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Inductions seem to be on the rise as the percentage of inductions has risen by almost 10% from 2007 to 2017(25.5%), with a more recent study finding that 31.37% of births were inductions.(1,2) Some estimates are that induction rates are as high as 50% of all labors.
There are conflicting opinions and philosophies about the advantages and disadvantages of inductions, and you may be surprised by how conflicting the most commonly referenced research is as well. Thankfully, many people, particularly doulas and midwives, have taken up the charge of siphoning through existing research and sharing their own and others’ experiences to help us arrive at some common understandings. Below is an introduction to inductions made possible by that work.
What is an Induction?
An induction is a process that attempts to start your labor artificially, either by using medications (such as Pitocin, Cervadil, or Cytotec), or other mechanical methods (such as a membrane sweep, artificially breaking your water (AROM), or a foley balloon). Some of these methods can be used after spontaneous labor contractions have begun, which is called augmented labor rather than induced labor. Induced labor typically starts with cervical ripening followed by artificially inducing labor contractions.
When is the safest point in pregnancy for the baby to be born? Just as infants reach developmental milestones like rolling over or crawling at different times, every baby is ready to be born at a slightly different time. The most reliable sign that the baby is ready to be born safely is when labor begins on its own at full term. (5)
Before beginning an induction, your provider should assess your body's readiness for an induction. They do this by giving you a cervical exam and assigning you a Bishop Score. Based on your cervix's readiness, you will be assigned a score of 0-13.
If you’re curious, here’s some more information on the methods for cervical ripening and bringing about contractions:
Cervical Ripening
Membrane sweep: loosens the amniotic sack containing your water
Cervical Osmotic Dilators (brand name = “Dilapan-S”): these are thin rods inserted through the cervix that expand and stretch the cervix as they absorb water from the surrounding tissue.
Foley Balloon: this method emulates the pressure of a baby’s head, causing the cervix to stretch and cervix-ripening hormones to be released. There is a double-balloon option, but it is not shown to be more effective and causes more discomfort.
Misoprostol (brand name = “Cytotec”): this drug is the synthetic analog of prostaglandin, a hormone that helps ripen the cervix. It can be taken orally or vaginally.
Dinoprostone (brand name = “Cervidil”): this drug is synthetic prostaglandin, but is thought to be the same as natural prostaglandin. It can be slowly released through an insert attached to a string, similar to a tampon in shape . It can also be given as an intracervical gel that releases the drug more quickly (brand name = “Prepidil”).
Contractions
AROM/Amniotomy: the provider uses a small hook to break your water, placing more pressure on the cervix and releasing natural oxytocin to increase contractions. It is not usually used in isolation, meaning it is more commonly used alongside other induction methods like oxytocin.
Oxytocin (brand names = “Pitocin” or “Syntocinin”): oxytocin is a synthetic version of…well…oxytocin, a significant hormone for labor that contributes to bonding, attachment, and inducing contractions. It is administered through an IV. According to Evidence Based Birth, 1 in 3 people are given Pitocin to speed up their labor.
One of the biggest unknowns of induction is how it affects labor hormones that occur naturally. Here is a video about the hormones involved in labor and some of the effects that induction may have:
As with many aspects of labor, it can be helpful to know what exactly providers are offering you, the benefits and drawbacks of the method, and what other options are available. This is no small task, especially considering there are seemingly three different names for every drug and procedure. These are all questions your doula can help you answer before or during childbirth.
Even without a doula, anyone offered any of these induction methods should be able to ask questions about the procedure and its purpose. You and your team may want to ask questions like:
“ Will you, my provider, push for more interventions if my labor is longer?
How do you define induction 'failure'?
If the induction ‘fails’, will you push for a cesarean?
Do we have time to wait or try other strategies before starting induction or augmentation methods?”
Here are four common reasons cited for being offered or choosing an induction:
Full Term, Late Term, or Post Term Pregnancy
The American College of Obstetricians and Gynecologists follows a 2013 study’s definition of these periods:
Early term: 37 0/7 weeks of gestation through 38 6/7 weeks of gestation
Full term: 39 0/7 weeks of gestation through 40 6/7 weeks of gestation. “Approximately 58% of births occur within this 2-week timeframe.”(3)
Late term: 41 0/7 weeks of gestation through 41 6/7 weeks of gestation Postterm: 42 0/7 weeks of gestation and beyond
Early Term Inductions: Although it was practiced in the past, induction for early-term birthing people (before 39 weeks) is not recommended. Many providers no longer offer this as it is not evidence based.
