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Induction?

  • IV drip with Pitocin

The following article discusses induction and getting labor going with a Spinning Babies approach. 

Spinning Babies doesn't recommend induction of labor, whether by natural means or with medications. Its not the place of this website to make medical decisions. 

What is induction or inducing labor?

The onset of labor (beginning of labor) is a normal physiological function at the end of pregnancy. The body does it. 

Sometimes there is a health reason to get labor started before nature begins labor on its own.

Sometimes a woman's hormonal function isn't optimal and the start of labor doesn't occur in time for the baby to remain healthy. This is quite unusual.

Inducing labor can be achieved with both medical or "natural" means. I put "natural" in parethesis because even if we are using herbs, foods, or non-pharmacuetical methods, its not our body that is starting the labor on its own, which is best when health is fine.

Pitocin (Syntocin) is the common medication for inducing labor. But there is also using a thin balloon, gels, a cheap but dangerous pill called Cytotec, or breaking the bag of water as medical methods to induce labor onset. Another medical method that is thought of as being less interventive is "stripping the membranes" where the midwife or doctor inserts a finger tip between the cervix and the amniotic sac and reams the two apart causing about 24 hours of cramping and occasionally causing labor to start.

Natural methods might include homeopathic and herbal remedies, including castor oil, acupuncture or acupressure, and certain foods. Activities associated with inducing labor are long walks, orgasmic sex, and nipple stimulation. Just because the things on this list are considered natural, doesn't mean that they are all equally safe. Consult your provider to discuss the options for you. 

Sometimes induction methods work well and sometimes it takes days to get labor to start. If it takes days to get an induction going it may be because the mother and baby weren't ready. But if the birth team is patient, the induction can still work without a cesarean even if it is three days in the doing.

What most first time pregnant women benefit from knowing is that labor often starts on its own at 41 weeks and 1 day, or about a day or a week after many doctors wish to induce these days. 

The first question I ask at Spinning Babies is, What position is your baby in? I don't see the point in trying to induce a posterior baby. Help the baby get better flexion, get into the anterior or left transverse position, or at least applied to the cervix. Then within 24-48 hours labor generally starts.

 

Why Induce?

Inducing labor can be beneficial when a pregnant woman is sick.  For instance, a woman has uncontrollable high blood pressure or the baby is clearly showing signs that the placenta is not functioning well.

Induction can be viewed as a way to avoid infection if the amniotic fluid membrane (sac, or "waters") has broken.

Though studies don't support it, there is a widely held belief that induction might prevent shoulder dystocia if early induction prevents the baby getting over 8 lbs. 13 oz.  This practice is not proven by the studies. Read the discussion in FAQs about whether or not to induce because a baby is thought to be large.

 

It is popular to induce labor rather than let the pregnancy go beyond 42 weeks. The concern is the placenta may not continue to function well. A test called a "Biophysical" exam can be done using an ultrasound machine to assess fetal well-being by looking at:

  • fetal movement, including swallowing 
  • amniotic fluid levels
  • blood flow through the cord
  • and other characteristics

The test can be repeated as needed. This test isn't perfect. Some providers induce even with good test results. 

The Biophysical and other maternal and fetal assessment tests seek to determine whether the pregnant woman or fetus are so sick that their chance of death out weighs the side effects and risks of induction. If they are that sick, then induction becomes a tool for their well-being.

 

Maintaining the support of one's birth team

Women might feel inclined to accept induction the midwife or family practice doctor can't or won't help her after 42 weeks gestation.  

This "rule" to limit pregnancy to 42 weeks or less varies among practitioners. Discuss your options with each individual midwife or doctor. 

Induction is tempting for social reasons such as having a doctor that you know, having a baby while a husband, partner or other special person is in town (perhaps on leave) or to avoid having a baby on a final exam or during another family event or before insurance coverage changes, etc.

Some women are so uncomfortable in late pregnancy that they are actually suffering. Induction can become very attractive. 

 

 

Why Not Induce?

The March of Dimes is on a campaign to reduce inductions to only those most medically necessary and not to induce before 39 weeks. Even a 35-36 week gestation baby, just 1-2 weeks earlier than what is considered term at 37 weeks, has a 1% higher chance of dying in the first year of life than a full term baby. Sometimes doctors and parents alike think (are sure!) the baby is due on a date that turns out to be earlier than the baby really was due and suddenly all are suffering over the challenges of a "late premature" infant.

