Inductions: What Do I Need to Know?
Are you 38 weeks pregnant and your provider has brought up the idea of an induction? If yes, then this blog is for you. Many other mothers may be having the same questions and conversations with their providers. The American College of Obstetricians and Gynecologists (ACOG) reports that 20 to 40 percent of pregnancies are induced. This blog will provide you with some insight into what an induction is, why providers may recommend them and what induction options mothers have if they choose to go that route.
What is an Induction?
Induction of labor refers to the use of medications or other methods to induce, or cause, labor. This practice is used to make contractions start so that delivery can occur.
Many inductions occur after 39 weeks unless there is a risk to the mom or baby prior.
Not all providers will recommend inductions at 38 weeks if the biophysical profile is where they would like to see it, some may chose to wait it out.
According to evidence-based birth, an induction that is done by 41 weeks can reduce stillbirths and poor health outcomes for babies, especially in first-time, older, and plus-size mothers.
What is a biophysical profile?
According to ACOG between 32 and 34 weeks your provider will complete a biophysical profile that is done to check the good health of the baby. The term “non-stress” means that during the test, nothing is done to place stress on the fetus. The biophysical profile is scored and depending on how far along you are in your pregnancy, you may have another BPP within the next 12–24 hours, or it may be decided to do an induction if the score is not as high as it could be.
Informed Consent
If you are approaching the 40-week mark with no signs of labor and with no other pressing factors like high blood pressure, gestational diabetes, or baby’s size you can stick to multiple weekly check ups rather than an induction initially. Your provider will continue to check your BPP to see what the best option will be. Would you want to schedule an induction or wait and see what happens with your biophysical score? This is where the acronym B.R.A.I.N. could come in and be beneficial. Look at all of the aspects going into this decision like risks, alternatives and benefits while doing what is best for you and your family.
Reasons for an Induction
The American College of Obstetricians and Gynecologists has several reasons an induction may occur:
The baby is 1 to 2 weeks overdue
Baby's weight or size
Decrease in amniotic fluid
Pre-labor or premature rupture of membranes, meaning water is broken before labor contractions start
High blood pressure or another condition that’s a threat to you or your baby’s health
Gestational diabetes or diabetes mellitus before pregnancy
Mother has health problems, such as problems with your heart, lungs, or kidneys
Baby needs medical treatment, but the risks of vaginal delivery are low
If other risks to you or your baby would be reduced if your baby was delivered
What is a Bishop Score?
The bishop score is used by your provider to assess the readiness of the cervix for labor.
In this scoring system, a number ranging from 0 to 13 is given to rate the condition of the cervix. A score less than 6 can mean that your cervix may not be ready for labor.
1. Dilation: How open or dilated the cervix is
2. Length (effacement): How short and thin your cervix is, the shorter the better in this instance, some providers use numbers or percentages for this section of the Bishop score.
3. Consistency: The texture of the cervix during the exam, a firm cervix has a consistency similar to the tip of the nose, while a soft cervix has a consistency similar to the lips of the oral cavity.
4. Position: The position of the cervix relative to the fetal head and maternal pelvis.
5. Head station: The position of the fetal head relative to the ischial spines of the maternal pelvis. At zero station, the fetal head is at the level of the ischial spines. As a fetal head makes its descent, the station changes from -3, -2, -1, 0, +1, +2, +3.
What Comes After a Bishop Score Assessment?
If a cervix has a bishop score of at least 8, induction of labor is likely to result in vaginal delivery, and any method of induction tends to work well. While any method can be successful, the most common for a bishop score of 8 or greater are an amniotomy or an IV administration of Pitocin/oxytocin.
If the Bishop score is under 8 there does not appear to be a superior method. The provider will focus on cervical ripening, a process that helps the cervix for labor, there are two categories for cervical ripening, prostaglandin use, and mechanical methods. Prostaglandins and mechanical methods can be used together.
Prostaglandins are a medication that can be given vaginally or orally to a patient with an unscarred uterus that can help the cervix progress to a more favorable Bishop score in 12 to 24 hours.
Some prostaglandins are not used if you have had a previous cesarean birth or other uterine surgery to avoid increasing the possible risk of uterine rupture (tearing).
Foley Bulbs and cook catheters are very similar in regards to both being balloon catheters, where they differ is the cook’s catheter has two balloons that go on either side of the cervical opening and a foley bulb is only one balloon.
The pressure of the balloon on top of the cervix also stimulates the release of natural hormones that promote cervical ripening.
According to Evidence Based Birth, researchers have found that the double-balloon catheter is no more effective than the single-balloon Foley catheter.
Different Medical Induction Options
If the cervix is not softened
Use medication to ripen your cervix for delivery like prostaglandins.
Open it manually, using a narrow tube with a balloon at the end also known as a balloon catheter. At Least 1 cm dilation is necessary for use of a balloon catheter.
Some dilation of the cervix
Sweep the membranes using a finger to separate the amniotic membrane from the uterus, once done this can cause contractions naturally.
Amniotomy (AROM) is the rupturing of the amniotic sac with a small, sterile tool that is used to break the water to induce labor.
Balloon catheters like Foley bulb and Cook’s catheters as previously mentioned above.
IV infusion of Pitocin, which is a synthetic version of oxytocin, a hormone your body makes naturally that triggers contractions, the epidural should be given when Pitocin is administered if you choose this method.
Pitocin may not be an effective method for first or second-time mothers
Use an oral or vaginal pill to help soften your cervix and start contractions.
Cervidil is an FDA-approved drug that softens the cervix and is administered vaginally around the cervix.
Cytotec also known as misoprostol is not FDA-approved but is effective and is administered vaginally or orally.
Pros and Cons
Pros
Mothers can have more of a choice when it comes to provider preference when scheduling an elective or nonelective.
This may lower the risks of further health concerns regarding hypertension and preeclampsia.
For mothers, induction at 39 weeks was linked to a lower rate of Cesarean births compared to expectant management (19% Cesarean rate versus 22%).
Cons
According to ACOG, some induction methods can cause the uterus to be overstimulated, causing it to contract too often. Too many contractions may lead to changes in the fetal heart rate.
Other risks of cervical ripening and labor induction can include infection in the woman or her fetus.
Things to Remember
Up to 40 percent of pregnancies are induced, you are not alone and others have many questions just as you might. Remember these few key aspects when thinking about inductions and also ask your provider about any specifics to your experience. The process may not be as quick or as easy as expected or it could be the opposite, everyone has their own experiences. Keep an open mind, not all moms plan for inductions! There are three main things for a stress-free induction, the first thing is the sequence of induction tools, your provider may have their order but knowing what may come allows for planning. Next, there needs to be a thorough assessment of the baby and mom by the provider to ensure an induction is the best approach and lastly, patience is key.