Should I Have an Induction?
Induction of labour is the process of a pregnant woman being given medication or undergoing a procedure to bring on labour, instead of waiting for spontaneous labour to begin on its own. There are a multitude of reasons why this is recommended and a number of methods, each with their own set of benefits and risks.
One of the reasons I wanted to write a blog post on induction is not only because its use is increasingly common in maternity care, it is also often recommended with very little, if any, explanation of the risks, alternatives and how the experience can be different to spontaneous labour. Often, when I am speaking with clients whose prior labours were induced, our conversation is the first time they are hearing that spontaneous labour can feel very different to an induced labour. Surprisingly often, nobody explained this to them before they agreed to the induction.
In data we have from the most recent Australian Mothers and Babies Report in 2021, 36% of mothers who gave birth in NSW had their labour induced. This has increased significantly since 2011, when 27% of mothers had their labour induced.
Induction has become incredibly common, so much so that it’s now the cultural norm, and if you are pregnant, it is almost without a doubt that you will have at least a few friends or family members mention their own induction, or who will ask you when yours is booked in. Have you ever heard someone say “they won’t let you go over 41 weeks”? I know I have, countless times.
You may have also heard the term ‘cascade of intervention’. This refers to what can happen when a woman is given a medical procedure or medication (such as those required in an induction), that results in complications that subsequently lead to more interventions to rectify those complications, some of or all of which she may not have initially wanted. This can ultimately lead to a very different birth to what the woman and her family were envisioning, and they can feel swept up in a series of events with no real explanation as to what happened to cause them.
Ultimately, the decision to have an induction, or not, is up to you, the birthing woman. Regardless of the circumstances, for you to have the best chance of an empowering and positive birth, it’s important that you are in charge of making the decisions about your body and baby. You need to feel heard, respected, supported, and your care providers need to obtain your fully informed consent before anything they do. To be able to give informed consent and make the decisions that are right for you, it’s essential that you understand all the risks, benefits and alternatives of what is being recommended to you.
What are the reasons for an induction?
In Australia in 2021, the most common reasons for inducing labour were a diagnosis of gestational diabetes, pre-labour rupture of membranes (PROM) and ‘prolonged pregnancy’ or pregnancy that has continued past the woman’s estimated due date.
Other reasons that a care provider might recommend an induction include a diagnosis of pre-eclampsia, suspected intrauterine growth restriction (IUGR), suspected ‘big baby’ (that is, a baby that is expected to be larger than 4kg), concerns about the woman’s health (e.g. chronic high blood pressure), concerns about the baby, (e.g. reduced foetal movement, or abnormal heart rates picked up on monitoring), suspected too-low or too-high volume of amniotic fluid, suspicion that the placenta is no longer sufficient, ‘advanced maternal age’ (the woman is over 35), if the pregnancy was conceived with assistive reproductive technology (such as IVF), if the woman has what is deemed a higher BMI, and more.
In other words, there are a myriad of reasons that induction may be recommended - it can be difficult to arrive at the end of your pregnancy without being offered an induction.
Inductions can also be given to women who request them for their own personal reasons. This would have to be discussed with your care provider.
Many reasons for induction are genuinely medically indicated, and in some circumstances inductions can improve medical outcomes, there is no doubt that that. No matter the reason you are considering an induction, it is important to become informed and consider all the risks and benefits. It is also important to find out about the method/s of induction that are being recommended to you, what will be involved and how you might experience it.
I highly recommend finding out more about potential reasons you may be recommended an induction, and what the research says about them. Often, it surprises women that many of the reasons for induction are not necessarily based on recent, good quality evidence, but instead on hospital policy, cultural practice (i.e. “this is just the way things are done”) or outdated research. Doing your own research is the best way to empower yourself to make informed decisions that feel right for you.
Methods of induction
There are a few methods of induction that are available and may be recommended, depending on your circumstances. In most cases, the process of induction involves preparing your cervix, breaking your waters and creating contractions.
Stretch and sweep / membrane sweep
Stretch and sweeps are not always described as a form of induction, but I am including it here because it is a procedure performed with the intention of starting labour. Ergo, in my opinion, it should be classified as an induction.
It may be offered towards the end of pregnancy, as early as 38 weeks (or even earlier), often as an attempt to avoid the woman going post-dates in her pregnancy. It occurs during a vaginal exam when the doctor or midwife uses their fingers to ‘sweep’ around the inside of the cervix to separate the bottom of the amniotic sac from the uterus.
If your care provider offers a stretch and sweep, they should be up front about the fact that it is a form of induction with its own set of risks. It is also worth noting that there is a Cochrane review on membrane sweeping for induction, which you can read here: https://pubmed.ncbi.nlm.nih.gov/32103497/.