Induction is associated with several other interventions. The more interventions the less mother-infant skin-to-skin time is likely as the baby may be more likely to need resuscitation.

Epidural anesthesia can be avoided with induction, but it is certainly a common expectation for a woman to have an epidural if they are being given Pitocin (Syntocin), as if both came as a set.

Finishing the labor with a sudden cesarean is more likely during a labor that is induced with medications. One problem is that the strong contractions from induced labor can pile up and block baby's recovery time between contractions. Natural labor is sometimes super strong and contractions can be close together, too, but aren't as likely to reduce baby's oxygen levels as much.

Natural inductions can sometimes come on stronger than is safe, but more likely, natural inductions may not be strong enough to advance labor all the way through to birth.Women can get exhausted mentally and/or physically.

Sometimes the fuss over either type of induction wears a woman out mentally. She expects a baby soon after the induction starts. Its not uncommon for an induction to take three days. Most of that time will be in early labor though. The IV Pitocin, prostoglandin on a string, or herbal drops can be stopped if a woman needs to rest, they aren't effective or they are too overpowering. (Cytotec can't be stopped and that's another problem with that popular inducing agent.)

A calm doula is a good addition to any induction. She should know the psychology of comfort, encouragement and patience to be with a woman from before the induction is begun all the way through to the birth. Two doulas allow each other to tag team for potentially long inductions (first babies, inductions before 41 weeks, inductions when baby is not yet engaged in the pelvis).

A mother writes,

What I want is to wait until 42 weeks providing all is well at my
biophysical exams. She has me going twice a week and so far all
results have been good.
I didn't do the glucose test since I don't believe that was anything
other then her trying to frighten me about the size of the baby.
I am feeling lots of irregular contractions, lost my mucus plug, feel
intense pelvic pressure, doing acupuncture, primrose oil, walking
three miles a day and to my husbands delight daily sex.  I have a
bottle of castor oil as a last resort but am trying to focus my
energy on things happening in their own time. I know I am up against
a 42 week deadline and I am willing to induce at that point if that
is what is best.
Your emails are a source of great comfort and wisdom and I thank you
again for taking the time to help me sort through this journey and
make informed decisions.

This is the same mother in an email nine days later:

Labor started on it's own Friday night. Water broke at home, went to hospital Saturday morning with light contractions and walked around central park until they were 2-3 minutes apart.  About 4 hours of labor at the hospital and our beautiful baby boy was born, 7 lbs. 14 0z. 21 inches. He did come out facing sideways looking straight at his father, but whatever way he was facing mattered little in the end, we were just happy to hold him. He nursed soon after birth and hasn't stopped since. Many thanks for all your support and kind thoughts.

Here is a link to the Coalition for Improving Maternity Care's Induction Fact Sheet listing the risks of Induction.  Click on the highlighted words if you want to download a free pdf. file (the free Adobe Reader software needs to have been downloaded first on your computer to read this pdf. file).



   

If the baby or mom isn't sick, why risk it?

If your child were one of 100 school kids on a field trip told to run across a freeway knowing that one of the children would get hit by a car, wouldn't you keep your child home that day?

 

Induction is a  a decision for mothers to make with their midwives and physicians based on needs not desire; on health, not size.

The risk of not inducing should be equal or higher than the risk of inducing.

One risk of inducing is disturbance of the mother-child relationship at the beginning. Hormones are important and induction by Pitocin doesn't release maternal hormones to prepare the brain for loving a dependent baby. Induced women may need extra support during and after birth.

Skilled doula support in a hospital induction can raise a mother's natural love hormone, oxytocin. She does this by calm presence, a soft and calming speaking voice, touch and rubbing, and helping the partner be close and comforting by modeling. She will help the environment be more conducive to laboring, dark and quiet, while encouraging the staff to talk slowly and give a bit more freedom for movement and position changes, if that's appropriate. Doula care was  shown to shorten induced labors in a pilot study done at two local hospitals in which I was a doula coordinator years ago.

If you are a woman who will be induced, increase your social support now and later. Be good to yourself and be good to your family.

Your mothering experience is worth it!



