What to Know About Inductions
As your due date approaches you might start hearing or thinking about being induced. For some pregnant people, inductions are recommended to address medical risk factors (for example, pre-eclampsia), whereas for others, inductions may be offered as a choice once they reach 39 weeks of pregnancy.
There are many things to know about how an induction works... so we will start from the beginning:
What to Expect Pre-Induction:Typically, when you arrive at the hospital for an induction you will be asked common admission questions (for example: What medications are you taking? Do you have any allergies? Do you have any medical conditions, or have you ever had surgery?). Most times, an IV is started and you will have your blood drawn for basic bloodwork (a complete blood count and a blood type and screen are the most common labs). Next, your cervix will be checked to see if you are dilated and then a conversation will happen about what methods your provider feels would work for you and about your preferences. It is your care team's responsibility to get your consent for these induction methods. They should be informing you of the risks (both common and rare) of each method before you consent to treatment.
Methods of Induction:
We frequently receive questions about the different types of inductions. Below is a list of common methods. Typically, patients who begin with any of the first three options below will need Pitocin or artificial rupture of membranes to augment the labor process. Additionally, inductions can include one or a combo of these options.
1. Cervidil is a prostaglandin medication that is inserted into the vagina (very similar to a very small tampon). Prostaglandin is a hormone that is responsible for softening the cervix. This is typically used when the cervix isn’t ripe (ready for labor) and would be described as closed and firm. This can stay in place for 12 hours or until the labor progresses to a point where it isn’t needed.
2. Cytotec/Misoprostol is also a prostaglandin medication that softens or ripens the cervix. This medication is offered in the form of a tablet that can be given three different ways. The first way is to give misoprostol vaginally. With this method, the tablet is placed in the vagina where it will break down and be absorbed by the vaginal/cervical tissue. The second way is called ‘buccal.’ With this method, the tablet is held between the cheek and the teeth where, once again, it will break down and absorb (fair warning: it tastes bitter!!). Finally, the last option that some providers use it to give the medication orally, meaning you swallow it. Regardless of method, medication is given every three to four hours until your contractions are frequent, or the cervix begins to soften.
Note: The risk of both Cervidil and Misoprostol is that these medications can encourage too many contractions which can cause the baby’s heart rate to change. Since this is the case, you will likely have continuous fetal monitoring with this method (these are monitors that sit on top of your abdomen and monitor contractions and baby’s heartrate).
3. Cervical Ripening Balloon (Foley/Cook) are methods of mechanical dilation. The device is a thin, sterile tube with either one or two uninflated balloons on the tip of the tube. The tube is fed into the cervix and then inflated with sterile water. In the single balloon option (Foley), the balloon is inflated on the inside of the cervix. In the double balloon option (Cook) the balloon is inflated on both sides of the cervix. Both the Foley and Cook methods apply pressure to the cervix, helping to soften, thin and dilate it. They are both typically left in for 12 hours or until they fall out. When they fall out, you are usually between 3-5 cm dilated. The risk of this method is your bag of water breaking during the placement. Many women find the pressure of these balloons to be uncomfortable but tolerable.
Note: The ripening balloon may be inserted in your provider’s office in some locations, and you will go home until it falls out and then come to the hospital. In other locations, it is only offered inpatient.
4. Pitocin is the synthetic version of a natural hormone called Oxytocin, which is a chemical/hormone your body produces that causes contractions. Pitocin is given and steadily increased until your contractions have reached a desirable strength and frequency. The main risk with Pitocin is that it can cause too many contractions and cause a change in fetal heart rate and very rarely stress to the uterus leading to injury.
5. Artificial Rupture of Membranes (break your bag of water) can be offered to break your bag of water should you be dilated enough so that baby’s head is low and putting pressure on your cervix. With artificial rupture, a long plastic tool with a hook at the end (similar in design to a knitting needle) is used to hook a piece of the bag and create a hole. This is not harmful to the baby as they hook a part of the bag that is not against the baby’s head.
Timing:There are many ways for inductions to start. As mentioned earlier, some facilities will place the cervical ripening balloon in the clinic and send the patient home for 12 hours or until it comes out. At other facilities they will start with Cytotec and Cervidil and let you sleep through the night. Other places will give you a ripening medication or balloon and start Pitocin right from the start. Each facility and each pregnant person are different. The moral of the story here is that you should always ask what to expect. You want to know this information so you can appropriately plan how/when to eat and sleep. Inductions start around the clock. You might show up at 9pm and think you will be sleeping and end up with regular contractions all through the night.
Every hospital is different, but many prefer that you restrain from eating solid foods once Pitocin or an epidural are started. Also, some people feel queasy from the contractions, so we recommend eating before coming in for your induction. It's gross but true – what went down sometimes comes up, so consider that when picking your snacks and meals.
If you talk to an older generation, you may have heard about people who “got some medicine, slept and woke up the next morning and started medicine to labor.” While that is an option at some hospitals, it is not the norm everywhere. Even if you are offered an option that is slower and allows for sleeping many hospitals still plan to continually monitor you during the night which involves vitals and baby monitors that are on your belly. No matter what, your sleep will most likely be intermittent and interrupted.