Everything You Need to Know About Induction
Induction of labour is when your birthing team use a series of interventions to bring on labour. Before consenting to induction, you need to be fully informed about the benefits and risks, what it will look like, what each procedure entails and what it means for your labour. Of course, your birthing team will give you some information beforehand, but how much of that 20-minute appointment do you actually remember? Particularly when your induction probably isn't until a few days or weeks after that appointment. That's where this blog post comes in. Think of it as your pocket guide to having an induction.
Let's start at the very beginning; why would you be offered an induction of labour?
- There are plenty of reasons a Mama may be offered an induction. Some of the more common ones include:
- A Mama develops a medical condition or pregnancy complication [e.g. pre-eclampsia or signs of infection].
- There are concerns about bub [e.g. recurrent reduced movements or growth restriction].
- There are concerns about the placenta [e.g. an ultrasound shows that the blood flow to bub isn't optimal].
- A Mama's waters break at full-term, and there are no signs of labour or is GBS positive.
- A Mama is pregnant past her due date and is heading toward 42 weeks.
Some of the more uncommon reasons I've seen for inductions include social reasons, mental health reasons and extreme symphysis pubis dysfunction. If you've got a private Obstetrician, they may also offer you an induction around 39 weeks as part of their routine practice [however, this depends solely on your doctor, so feel free to ask them what they normally recommend!]
After you've started talking about having an induction with your pregnancy and birthing team, one of the first things that may happen is a vaginal examination to determine the best method of induction for you to meet your bub. The doctor will assess your cervix and check for:
- How dilated your cervix is. This means how open it is on a scale from 0-10cm.
- How long your cervix is.
- How soft it is [hard, moderate or soft].
- If it's pointing towards the back, middle or front of your body.
- How far down bub's head is in your pelvis.
This assessment will give you a 'Bishop's Score', which indicates how favourable your cervix is for induction. A score of 7 or above means that your Doctor or Midwife may be able to break your waters immediately. A score of 6 or below means another option is required to get you to the point of being able to break your waters.
So if your score is 6 or below, what are the other options?
There are three options available to use to help make your cervix more favourable for induction.
- Prostin gel.
- A balloon.
Let's break them down further.
Prostaglandins are hormones produced naturally by the body that helps to kickstart labour. Prostin gel and Cervidil are synthetic forms of prostaglandins that are put behind the cervix to help it soften and open. In some cases, these hormones also stimulate contractions.
Prostin is a gel that is squirted behind the cervix and left for 6 hours prior to reassessing a Mama's cervix for changes. There are different strengths, which your doctor will decide based on if you've had bubs before, how much you've had previously, and how you reacted to the first dose. The benefit of the gel is that it is easily inserted, can be repeated 3 times, it may stimulate some contractions, which can help things along, and it works reasonably quickly. Some negatives include a risk for you to develop too many contractions or contractions that last too long, it requires a vaginal assessment and that it may not be recommended for Mama's who have had a c-section before.
Cervidil looks like a flat tampon, with a small strip containing medication that's connected to string. The tape is inserted behind the back of the cervix, with the string left trailing out to sit on the outside of the vagina. A benefit of Cervidil is that it can be easily removed using the string, is effective and continues to slowly release prostaglandins over the [minimum] 12 hours that it's left in for. A negative is that it may fall out when a Mama does a wee if not careful, and it may not always work. I've also seen a handful of Mama's who react to Cervidil [which is rare].
A balloon is a catheter that sits in between bub's head and the cervix, as well as outside the cervix. Water is put into the catheter, which makes it blow up like a balloon. It then puts pressure on the cervix from inside [similar to what bub's head would do if pressed down on the cervix] and from the outside as well to make it soften, thin and open. A good thing about the balloon is that it can be easily removed and doesn't contain any hormones, making it a good choice for Mama's having a VBAC or bubs with health concerns. One negative is that it requires a speculum for insertion, and some Mama's find having the balloon painful. If that's the case, your team may remove some of the water inside the balloon. A balloon is generally left in for 12 hours, then removed to check if a Mama is able to have her waters broken.
The insertion process for all three methods of inductions is similar. Generally, here's how it goes:
- You'll meet with your doctor to talk about the benefits, risks and processes involved in your induction.
- You'll be admitted to the hospital and be allocated a Midwife.
- The Midwife will do your heart rate, blood pressure etc, test your wee, feel your tummy for bub's position and put on a CTG monitor.
- A Doctor will see you before starting the induction to check you understand the process, that you're healthy and that bub's heart rate is normal.
- Then your Doctor or Midwife will perform a vaginal examination to decide the best method of induction [Prostin gel, Cervidil or a balloon].
- Once everyone is happy with what will happen [including you, Mama], your birthing team will insert the chosen method.
- You'll stay on the CTG for at least 20minutes after to make sure bub's heart rate is normal and that you're not having a reaction to the medication by checking your observations again.