 

How to Induce

Induction of labor can be started by natural means when the natural substance supports something that the mother needs. Medications are generally more effective, but will require medical supervision and usually a hospital stay with monitoring for mother and baby to reduce the risk of overdose (contractions that are too strong and too close for good oxygenation between contractions, or rupture of the uterus). 

Pitocin in an IV bagPitocin (oxytocin, which is the natural blood chemical from our brains, or Syntocin another brand name, but in the UK and Down Under) is given with IV fluids through a catheter in the arm or hand. "Prostaglandins" are artificial hormones. The gel is put on the cervix to ripen it and sometimes labor can start just from a few applications of gel. Another form is by a very inexpensive pill called Cytotec, which though often effective is associated with a high rate of rupture of the uterus, amniotic fluid forced into the mother's lungs with resulting shock, and/or maternal death.)

There are a variety of natural means to induce. Special foods, walking, lovemaking, nipple stimulation, castor oil, herbs, homeopathy, body work, moxibustion and acupuncture.

One medical way that is sometimes thought to be a "natural way" that makes me uncomfortable is breaking the water, also called rupturing the membranes. A plastic hook is inserted through the cervix to snag the membranes and make a leak or a gush. Obviously, if the mother's water breaks first, without contractions starting on their own, this method isn't an option.

The amniotomy hook to tear the amniotic membranes during an intervention called amniotomy.The rule of thumb about rupturing the amniotic sac is, if labor is slow, breaking the water slows labor more; if labor is (or would be) fast, breaking the water may speed it up.

If a first baby is OP or ROT, please do everything else first! Babies born in the sac seem the most alert and peaceful. They've had an internal water birth! The intact sac is useful to put a thin cushion of fluid between their head and their mother's pelvis with the contraction making a thin stream of water between them and assisting rotation. That's my opinion.

homeopathics can be used to induce labor in harmony with your bodyI'll leave it to you to find an experienced practitioner when you get into herbs and homeopathy. Because natural ways can also have side effects, I can only recommend using the support of a skilled practitioner. But typically what I observe is that women take too little. But again, too much is not too good either. There is a way of blending homopathy and herbs that seems more effective than either alone. Acupuncture seems effective, more so when done by a very experienced Chinese-trained acupuncturist.  I prefer natural methods, but take self induction very seriously. Be mindful.

That said, I think that a natural induction can be worth a try before a medical induction when the healthy mother is motivated to try it and she is open about it with her birth team. Many times using a mixture of methods works. For instance, taking homeopathic ipecacuanha 15 minutes before gulping down the 2 ounces of castor oil and 2 ounces of orange juice prevents vomiting or the urge to vomit. Some women rinse with orange juice to cut the oily after taste. Dehydration and frustration can be side-effects of self-induction if not pre-hydrated and supported mindfully.

 

 

The Spinning Babies point of view on Induction

Fetal positioning is at times a cause for delay in the start of labor.

When doulas and midwives have asked my advice about natural induction methods they are often surprised to hear me turn away from herbal tinctures and focus on the baby's position and station. I want to know if the baby is engaged. That's more important than anything else. 

Getting baby engaged often starts labor once a woman is overdue when baby hasn't been engaged previously.

A few studies have shown that over due babies are more often posterior; a few studies did not find that. A few studies have shown that when the water breaks before contractions start in, the baby is often posterior. When water breaks earlier than term in pregnancy, an infection may be present, even if the mother doesn't feel sick. When the water breaks before labor starts for a full-term baby, it may be worth trying out the Spinning Babies approach to labor progress. Again, I don't recommend breaking the water to advance labor or cervical dilation. I don't care how much the cervix is dilated. I care how the baby is presenting.


Help the baby into position and the rest will happen by itself.

 

Exceptions

The exception may come with hypertension in pregnancy. If a woman's metabolism is "sloshy" due to the cause behind the fluid retention, slight rise in blood pressure and the subtle malnutrition that goes with that picture, her body may not pick up on the baby's signals that he or she is ready for birth and the signal to start labor may be missed by her body. This is my 'lay' explanation for what I see when labor onset is missed and babies are indeed overdue.

