You’ve been counting down the months, weeks, and now days until that extra special date… and now your due date has passed you by. For most moms, the last month of pregnancy can be trying – they are uncomfortable, bigger than they’d like to be, and anxious to get back to normal life (or whatever the new normal will be with a newborn!).
But by some accounts only 5% of women go into labor on their due dates, and other studies have found that due dates are often miscalculated by five or more days. And the average first-time mother goes into labor spontaneously 8 days AFTER her due date. Which is to say, you (and your doctor) can’t easily predict when you’ll have your baby.
Cue induction conversation! This is the moment when a doctor or midwife will begin to discuss a mom’s options with her, and honestly, the options are varied and confusing: as a parent, it can be hard to determine when to intervene and when to wait. I’ve compiled this guide for my clients and readers as a way for them to weigh the options and decide for themselves what they prefer for themselves and their baby.
NOTE: I AM NOT A MEDICAL PROFESSIONAL. I DO NOT RECOMMEND ANY OF THESE METHODS FOR YOU PERSONALLY, AND YOU SHOULD ALWAYS DISCUSS ANY MEDICAL DECISION WITH YOUR CARE PROVIDER.
First off, you should know that determining your “bishop score” is a helpful tool (though not a flawless tool) to predict how an induction will go for you personally. You can see the attachment “Bishop Score” to judge your score.
You receive a “score” for each box that applies to you – if your cervix is dilated (opened) or not dilated (closed), you receive a score of 0 to 3. If your cervix has effaced (shortened) or is still thick, you receive a score of 0 to 3. You receive a score based on whether your baby is low or high in your pelvis, whether your cervix is facing back (posterior) or forward (anterior), and whether your cervix is firm (not ripe) or soft (ripe).
Each of these things indicate whether your body is preparing for labor or not. The higher your score, the more prepared your body is for labor, and the more likely that your body will respond to an induction (in which case, your body just need to be tipped over the edge into spontaneous, active labor). Often the cervix ripens, moves forward, and shortens before any dilation occurs, particularly in the case of first-time mothers.
At this exact moment, if you are a first-time mom who has experienced no noticeable contractions, you most likely have a score of zero. In that case, your cervix is probably firm, posterior, un-effaced and closed, and your baby is probably still quite high in your pelvis. Most first-time mothers experience slight cervical change before the start of early labor, and then throughout an extended early labor, their cervix does the majority of change to prepare for the dilation stage of labor. (Of course, this is not the case for every first-time mother.)
If you are a second- or third-time mother (or more!), most likely you have a higher score and a higher likelihood that an induction will “push you over the edge” into active labor.
Either way, I recommend that you ask your doctor to give you an assessment at your next cervical exam. Ask specifically for your bishop’s score, as this will give you an idea of how successful an induction might be for you.
REASONS FOR INDUCTION – AND ITS RISKS
Sometimes there are reasons to do an induction that are completely necessary (for example, if there are signs that mom’s placenta is no longer healthy, if non-stress test results reveal that a baby is not doing well, or if mom’s health is in any danger).
Sometimes it is unclear why an induction is being suggested. For that reason, it’s always helpful to ask exactly why your doctor is recommending an induction for you and your baby and to ask what other options you have – especially because many parents are not crazy about the idea of induction and its risks. One big risk for first-time moms who get induced is that the cesarean rate goes up from 30% to nearly 50%!
One reason induction is suggested is for a mother who has passed her due date. Unfortunately, the science does not support inducing a healthy pregnant mother and her baby simply because she’s still pregnant beyond the 40-week mark. As I discussed above, due dates can be inaccurate, and so arbitrarily setting a labor date via induction or scheduled cesarean based on a possibly inaccurate number could be harmful – and in fact, in general, the science shows that it is safe to remain pregnant up until 42 weeks (and possibly longer, though other risks rise after 42 weeks).
HOME INDUCTION METHODS
You can try these methods at home, though I do recommend you discuss any medical decision with your care provider. Remember that every intervention – both natural and chemical – has risks and benefits to both mother and baby. Please do your research and ask questions to determine exactly what the risks and benefits are to each method described.
Sex & Nipple Stimulation
Both sex (with orgasm) and nipple stimulation produce the h0rmone oxytocin (AKA the “love” hormone) – this is the hormone the sustains labor and causes contractions. Consequently, any natural boost of that hormone may cause contractions, and in the case of an already ripe cervix, could push a pregnant woman over the edge into labor. Additionally, semen has high concentrations of prostaglandins, hormones which encourage ripening of the cervix.
Nipple stimulation can also be helpful for restarting a stalled labor or for making contractions longer and stronger in a slow-to-intensify labor. However, in order to be effective, nipple stimulation should be done for two hours at a time to receive any sustained benefit (which is quite a commitment since it’s rather uncomfortable to do, in spite of the fact that it sounds sexy!).
Any sort of movement irritates the uterus, which increases the production of the labor-starting hormones. Movement in the midst of labor is also critical for helping labor contractions to continue and to be effective. Additionally, movement allows your baby to rotate easily in your pelvis and to find the ideal position for your baby’s big entrance!