If your midwife or doctor is offering a vaginal exam, I would always recommend clarifying if they intend to also give you a stretch and sweep at the same time. I have heard many women talk about being told after their vaginal exam that a stretch and sweep was also performed without their consent. This is obstetric violence and if you have experienced this, it should be reported if you feel comfortable doing so.
Prostaglandin gel (e.g. Cervidil or Prostin)
Before a ‘formal induction’ can begin, your cervix will need to have softened and dilated enough for further procedures to occur, if needed. If a vaginal exam determines that your cervix is closed, long and/or firm, you will likely be recommended having a prostaglandin gel or pessary placed on or inside your cervix (you may have heard this product be described by brand names such as Cervidil or Prostin).
This will be administered during a vaginal examination. Often, after a number of hours, surges may begin, and your cervix may start to dilate.
It is worth noting that there is a Cochrane review on the use of prostaglandins for induction, and the risk of hyperstimulation of the uterus (with foetal heart rate changes) increases from 1% to 4.8%, when compared with spontaneous labour. I have included this statistic because it does not seem to be something that is disclosed or discussed with women when an induction is recommended, and I believe it is a very important consideration for women, as a diagnosis of uterine hyperstimulation (especially if the foetal heart rate is affected) will almost always lead to to an emergency caesarean.
You can read through this research here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138281/
Balloon catheter (Foley’s or Cook’s catheter)
A balloon catheter is a device used to stimulate the cervix to release prostaglandin to begin softening and dilating, in a similar way to a stretch and sweep. The placing of the catheter will feel different for every woman, and it really depends on your personal circumstances and your relationship with your doctor or midwife. I have heard some women described as quite uncomfortable and painful, and others that it didn’t feel painful at all.
It is a ‘mechanical’ induction rather than one performed with hormonal medications, so it can be recommended if you have any contraindications to the use of synthetic prostaglandin (for example, if you are having a VBAC or are suspected of having a baby that may not handle a chemical induction very well).
Artificial rupture of membranes (AROM)
If your cervix has started to dilate, often you will be recommended to have your waters broken (or membranes ruptured).
An AROM is carried out with an amnihook (you may have heard it referred to as a ‘crochet hook’, as this is what it looks like), which is inserted into the cervix and manually used to break a hole in the amniotic sac to release the amniotic fluid.
The purpose of this is to create stronger surges; the loss of fluid means that the baby’s head will likely come down on the cervix to stimulate more oxytocin release. The prostaglandins in the amniotic fluid that is released may also work to further soften and efface your cervix. Many women describe their labour as suddenly becoming a lot more intense after their waters are broken (either artificially or spontaneously during labour). The idea is that further progress made from an AROM (i.e. your cervix dilating) may mean you can avoid the recommendation of further induction procedures, such as the syntocinon drip.
The Midwife Thinking blog has an informative article all about AROM, which I highly recommended reading. Find it here: https://midwifethinking.com/2015/09/16/in-defence-of-the-amniotic-sac/?amp
Syntocinon drip (synthetic oxytocin)
Labour contractions, surges or waves are created by the release of oxytocin and the muscles of the uterus responding and contracting to bring your baby down into your pelvis and ultimately push them out of your vagina. If the above procedures have not caused contractions to begin on their own (and often even if they have), many women will be given an IV infusion of synthetic oxytocin called syntocinon (called pitocin in other countries).
Syntocinon is often referred to simply as ‘oxytocin’, which many care providers and birth workers take issue with, because there are differences that women considering its use should be aware of. The key one being that syntocinin works to create contractions, but it does not cross the blood brain barrier to do the important work of contributing to the altered state of consciousness associated with labour and promote bonding feelings and behaviour³ that are so impactful to the wellbeing of mother and baby. This is the role that natural oxytocin produced by the woman’s body on its own does so well.
Synthetic oxytocin use comes with increased risk of various outcomes, including uterine rupture, postpartum haemorrhage, coma and/or death, reduced breastfeeding rates and increased postpartum depression and anxiety for the mother. For the baby, there is an increased risk of hypoxic brain damage, neonatal jaundice, neonatal retinal haemorrhage and death. Dr Rachel Reed breaks down these risks and references the research in her blog post, which can be found here: https://midwifethinking.com/2016/07/13/induction-of-labour-balancing-risks/.