Emotional reasons for labor onset to be delayed are usually immense stressors and not normal stress. But an "airing out" day is a good thing, too. Sometimes it's just that there is more time to ponder the "reasons" why baby may not be coming that women who give birth earlier in gestation don't have time to ponder. Every situation is different, but generally, we providers should be more reluctant to find fault with the woman's head - at least not before investigating the baby's head position!

 

Goals:

Head flexion (baby's chin to chest)

Optimal Fetal Position (LOT, LOA, OA)

Head engagement (baby's head has dipped well into the pelvis)

Then,

Physical activities to bring the crown of baby's head onto the cervix

 

Here are ways to meet these goals:

Rebozo sifting for pre-labor, before other techniques to reposition the fetusSifting with the woven Rebozo (Mexican scarf) to relax the broad ligament and help the woman relax that which she can not consciously relax at will.

When a birthing woman is lying down on her back, propped up in bed or on the couch, do an diaphragmatic release (abdominal release). Its a myofascial technique that a birth partner can do or another person who does myofascial release.

Do a forward leaning inversion for 30 seconds. Once labor contractions are regular, its OK to repeat this type of inversion for 1-3 contractions in a row.

Reposition the baby towards the cervix. 

Sitting upright with a straight back during contractions when you rest and walking when you are awake.

Also, standing and leaning forward during a contraction and straightening up between. 

Keeping your knees soft so the fascia around your pelvis is flexible, not taunt.

Sitting on the birth ball with feet solidly on the floor and hips fluid and making circles for 20 minutes. Have a helper near by and have a railing of some sort to hang on to or a person behind you to rest back on between contractions if you get tired.

Rapid circles on the birthing ball seem more helpful in bring the baby down into the pelvis than slow circles. Use happy music to keep the pace. Be mindful of your own body and needs, don't hurt yourself.

The Belly Lift

If you know that the baby is facing forward (posterior presentation) or you have back labor in any case, there is a simple technique that works wonders.

When you can anticipate a contraction coming (contractions have to be somewhat regular)  begin an Abdominal Lift, also called a Belly Lift, and hold it during the contraction. See photo here.

Let go of your belly in between contractions. Do a Belly Lift  ten-times in a row if your labor has the pattern described on the Abdominal Lift description on this website.

 

 

Labor starts, but is slow

Whether labor starts spontaneously with these techniques or an induction is now underway, use the above techniques again as needed. If after that the baby is still high, try the following.

Walcher's in the waterIf the first baby seems to be in a good position but not engaged, use Walcher's Position to open the pelvic brim.

If a mother has had a good labor progress in previous births, you can take a chance at Walcher's even with a posterior positioned baby. The baby may engage OP and rotate later or fit all the way through in an OP position. Not all OP babies fit, though, so if the mother has had a cesarean for a previous OP birth, this is a first baby, the baby is large, or the mother has an android pelvis, I would do more to get the baby into an anterior position first (LOT is included in the anterior positions).

 

Listen to your baby first. Don't get trapped by ideology - labors always start when baby's ready (not true when there are metabolic issues) or placentas wear out (Good grief!). But do listen to your baby, pay attention to fetal movement and seek wise help. You will do what you feel you must do when your instincts don't match the care you are receiving. Talk about your desires as an equal, not as a plea. If you feel you have to induce, make the induction work for you. 

 

Laboring with an induction

Since Pitocin (syntocin) doesn't cross into your brain to alter your perception of pain in labor, induced labors can be more painful. But there is something you can do to take the edge of the pain of an induced labor. 

  • Do a Pelvic Floor Release (sidelying release) before labor and in early labor on both sides. See how. 
  • Keep the lights low and reduce mental stimulation (tvs, debates, worry, family gatherings in your room, computer time).
  • Increase rubbing, massage, loving touch and smooching, cooing, and loving expectation of meeting your little one together with your loved one(s).
  • Get a calm doula who knows how to talk to you to calm you and knows soothing methods and comfort techniques.
  • Dark, slow and long massage strokes, quiet.

Its often effective to start Pitocin at a half-dose and bring it up more slowly than a typical in-and-out schedule for a busy hospital. Negotiate with your doc and remind the nurses. Ask to speak to the doctor/midwife if the labor contractions come on too fast and hard. The dose can be slowed by the nurse at the provider's instruction. 

