“If we wait longer and the baby is too big, then we may have to do a C-section,” Tina Klonaris-Robinson remembers her doctor explaining. “She said, ‘I prefer for you to have an easier delivery and inducing will allow you to have that natural, vaginal delivery that you want.’”
“I had this feeling within me that said ‘no, don’t induce’ but then I thought, well she must know better,” she said.
Klonaris-Robinson was 38 and a half weeks pregnant with her second child when she was given Cytotec, a medication used to induce labor. At first, everything seemed normal as she started to have contractions. About 10 hours later she was given a second dose. Her contractions were coming much faster and now she had a sharp pain in her left side. “It went on and on, and I just kept saying, ‘Please, this pain doesn’t feel right.’”
“Two hours later, they finally listened and it was too late,” she said.
Her uterus had hyper-stimulated and tore top to bottom, front and the back. She was bleeding out and her daughter Meah was dead.
“I awoke to all my family members around me. They put her in my arms and she was perfect. Everybody was crying and they said we’re so sorry she’s gone.”
Induction methods
When labor doesn’t start naturally, there are many methods providers can use to get labor going. According to the Listening to Mothers Survey III, 30 percent of women had medically-induced labors between 2011 and 2012.
Pitocin, the synthetic version of the hormone oxytocin that a woman’s body produces to start uterine contractions, is the method most women think of. It’s given through an IV and dosage can be adjusted. Pitocin works best when the cervix is favorable—meaning it’s dilated, effaced (soft), and in an anterior position.
Some women worry that Pitocin could put stress on their babies, but it depends on how aggressively it’s given.
“There are a lot of ways that you can control it so it doesn’t stress the baby out,” said Dr. David Ghausi, an OB/GYN at Los Robles Hospital in Thousand Oaks, Calif.
There’s also a concern that Pitocin makes contractions very strong but it varies from woman to woman and could also be the case with natural labor, he said.
Another induction procedure is artificial rupture of membranes (AROM), which might help, although Pitocin is often given as well.
“If you break someone’s water in the hospital, it’s not a guarantee that you’re going to go into labor in the next hour or two hours,” Ghausi said.
Prostaglandin medications like Cytotec and Cervidil help to soften the cervix and in some women, it may also cause contractions. These medications may not work if the baby is preterm and if the cervix is not favorable. Unlike Cervidil, which can be removed if the uterus hyper-stimulates or the contractions are too close together, Cytotec dissolves in the body.
Providers can also insert a Foley catheter balloon filled with sterile water into the cervix to mechanically dilate it and cause a release of prostaglandins. Providers can also “strip the membranes,” by inserting a finger through the cervix and moving it side to side to release prostaglandins. This procedure can be painful and there’s no guarantee with either method that labor will start.
When is induction necessary?
For women with certain medical conditions like high blood pressure, preeclampsia, uncontrolled diabetes or placental abruption, induction is necessary for their health and the health of the babies. Another medical indication for induction is if the baby is not growing at a normal rate.
Experts agree physicians may also persuade women to be induced because their babies are measuring large, even though ultrasounds can have a margin of error up to 20 percent. In fact, women whose providers expressed concern about their baby’s size had babies whose weight on average 7 pounds, 15 ounces, according to the Listening to Mothers survey.
Some providers may also follow the rule “41 and done,” while others may wait longer.
Induction risks
As with any medical procedure, induction comes with risks. For starters, if a woman’s cervix is unfavorable, the risk of having a cesarean is 30 percent. If the cervix is favorable, the risk is the same as natural childbirth, Ghausi said.
Elective inductions before 39 weeks could pose problems for babies whose lungs are not fully mature. Other risks include fetal distress, infection for both mom and baby, umbilical cord problems, uterine rupture and hemorrhage. What’s more, a recent study out of Beth Israel Medical Center found that induction with Pitocin increased the risk that newborns would be unexpectedly admitted into the NICU and have lower Apgar scores.
Even though induction is meant to jump-start labor, it doesn’t necessarily speed it up. “You could be in the hospital 24, 36, or 48 hours before you have the baby,” Ghausi said.
Induction rates are on the decline, but still cause for concern.
“So you want to have the baby today?” Kerrie Hopkins of New York remembers her doctor asking during a prenatal visit on her due date, more than 10 years ago.
Hopkins arrived at the hospital and was quickly set up with Pitocin.
“The nurses said, ‘Wow, this doctor wants you to have this baby on his lunch hour,’” she said.
And sure enough, within two hours of her doctor’s appointment she gave birth. Since she had waited past her due date and had 17 hours of labor with her first child, Hopkins was grateful to have been induced.
“Anything to avoid pain—it was fabulous,” she said.
For other women, having an elective induction may not be medically necessary but their reasons may be equally as compelling.
Danielle Rothweiler of Shawnee, Pennsylvania had her water broken two days before her due date. She had two herniated discs and problems with her sciatica, which became worse during pregnancy. She had intense pain, used crutches to get around and couldn’t walk up the stairs.
“I just could not deal with the pain anymore,” she said. “I knew [from the doctor telling me] that the baby was going to be healthy so I knew it was important to get out of pain.”
After almost 20 years of induction rates on the rise, they are slowly declining. In 2012, 23.3 percent of women had induction, according to the Centers for Disease Control and Prevention (CDC). Elective inductions before 39 weeks have also declined, from 17 percent in 2010 to 4.6 percent in 2013, according to a survey by the Leapfrog Group.
Last year, The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine released new recommendations against induction before 39 weeks without a medical reason. A few weeks ago, the Association of Women's Health, Obstetric and Neonatal Nurses got on board by issuing the same guidelines.
“In my opinion, we need to do more. Forty weeks is just an estimated due date,” according to Dr. Michelle Collins, a certified nurse-midwife and director of the nurse-midwifery program at Vanderbilt University School of Nursing in Nashville, Tenn. Collins said the research shows that if women are not induced, most will go into labor at 41 weeks and one day.
What’s more, during natural labor, the baby’s brain sends a message to the placenta and the mother’s brain that it’s go time.
“It’s a very complicated biochemical process that has to happen and so when we bypass all of that and play Mother Nature, it doesn’t work so well,” Collins said.
Although most hospitals have policies against induction before 39 weeks without a medical indication, experts agree that some physicians still push for it and many women request it as well.
“If you sit down and discuss with them the risks and the benefits of waiting, all patients are fine with it,” Ghausi said.
As with any decision about pregnancy and childbirth, women should arm themselves with relevant information, advocates and supportive providers, and who will help them make the best choices for their families.
“The most important thing is to find a physician who will listen to them and who will be receptive to their wishes in labor,” Ghausi said. “There should be a dialogue between the patient and physician as to the reasons why and the risks and the benefits.”