The increased risks to mother and baby are why women are recommended continuous monitoring and will be put on a ‘time-limit’ for how long they can stay on the syntocinon infusion before they are recommended a caesarean. Babies are resilient and are very well adapted to handle the contracting of the uterus in physiological labour, but they can have a much harder time recovering from contractions created by synthetic oxytocin. This is why many women having an induction will be told that their baby was discovered to be in distress (picked up by changes in foetal heart rate) and have to make decisions about whether to have an instrumental birth or caesarean section (depending on how far down the baby is at the time). Again, this is what’s referred to as the cascade of intervention. Caesareans and instrumental births are recommended to rectify the complications that can arise from interventions like syntocinon and artificial rupture of membranes. It is important to be aware of these possibilities before agreeing to begin a potential cascade when making the decision to have an induction or wait for labour to begin on its own.
How is induction different to a labour that begins spontaneously?
Everyone considering an induction should be aware that the experience of an induced labour is often very different from spontaneous physiological (natural) labour.
With induction being so commonplace and normalised in our modern culture, it seems that many women are mostly unaware that an induction is a deviation from the normal, natural processes of our bodies, and that once you are having an induction of any kind, you are no longer having a physiological birth. For those who don’t know, physiological birth is where labour and birth are able to completely unfold the way our body is designed to, with no intervention, procedure or medication inhibiting or interrupting the natural flow of hormones.
To find out more about the benefits of physiological birth, read Gentle Birth, Gentle Mothering by Dr Sarah Buckley or Reclaiming Birth as a Rite of Passage by Dr Rachel Reed.
For labour and birth to unfold and progress physiologically, the birthing woman needs to feel private, safe and unobserved. This is a well-known adage of Dr Sarah Buckley, birth and parenting researcher and author. During labour and birth, we drop into our mammalian (or animal) instincts and become incredibly vulnerable, and so it makes logical sense that we would need to feel instinctively safe for our babies to be born effectively and without complications.
There are a set of complex and delicate hormonal processes within your body that initiate the beginning of contractions. These processes ensure that mother and baby are both perfectly prepared for an effective labour, birth and postpartum/newborn transitions, including breastfeeding and bonding.
Oxytocin creates labour contractions and produces feelings of love, calmness and connection. For contractions to build and work effectively, it’s important to feel relaxed, loved and supported leading up to and during your labour. The way oxytocin works during labour is by a ‘positive-feedback loop’: it works to contract the uterine muscles to efface and dilate the cervix. This dilation will then cause the baby to press further against the cervix, which helps to trigger more prostaglandins, which triggers the release of more oxytocin.
Beta-endorphins are naturally-occurring pain relievers, which are incredibly effective and helpful in labour. There are, of course, many more hormones working in wonderful synergy, but it is important to know that the interplay between these key hormones can often be inhibited during an induction.
Each step of the induction process is an interruption of the physiological process of labour because you are being given medications and/or undergoing procedures to begin this hormonal process artificially. Without that trigger of spontaneous labour that begins on its own, the positive feedback loop that your labour hormones undergo is unable to commence.
It surprises some people to know that the artificial oxytocin that you are given during an induction (called syntocinon or pitocin) only works to create contractions and does not do all the other work that naturally-occurring oxytocin does, including triggering the release of beta-endorphins. It also can produce strong and very frequent contractions, often without the buildup that you get in spontaneous labour. This is why many women often describe their syntocinon induction as more painful and intense than a physiological labour, and why epidurals are more frequently administered during inductions with synthetic oxytocin6.
It can be difficult to feel private, safe and unobserved when you are in a hospital and undergoing an induction that can involve triggers that may cause your mind and body stress. These include being in an unfamiliar place where you may feel uncomfortable, bright lights and noise, medical equipment (especially loud, beeping machines), strangers coming into the room, frequently being spoken to and asked questions and having vaginal examinations. If these things make you feel uncomfortable or anxious, your body (i.e. your nervous system) will likely perceive them as a threat and think you are not in a safe enough place to give birth. Feeling stressed and releasing adrenaline during labour inhibits the cocktail of hormones I mentioned before, because this perceived threat can cause your body to slow or stall labour to decrease your vulnerability and chance of potential harm to you and your baby.
The interventions recommended to accompany induction procedures (e.g. continuous monitoring, IV cannula, etc.) can be very disruptive to the hormones of labour and come with their own set of risks, which will be broken down below. The need for continuous monitoring and being attached to tubes and cords also means that you can feel constrained during labour, and find it more difficult to be active and instinctive with the labour and birth positions that you want to utilise
Allowing naturally-occurring oxytocin to flow during labour also has significant impacts for immediately after birth. The peak of oxytocin happens around this pivotal time, which causes that ‘oxytocin high’ many mothers speak about after a physiological birth. This release is responsible for the placenta coming away from the wall of the uterus that was its home during pregnancy, and for the uterine contractions that allow the placenta to be birthed and to reduce blood-loss thereafter.