- Your birthing team will keep a close eye on you and bub by doing your observations, keeping a close eye on your contractions, checking bub's heart rate and doing CTG's when required.
- Once the recommended time has passed, your birthing team will restart the CTG, assess your cervix and make a plan with you on what the next steps will be, whether that's giving you further medication, putting in a balloon or breaking your waters.
In a few cases, some Mamas' cervix won't budge despite various induction methods. In these cases, Mama's are generally offered to go home and come back in a few days to try again or an elective c-section.
Your doctor can break your waters; now what?
Once you get to the point of being able to break your waters [sometimes called ARM-able], your Doctor or Midwife will use a plastic stick-like tool with a hook on the end or a plastic roll-on condom-like tool that also has a hook on the end to break your waters by putting a hole in bub's sac. You might feel a gush, trickle or like you're constantly wetting yourself. And unfortunately, Mama, this will most likely continue until bub is born. Your Midwife will continue to assess the colour of bub's fluid throughout labour, with clear or pink considered 'normal'.
Depending on the hospital policy, what your body is doing, your preferences, if it's your first bub or not and the recommendations of your doctor, your Midwife may start the hormone drip [Oxytocin] straight away after one hour or two hours. At this point, if you're GBS positive and planning to have the antibiotics, your Midwife may also give you the first dose of antibiotics. Some Mama's go on to require the hormone drip, while others will start labouring on their own. This is definitely a conversation to have with your doctor well before getting to this point. It's also at this stage that you can start to think about your pain relief options. Some Mama's opt for an epidural as soon as the hormone drip is started to minimise the pain they feel, while others like to look at other options, like a hot shower, sterile water injections or nitrous gas. Having done your research and created a birth guide beforehand will be really beneficial with things like this, so you know the benefits and risks of each choice and what's best for you and your bub during your labour.
During this time, your Midwife will continue to keep a close eye on your observations, bub's heart rate via a CTG, your contractions and the colour of your waters. As time goes on, your Midwife may continue increasing the rate of the Oxytocin hormone drip to get you to the point of having 3-4 [max of 5] contractions in 10 minutes that are strong, regular and last around 1 minute. One of the most important things, though, is making sure you have enough rest between contractions.
The way I teach many Mama's who I'm caring for in birth suite about contractions is to think of contractions as waves at the beach. If you're swimming at the beach and see a big wave coming, you take a deep breath, go under until it passes, and then come up for air. But if you start getting too many waves, you don't have enough time between them to catch your breath properly, and you'll start to get tired. Similarly, if the waves are lasting too long, you'll start feeling tired from having to hold your breath for so long. If that continues for a period of time, eventually, you'll say, "nope, that's enough", and show signs of becoming really tired. Now think of these waves as contractions, and you holding your breath as bub managing their heart rate and oxygenation levels during contractions. If they get hit with too many contractions or contractions that last too long, eventually they get tired and say, "nope, that's enough", which may show up in changes in the CTG monitor.
After around 4 hours of strong, regular contractions or 6 hours after starting the hormone drip, your birthing team may offer you a vaginal assessment to check your progress. If the number they say isn't what you're hoping for, please don't stress. Labour is a marathon, not a sprint! The best thing you can do at this point is to focus on yourself and envisioning that sweet little person who will be in your arms in a few short hours.
At some point in your labour, you'll either reach 10cm dilated and begin to push or go for an emergency c-section. This is a good time to remind you of a few important things:
You birthed your baby, regardless of whether they came out through your vagina or tummy.
You are a strong, powerful Mama.
You're allowed to be angry and upset if things didn't turn out the way you had hoped.
You're allowed to grieve for the birth you thought you'd have.
You're allowed to express your feelings, even if they're negative. But also if they're positive because telling your positive birth story doesn't take away from someone else's negative one.
Some inductions can take a matter of days. It's a marathon, Mama.
A healthy Mama includes mental health. If you're traumatised from your birth, get help. 'It ain't weak to speak' applies to Mama's too.
Particularly when it comes to birth, bubs have a mind of their own. Some miss the memo to get in a good position for birth, and some become unhappy during labour. All things which are out of your control.
You're allowed to speak up. In your birthing room, YOU are in control. Not your partner. Not the Doctor. Not the Midwife. You. It's your body, your baby and your birth. You can ask what the alternatives are. You can ask what's the evidence behind that recommendation. You can say no.
Sometimes, regardless of how much we plan; how much we educate ourselves; how much we imagine, thing's just don't turn out the way we expected. And that's ok.
This post is a general guide to inductions. It may be slightly different at your hospital, so my best piece of advice is to read this post, educate yourself with a birthing class [I know Tiny Hearts runs a fabulous one ], and write a list of questions that you want answered at your induction appointment. That way, when you turn up at the hospital, you know exactly what you want and what to expect. Sending you lots and lots of baby birthing vibes.