You may be surprised to hear it, but a recent scientific study found that eating dates shortens labor. In fact the active labor stage (the dilation stage) in those pregnant women who consumed 6 dates a day in the four weeks leading up to their birth was, on average, SEVEN HOURS shorter than the active labor stage of those who did not eat dates. Um, so then why in the world wouldn’t you eat a whole truckload of dates to prepare for labor?
Consumption of Various Herbs
There are various herbs that have long been used to help prepare women’s bodies for labor and to induce labor. Evening primrose oil is said to help ripen the cervix; red raspberry leaf, and black and blue cohosh are said to stimulate the uterus. I have known people who have had success with herbal tincture formulas as a way to prepare their body for labor (like Gentle Birth formula).
Red raspberry leaf tea, in particular, has been proven to be effective in toning the uterus (i.e., giving your uterus daily workouts before the “big day”), and to benefit the outcome of your birth. One study showed that women who drank red raspberry leaf during pregnancy were less likely to receive an artificial rupture of their membranes (breaking of the waters) and were less likely to require cesarean section, forceps, or vacuum deliveries (it was a small sample size, but still an amazing finding!).
As a doula, I’m not qualified to give you dosages or recommendations about this in particular, so I recommend you discuss any plans you have to take herbal formulas in preparation for labor with your care provider.
Castor oil is a diarrhetic that stimulates the intestinal tract, which, by proxy, stimulates the uterus and causes an increase in the production of labor-starting hormones. One study found an increased likelihood of a spontaneous labor within 24 hours of pregnant women taking a dose of castor oil. Many women who take castor oil find the labor experience to be unpleasant – imagine having the flu while you’re in labor! – but it does seem that if you take a conservative dose of castor oil, the other side effects (diarrea, sometimes vomitting) are less severe, and labor often starts on its own. In my experience, it seems to have often be a similar labor experience to taking a drug like cytotec (the drug stimulates the uterine muscles in the way that castor oil seems to stimulate the intestinal muscles).
I often hear folks talk about acupressure (pressing particular pressure points for a certain amount of time) as a way to stimulate labor contractions, though in my experience, this has not been an effective way to start labor.
Chiropractic Care & Exercises
Occasionally, a baby’s particular position might be the cause of a delayed spontaneous labor, simply because the baby’s head is not providing the right amount of pressure onto the cervix to cause it to open and to release necessary hormones to start up labor. This can often be the case for second- or third-time mothers who are experiencing prodromal labor (nonprogressing labor), whose abdominal muscles are less firm than first-time mothers – making it more difficult to hold baby in the optimal position! (Note: I don’t have studies to back up these claims – just experience for this one). For these moms, I also recommend regular visits to the chiropractor, who can help align your body in such a way that the baby is positioned well and putting even pressure on the cervix. You can also do particular exercises and stretches to encourage your baby to get comfortable in a great position. (Read more at the link below).
HOSPITAL INDUCTION METHODS
Many doctors and midwives will begin inductions in the least interventive ways first. If they do not suggest nonchemical options with you, be sure to ask why and whether those could be helpful alternatives in your particular case.
They usually make sure the cervix is ripe (by doing membrane sweeping, using the foley bulb, or by administering cervical ripening drugs), and then they introduce synthetic oxytocin, the contraction stimulating drug. The process is usually S L O W – think 1-3 days – and once labor begins, it is possible you will still have a long slog ahead of you. (So make sure you get lots of rest whenever you can!)
Remember that every intervention – both natural and chemical – has risks and benefits to both mother and baby. Please do your research and ask questions to determine exactly what the risks and benefits are to each method described.
Stripping the Membranes (also called Membrane Sweeping)
Membrane sweeping is performed during a cervical exam. Your care provider pushes a finger into your cervix and gently separates the bag of waters from the uterine wall. (The bag of waters remains intact.) The goal of this method is to stimulate the labor-starting hormones. If your care provider cannot reach your cervix because it is posterior, this method will not be an option. If membrane sweeping is successful, usually labor will start within 24 hours. The only real side effect seems to be the discomfort many women feel during the exam itself – the procedure can be painful for some women, and often, women experience cramping and light bleeding after the membrane stripping.
A foley bulb is a catheter with a balloon on the end. Your care giver inserts the device into your cervix during an exam, and then “blows up” the balloon with a saline solution to stretch out the cervix. When the cervix reaches 4cm dilation, the foley bulb falls out on its own. This method of induction stimulates hormone production and can help the cervix to dilate, but is not an option if you are already dilated to 4cm or if your cervix is posterior. Again, this procedure has almost no side effect except discomfort as the bulb stretches the cervix and the bleeding/discharge that can happen as a result.
Artificial Rupture of Membranes (Breaking the Waters, also known as Amniotomy)
A care provider does not usually suggest breaking your waters as a way to initiate labor, though it may come up as a way to augment a stalled labor (or to make sure a labor keeps trucking, in the case of receiving pain medication which renders you immobile). Very occasionally, a doctor or midwife might discuss amniotomy as an option for starting labor, which is why I include it here.