The euphoria felt with the oxytocin rush helps with the initial bonding between mother and baby that is essential for the dyad relationship and to initiate breastfeeding. Oxytocin is also responsible for the milk-ejection reflex or ‘let-down’ during breastfeeding. During an induction, when synthetic oxytocin is given and natural oxytocin is inhibited, the benefits are not experienced nearly as effectively by mother and baby.
Most women having an induction will be recommended to accept the syntocinon injection to birth their placenta to try and avoid subsequent blood loss.
For comprehensive insight into the hormones of labour and birth, I highly recommend reading Dr Sarah Buckley’s Gentle Birth, Gentle Mothering or listening to a podcast featuring her (a list of which you can find here). Dr Buckley is a GP and the foremost researcher on labour hormones and their role in labour, birth and post-birth.
Evidence on the risk of induction
According to a 16-year population-based linked data study completed in 2021, induction of labour in first time mothers results in higher rates of instrumental birth, epidural, emergency caesarean section, episiotomy, postpartum haemorrhage.
Induction versus spontaneous onset of labour statistics:
instrumental birth: 28.0% for induction vs 23.9% for spontaneous labour
intrapartum (after labour begins) caesarean section: 29.3% for induction vs 13.8% for spontaneous labour
epidural: 71.0% for induction vs 41.3% for spontaneous labour
episiotomy: 41.2% for induction vs 30.5% for spontaneous labour
postpartum haemorrhage: 2.4% for induction vs 1.5% for spontaneous labour
resuscitation of baby:
In that same study, it was discovered that for babies whose labours were induced, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years.
Read all about the findings in this research here: https://bmjopen.bmj.com/content/bmjopen/11/6/e047040.full.pdf
‘Failed’ induction?
If induction does not lead to labour progressing normally and the uncomplicated birth of your baby, it is often termed a ‘failed induction’, and women can feel as if their body ‘failed’ them. If you understand the physiology of birth and labour hormones, you will know that actually, your body is incredibly clever and very likely did exactly as it should in protecting you and your baby from something that perhaps they were not ready for.
Your body is perfectly designed to grow and birth your baby. Let’s give her a bit more credit. Whether it be because of an internal circumstance with the baby or an external factor such as your nervous system responding to a perceived threat, we can conclude that there was almost definitely a very good reason your body did not deem this the right time for your baby to be born. Rather than blame our bodies or feel guilt that they did not ‘work’ the way that they were expected to, I think they deserve immense gratitude for protecting us and our babies the way that they are designed to do.
If you’d like to dive deeper into induction and want to arm yourself more with high-quality information and research to make the right decision for you and your family, further reading and listening I recommend are:
Dr Rachel Reed, who has written a best-selling book on induction, Why Induction Matters and several articles on her website that delve into the research on induction and the reasons why it may be recommended: https://midwifethinking.com/. She also has an article on everything you should know about the induction process: https://midwifethinking.com/2015/03/18/induction-a-step-by-step-guide/?amp
Dr Sara Wickham, who has written two best-selling books on induction, In Your Own Time and Inducing Labour and several articles on her website: https://www.sarawickham.com/
The Midwives Cauldron podcast, hosted by Katie James and Dr Rachel Reed, have some incredibly insightful episodes about induction, including ‘How western medicine controls the start of labour and why this needs to stop - an interview with Dr Sara Wickham’ and ‘Induction of labour from the baby's perspective’: https://themidwivescauldron.buzzsprout.com/1178486
The Great Birth Rebellion podcast, hosted by Dr Melanie Jackson (and formerly B from Core and Floor Restore), features episodes on induction and the cascade of intervention, as well as having episodes that dissect the research into the reasons induction may be recommended in a way that is accessible and easy to understand: https://www.melaniethemidwife.com/podcasts/the-great-birth-rebellion
References:
Australia’s mothers and babies, onset of labour. Australian Institute of Health and Welfare. (2023, August 17). https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/onset-of-labour
Finucane EM, Murphy DJ, Biesty LM, Gyte GML, Cotter AM, Ryan EM, Boulvain M, Devane D. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub3
Reed, R. (2015, March 18). Induction: a step by step guide. Midwife Thinking. March 15, 2024, https://midwifethinking.com/2015/03/18/induction-a-step-by-step-guide/
Thomas J, Fairclough A, Kavanagh J, Kelly AJ. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD003101. DOI: 10.1002/14651858.CD003101.pub3. Accessed 11 March 2024.
Buckley, S. (2012, July 17). Labour Induction: Making Choices – Dr Sarah Buckley. Dr Sarah Buckley. Retrieved April 8, 2024, from https://sarahbuckley.com/labour-induction-making-choices/
Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003246. DOI: 10.1002/14651858.CD003246.pub2
Dahlen HG, Thornton C, Downe S, et al. Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open 2021;11:e047040. doi:10.1136/bmjopen-2020-047040