Realize that contractions will get harder before the amount of dilation that that amount of umph is expected for, so that at 4 cm, contractions may be 90 seconds long and 2 1/2 minutes apart for a while and then the cervix dilates to 5 cm. In a spontaneous labor contractions must get quite strong and close together so give the induction "permission" to do this also. Its what gets you past 8 cm. 

Change the way you look at the induction. Instead of seeing it as something done to you, see the induction as a tool you have chosen, or allowed to be used, to bring your baby to you. Seeing our life events as being within our control makes life more manageable and satisfying. We can't always change what we have to face at the time its happening. Now that we are here at this point, we can activate the inner strength and the social support needed to walk the path ahead of us. 

Induction decisions are parenting decisions. You get to pick. You are the Mama.

 

 

Email:

 

Hello Gail, 
 
I appreciate that you probably receive many emails and completely understand that you do not have the time to respond directly to everybody.  Even if you don't get the chance to respond I would like to thank you for the highly informative detail on your website, which has already provided me with some hope for the coming week. 
 
I am currently 41 weeks and 4 days pregnant, and have the time pressure of an impeding induction.  My dates are accurate and match up with the ultrasound dates. 
 
My baby has been almost always ROP throughout my pregnancy, at 38 weeks [baby] changed to ROA and at the same time engaged to 1/5 down, [baby] stayed ROA for next 3 weeks and continued to drop to 2/5 down.  
 
However, in my appointment today the baby has moved back to ROP and is now her head is not in my pelvis at all.  In fact her head is above the pubic bone.  I am 1cm dilated with no signs of impeding labour (no cramps, show etc. etc.).  This is my first baby. 
 
From reading your website I wonder if the change in her position has resulted in her head coming out of the pelvis.  I have been advised to do a lot of walking and rotations on the gym ball etc. to try and bring her head down as much as possible before Thursday. Although I am wondering if I should be working on exercised to get her more LOA rather so that she engages naturally.  
 
I realise I have little time but want to try what I can ... as I am terrified that I will end up having to have a C-section.  
 
Your website is very clear on the exercises to be used to encourage engagement and to move from a posteria position - I suppose I am just wondering considering the time restraints which is the best option for me both over the next few days and also whilst in labour after they have applied the gel. 
 
Thank you.
 
Response:
 
 
Dear [Pregnant Mama],
Thank you for imbuing your email with sweetness and understanding about time! But its your time, too, and your baby's!
So,
Please try the sidelying release on both sides, using the instructions carefully. 
 
I agree, if your baby came up higher it may be because the baby is trying to rotate to LOA/T
or,
Your baby found Less room below as your lower uterine segment may have reduced space there due to muscle tension or a short ligament.
Likely both are true as the lower uterine segment gets "crowded," babies come up and would like to rotate if the round ligaments in front allow room to do it.
 
Getting the baby to engage now in ROP may or may not address your goals.
If you are a first time mother (and you are) engagement in ROP isn't ideal for labor progress later. If you have given birth easily before (for some of our readers), especially during 2nd stage, engagement in a posterior position may not prevent vaginal birth or even a slow down, esp when your body is balanced. But for some women engaging a posterior baby isn't a good thing. 
 
But, then how to you get labor to start on its own by 42 weeks? Add balance, seek to help baby to the left. 
 
Labor contractions may be the necessary ingredient to get baby to rotate.
That is more common today that it was 5 years ago, perhaps due to soil depletion? I don't know, more sitting and driving in our society?
 
Body work is often useful as can be professional Chinese acupuncture. 
 
Homeopathics can also be effective, you may need to consult a homeopath such as Homeopathic Medicines for Pregnancy and Childbirth
as well as find a good homeopathic Pregnancy practitioner.
 
I suppose you found the "Induction?" page on my site and have read what is in Start/InPregnancy and Start/InLabor  
 
On the other hand, I've been with many induced women and there is a way to take it slow, add massage, calm music, touch, and laughter, a rebozo sifting, and have a "natural" labor in other ways, meaning no need for an epidural for many, but not all, of these women. Motivation and the best response to the Pitocin are part of making it through without other meds. A doula is key, a doula who has lots of experience with "natural" comfort measures during inductions. 
 
So much love to you and your baby. I hope you keep a perspective of love and practicality through this. 
 
Peace is an action,
Gail Tully