The induction talk
Patience Is a Virtue
To induce or not to induce? There are times when it’s medically necessary to induce because it is safest for mother or baby (or both!). However, if you’ve heard about the ARRIVE study you might have some questions about the benefits and risks associated with an elective induction.
The ARRIVE study (A Randomized Trial of Induction Versus Expectant Management) looked at whether inducing at 39 weeks would decrease the rate of c-sections and adverse outcomes for mothers and babies compared to women who went into labor spontaneously or were induced after 40 weeks and 5 days.
The results: Inducing labor at 39 weeks did not improve the primary outcome of death or serious complications for babies. For mothers, 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%).
The ARRIVE study found that inducing low-risk women may help to lower the Cesarean rate from 22% to 19% if care providers follow the same induction practices as they did in this study. The induction protocol in the ARRIVE study allowed women plenty of time to get into active labor before opting for c-section.
Do women want to be induced?
In the book, Optimal Care in Childbirth, the authors reviewed the literature to see if women are pushing for inductions. They found that 75% of women who chose an elective induction indicated they did so because their provider suggested it. Only 25% of women said an elective induction was their own idea. In the ARRIVE study 73% of eligible women refused to participate in the study because they wanted to avoid an elective induction. Women are not routinely asking to be induced but consider it because their provider suggested it.
If you’re interested in an elective induction I would first talk to your provider about their induction protocol. Time (and then more time) is key to a successful induction (well, that an a ripe cervix!). A fast induction is not safer or more effective than an induction that takes more time. Fast inductions have been associated with uterine hyper stimulation and abnormal fetal heart rate without improving c-section rates.
Best Practices for Induction:
-Cervical ripening if patient has an unfavorable cervix (Bishop score of less than 5).
Cervical ripening agents include: balloon catheter, Cervadil, or Cytotec. These agents can each take around 12 hours to ripen the cervix. They can be used together or separately.
-12 hours in early labor (early labor is when the cervix closed-4cm dilated) before diagnosing “failure to progress”.
How to reduce your risk of a c-section:
-Use a midwife. Hospitals with 40% of their deliveries attended by a midwife had a much lower c-section rate (15%).
-Ask you provider what their personal c-section rate is AND what the hospitals c-section rate is.
-Have continuous labor support like a doula.
-Move around during labor!
-Ask about intermittent fetal monitoring.
How to advocate for optimal care when term:
-Discuss with your provider the rational for fetal surveillance testing if you are a healthy woman .There is a high false positive rate with fetal monitoring near the end of pregnancy that leads to unnecessary inductions.
-Unless there is a high risk scenario, avoid elective inductions prior to 41 completed weeks of pregnancy.
-If your cervix is unfavorable, be patient. Give yourself more time. Walk, squat, drink red raspberry leaf tea, have sex, and be patient!
How to advocate for optimal care during an induction:
-If possible, ask for a cervical ripener if your Bishop score is less than 5.
-If your cervix is favorable it is ok to proceed directly to oxytocin. Oxytocin has a very short half life and can be easily titrated to the appropriate dose for you and your baby. Your provider should follow an evidenced-based oxytocin dosing interval (gradually increased by 1-2mU/min every 30-60 minutes. An infusion rate of 6mU/min give the same oxytocin levels found in spontaneous labor). Request oxytocin be decreased or turned off once in active labor.
-Request to wait on breaking your bag of water. If your water is broken, request limited vaginal exams.
-Have patience! If your birth team is rushing you or you feel pressure to “just have this baby already!”, ask your birth team (provider or nurse) if there’s any medical indication for things to be moving faster than they are. Are your vital signs stable? Is baby’s heart rate reactive? Has your water been broken for longer than 24 hours? If everything is stable patience is key!