Full Term Inductions: People who are full term may elect to induce their labor (eIOL) at 39 weeks of after. This may be to reduce the risk of cesarean; however, there are many methods that can be utilized to reduce the risk of cesarean that do not include induction and are more effective. These alternatives include intermittent hands-on listening rather than electric fetal monitoring, continuous labor support/a doula, walking around during labor, staying hydrated, and having a water birth. A recent study cited in support of 39 week inductions is the ARRIVE study. This study found induction at 39 weeks did not improve outcomes of serious complications for babies. However, for first-time, low risk birthing people “induction at 39 weeks was linked to a lower rate of Cesarean compared to those assigned to expectant management (19% Cesarean rate versus 22%) and a lower chance of developing pregnancy-induced high blood pressure (9% versus 14%).”(4) When someone has high blood pressure at full term, induction can “[reduce] the chance that the [person] will develop severe high blood pressure or related complications.”(5) Other research has been published contradicting the ARRIVE trial since 2018. Researchers hypothesize that one reason that the ARRIVE trial was different is because everyone in the study was given true informed consent, and once they knew the risks of induction, 76% of people dropped out.
Late Term & Post Term: Two robust 2019 studies found that induction at 41 weeks might produce better outcomes for the baby than waiting until 42 weeks+. There is also a lower risk of cesareans and stillbirth when induced during 41 weeks rather than 42. The ACOG states that “the health risks for you and your fetus may increase if a pregnancy is late term or post term, but problems occur in only a small number of post term pregnancies. Most women who give birth after their due dates have uncomplicated labor and give birth to healthy babies.”(6)
So, what’s the worry?
Post term births have been linked to…
Macrosomia - larger baby (9-10 lbs)
Still birth (3)
39 weeks = 4 per 10,000
40 weeks = 7 per 10,000
41 weeks = 17 per 10,000
42 weeks = 32 per 10,000
Post maturity syndrome - may include macrosomia and issues due to umbilical cord loss of functionality (nutrients and oxygen) and meconium. May cause dry skin, long lean figure, scalp hair, over grown nails.
Meconium passed by the fetus getting into their lungs
Decreased amniotic fluid, which can cause the umbilical cord to pinch and restrict the flow of oxygen and nutrients
& For the birthing person
Increased risk of infection
Increased risk of postpartum hemorrhage
For Health Issues
Water Breaking
Suspected Big Baby
Failed Inductions
The American College of Obstetricians and Gynecologists says that early labor can last 24 hours or more if there are complications, and oxytocin can be given for 12-18 hours after the water breaks before an induction is deemed to have failed. However, there is no set standard for when an induction has “failed” other than the fact that the person did not reach 6cm. Evidence Based Birth describes that, if your membranes are intact, you could go home if your induction fails and wait for spontaneous labor to start or reschedule your induction.
Why Do People Try to Avoid Inductions?
Inductions can be long and grueling. Most people who are induced have an increased hospital time and some studies also indicate an increased risk of unplanned cesarean.(9) Here are some of the reasons why people may avoid inductions:
Misalignment of Evidence: The evidence on inductions for various stages and circumstances has contrasting findings and gaps, leading to skepticism over when it is beneficial or necessary.
IV and Fetal Monitoring: being connected to an IV or electric fetal monitor can make it harder to be mobile, which is one of the best ways to aid labor. Additionally, many hospitals follow non-evidence-based practices of restricting what birthing people can eat or drink during induction.
Health Concerns: the ACOG notes that ”the risks of labor induction may include changes in fetal heart rate, infection, and contractions of the uterus that are too strong…The method used to induce labor may need to be repeated. In some cases, you may need to have an assisted vaginal delivery or a cesarean delivery.”(6)
What can you do?
Try to choose a provider and birth space that has a lower induction rate.
Hire doula and take childbirth education classes.
Try to calculate an accurate EDD: “An EDD is often calculated from the first day of the last menstrual period, which assumes the woman’s menstrual cycle is 28 days long. If your cycles are longer or shorter than 28 days, or if they are irregular in length, tell your care provider. An ultrasound early in pregnancy can provide a more accurate estimate of your EDD. A later ultrasound is not a good way to estimate your due date.” (5)
Advocate for your birth plan, knowing that your opinion may change with the circumstances, and that is more than okay.
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