Amniotomy is performed during a vaginal exam. The care provider checks the cervix and then inserts a plastic hook (it looks like a crochet hook) into the vagina and nicks the membrane, causing the water bag to empty. The procedure hurts neither the mother or the baby, and usually does not cause any serious complications.
However, once the waters have broken, the baby no longer has a cushion as he/she descends into the pelvis – this can cause baby to get wedged into an unfavorable position, making the baby’s descent more challenging, or could cause the baby’s heart rate to fluctuate more often, as baby is squeezed more dramatically by contractions. The risk of infection becomes a question, particularly in the case of a very long labor, which of course causes its own issues. There are other potential risks as well, though their occurrence is more rare.
On the upside, breaking the waters can often shorten labor or can get a stalled labor moving again.
Cervical Ripening Drugs (Cytotec, Prostaglandin Gels/Wafer)
The prostaglandin drugs are either rubbed onto the cervix in gel form or inserted into the cervix as a wafer during a vaginal exam, and over 6 to 12 hours, they release prostaglandin hormones into the cervix, in hopes that the cervix will move forward and ripen. I personally have not seen these drugs be effective during inductions.
Cytotec (misoprostol) is a pill traditionally used to treat stomach ulcers. However, it has been used by doctors to ripen the cervix as well. Typically a pill is cut in half or quarterted and inserted into the cervix. Over fours hours, the drug dissolves and ripens the cervix, occasionally also causing contractions.
The side effect of all of these drugs could be hyperstimulation of the uterus (which could, rarely, lead to a uterine rupture), though in my personal experience, I have only seen cytotec produce the hyperstimulation side effect. Hyperstimulation of the uterus affects both moms and babies – moms experience a constant contraction, since the uterine muscles never fully relax, and babies who experience hyperstimulation can often have heart rate issues due to changes in their oxygen supply (because of a near constantly squeezed umbilical cord). In the case of hyperstimulation, medical facilities have drugs they use (usually magnesium given through IV) to help the uterus relax, though this will not solve the problem of how to help labor keep progressing.
Synthetic Oxytocin (Pitocin)
Pitocin is by far the most common induction method used today, as it is the most effective tool care providers have in starting labor. Given intravenously (through IV), the medication acts similarly to oxytocin, stimulating labor contractions. Mothers often say that the experience of pitocin contractions differs from that of natural labor contractions – anecdotally, pitocin contractions feel like a plateau of pain (as in, you experience the “peak” of a contraction the whole time), unlike spontaneous labor contractions, which build to peak of pain and then decline from the peak.
Additionally, pitocin has many side effects, some of which affect mothers (such as uterine rupture), and some of which affect babies (such as increased outcomes of staying in the NICU). Generally, hospitals are careful not to overuse pitocin and there are many restrictions in place to monitor how hospital’s use pitocin. Despite its prevalence, pitocin has not yet been carefully studied to determine its longer term effects in mothers and babies.
Before an induction begins, I always recommend that my clients have a conversation with their caregiver about all the options that are on the table – and what will happen in the case of an “unsuccessful” induction. This takes some pressure off of my clients if they know the plan at the outset, and it helps them to set reasonable expectations for the process. An induction might be declared “unsuccessful” if the cervix is not opening, even with the stimulus of natural and chemical means, or perhaps the baby isn’t descending into the pelvis (although, dilation and station are often linked). There are a few possible next steps in this case:
1) Give more time to allow a mom’s body to prepare on its own and send a mom home (this option is not usually one doctors offer to moms who have already arrived at the hospital and have been hooked up to monitors, IV, etc., though a midwife might be more open to this option);
2) Give a mom more drugs (up the dose of pitocin), which can sometimes exhaust your uterus or cause the baby distress; or
3) Offer the option of another intervention (such as breaking your water, using forceps or vacuum extraction to remove the baby if you’re fully dilated and baby has descended enough to be helped down the birthing canal, or a cesarean section to get the baby out once and for all).
Your caregiver and birth place will likely have preferred ways to deal with this sort of situation, and it is your responsibility to learn about the options you personally prefer and to advocate for yourself in order to receive your preferred method of care. Remember, you’re footing the bill – so ultimately, the choice about how to proceed is yours. (Though, of course, I do always recommend that you take into consideration your caregiver’s expert opinion).
If allowed to continue on in pregnancy, most women will go into labor all on their own. If you are considering an induction simply because you are DONE being pregnant, I urge you to consider the wisdom of this beautiful illustration by Brazilian artist Itaiana Battoni.
As a doula, I spend a lot of time waiting alongside my clients – because pregnancy and birth are generally slow! I can understand the urge that pregnant mothers in their last weeks have to want to get things moving. Those moments are the moments when induction and scheduled cesareans are most seductive.
But the other choice – to accept today as it is, to trust your body and your baby, to choose patience – bears its own reward.