#33 Inductions

There are many reasons for induction of labor. These include hypertension, babies that are large or small for gestational age, women who do not deliver by their 42nd week of pregnancy, fetal death, and abnormal fetal heart rate patterns. But there are conditions in which induction should not be undertaken. These include abnormal presentation, fetal distress, placenta previa, prolapsed cord, women who have had a previous c-section with the classical scar running from the pubic bone up toward the naval, ruptured uterus, and a normal preterm fetus.

Inductions for logistical reasons has become more common and more accepted with the advent of obstetric deserts, most of them in rural areas. With the disappearance of obstetrical services in rural areas and the rural hospitals which opt to no longer delivery babies, there is some value in induction if we consider that some women live 100 miles from a hospital which will deliver babies. In North Dakota, that could mean delivering a baby in a car when the outside temperature is 30 below, which could in itself be deadly. I have long supported obstetrical hotels in hospitals where women who live a hundred or two hundred miles from their birthing center could stay for a short time until their labor begins.

For induction to work well, the cervix needs to be favorable, that is, soft and thinning. If the cervix is unfavorable, there are some preparatory treatment options including prostaglandins and laminaria to prepare the cervix for induction and delivery called cervical ripening.

If the cervix is favorable but there is no labor or early labor, cervical sweeping, a form of induction, can be done. With cervical sweeping, your doctor inserts a gloved finger into your cervix and runs it around the cervical opening to loosen your amniotic sac from your uterus. In doing this, your doctor helps release prostaglandins, the hormones which helps soften your cervix and prepare your body to deliver your baby. This procedure can be painful and might be associated with some bleeding. Cervical sweeping should be done with a favorable cervix, near term, and in the absence of placenta previa or an abnormal presentation. Although many doctors use and like cervical sweeping, I feel that there is an increased risk for infection of the cervix, especially if the procedure is performed before labor starts.

The most common form of induction is done with IV oxytocin (Pitocin) because it is short acting and therefore easily and quickly undone. If the Pitocin is stopped because of fetal distress or too many contractions, the problem is relatively quickly resolved because the Pitocin doesn’t stay in the blood stream very long. It is important to be able to rescind medications quickly in inductions should complications arise.

Normally, in order to get an effective contraction with Pitocin, you will be given enough Pitocin that you will be unable to stand the pain of the contractions, and you will have to have an epidural. If this is what you want, you may be satisfied with the induction and the epidural. Some women really don’t want to undergo the pain of labor contractions, although without Pitocin, most women can tolerate the pain or a normal contraction. Plus, with natural labor, the contractions don’t last as long and although painful, they are less painful than contractions from Pitocin.

There are many concerns to be addressed with induction. I recommend patients talk to their doctor about cervical ripening vs. the need for epidurals, which are common with Pitocin inductions. You have many choices in labor and delivery, but my experience leads me to believe the less intervention in labor and delivery, the better.