Making Contractions

You now have a cervix ready to respond to contractions and no amniotic fluid in the way, next you need contractions. In a natural physiological labour, oxytocin is released from the brain and enters the bloodstream - it has two main functions:

1. It works on the uterus to regulate contractions
2. It works in the brain to contribute to the altered state of consciousness associated with labour and promotes bonding feelings and behaviour

In an induced labour, artificial oxytocin (Pitocin / Syntocinon) is given via a cannula directly into the blood stream. It cannot cross the blood brain barrier, therefore only works on the uterus to regulate contractions.

The following are slides from my lesson Induction vs Spontaneous labour (in my Medical Birth Lesson Package) explaining the difference between natural oxytocin and artifical oxytocin:

I have written about the risks associated with artificial oxytocin here along with references. Essentially, Syntocinon/Pitocin is a very risky medication and is the most common cause of fetal distress in labour. Therefore, your baby will be monitored closely using a CTG. Women usually describe artificially stimulated contractions as being different and more painful than natural contractions. Having supported women during inductions, I am also convinced there is more pain associated with induced contractions. During an induced labour, the contraction pattern and intensity increase quickly compared to most natural labours. Women are not able to slowly build up their natural beta-endorphins and oxytocin in their brain to reduce their perception of pain. In addition, the circumstances and environment that often surround induction (intervention, equipment, etc.) can result in anxiety, increasing the perception of pain.

Once your baby is born, you will need to continue using artificial oxytocin to birth the placenta. A physiological placental birth is not safe because you are not producing natural oxytocin at the level required to contract the uterus strongly and prevent bleeding.

In Summary

Inducing labour involves making your body/baby do something it is not yet ready to do. Before agreeing to be induced, be prepared for the entire package, ie, all the steps. You may be lucky enough to skip one step, but once you start the induction process you are committed to doing whatever it takes to get the baby out. An induced labour is not a physiological labour and you and your baby will be treated as 'high risk', because you are. However, understanding the induction process can improve the experience of an induced labour, minimise risks and improve outcomes.

Further Resources

You can find more information on this topic in my Medical Birth Lesson Package or Reclaiming Childbirth Collective.

Search this blog for more posts about induction (click on the tag induction).

Related podcast episode:

Reference

1. Cochrane Review (2020) Membrane sweeping for induction of labour