To Induce or Not to Induce? That is the Question
Midwifery Today, Issue 143, Autumn 2022.
Join Midwifery Today Online Membership
Hannah was 39 weeks and a few days pregnant with her first child one summer when she went to her scheduled prenatal appointment with her obstetrician/gynecologist. As a part of her examination, a late ultrasound was performed, and she was diagnosed with “low amniotic fluid.” She was told to drink a lot of water and go straight to the hospital to begin induction of labor. Fearing that her baby was going to die, Hannah immediately complied with her doctor’s advice.
What is induction?
The American College of Obstetricians and Gynecologists (ACOG) defines induction as “the use of medications or other methods to bring on (induce) labor” (acog.org). It is different from augmentation because the pregnant mother has not started labor: she has no uterine contractions. Her cervix may or may not show signs of thinning and opening; she may or may not have premature rupture of membranes (PROM), that is, an opening in the amniotic sac allowing amniotic fluid to come out.
Although doctors sometimes choose to ripen the maternal cervix with Cervidil (a synthetic prostaglandin) or laminaria (seaweed), Hannah’s did not. Hannah’s doctor began the induction with the use of a foley bulb: a catheter with a small balloon at the end, which was inserted into the cervix and then inflated with saline solution to dilate (open) the cervix. She was started on an IV drip of synthetic oxytocin, as well, in order to stimulate the uterus to contract. Her contractions started gradually but soon became more painful as the dose of synthetic oxytocin in the drip was continually increased.
Oxytocin, sometimes called the “love hormone,” is a naturally occurring hormone in the human body. It is what causes muscles in the body to contract. It is released during sex, birth, and breastfeeding, and can help to create a sense of calm and connection between human beings (Moberg 2016). In the hospital, synthetic oxytocin (sometimes called Pitocin or Syntocinon) is used to start labor, speed up labor, and stop bleeding afterward.
There is a key difference between naturally occurring and synthetic oxytocin in labor. The mother’s own natural oxytocin can cross the blood-brain barrier and have pain-relieving effects during contractions because it helps to release endorphins. Synthetic oxytocin cannot cross that barrier because it is a hydrophilic and polar neuropeptide (Wiberg-Itzel, Soderstrom, and Uvnas-Moberg 2021). Therefore, it has no pain-relieving effects. Furthermore, it can have adverse effects when administered, including nausea, vomiting, allergic reactions, postpartum hemorrhage, abnormal fetal or maternal heartrate (bradycardia, tachycardia, and arrythmia), hypertension, and uterine rupture, among others (Cunha 2022).
Even more critically, the synthetic hormone does not promote maternal-infant bonding in the same way that natural oxytocin does (Moberg 2016). Mothers who have been induced may not feel the “rush of love” at birth when they first hold their babies that they do after an unmedicated birth when natural oxytocin surges to 30 times its normal level in women’s bodies. Sometimes the lack of the surge in natural oxytocin, caused by the use of the synthethic in induction, can be remedied by breastfeeding, which gradually releases natural oxytocin and promotes attachment between mothers and babies over time.
The intensity of labor contractions early in an induced labor (when the cervix is dilated between 1–4 cm) can feel more intense than the transitional contractions (when the cervix is dilated between 7–10 cm) late in a natural, unmedicated labor—especially after artificial rupture of membranes (AROM). This was the case for Hannah. After several hours of painful and exhausting labor, while her cervix progressed only very slowly in thinning and opening, she requested an epidural for pain relief. The anesthesiologist inserted lidocaine with a needle into the epidural space of the spine of her low back successfully, and Hannah lost nearly all feeling of pain from the contractions as well as any sensation in her vagina, pelvis, low back, and legs.
Once Hannah had the epidural, she could no longer get up out of bed to walk around, even to use the bathroom. A urinary catheter was inserted. When the fetal heart rate appeared to drop on the fetal monitor at the time of placement of the epidural, the doctor decided to monitor the baby’s heart rate transvaginally and inserted a catheter to place an electrode on the baby’s scalp. With waters broken, several cervical checks, and the insertion of the urinary catheter and transvaginal electronic fetal heartrate monitor, Hannah was now at risk of infection, so the doctor gave her a round of IV antibiotics.
Hannah was also at risk of cesarean if her cervix did not fully open to allow her to push her baby out within 24 hours—the timeframe set by the hospital for delivery in cases of induction in order to reduce of the risk of chorioamnionitis (infection of the uterine fluid) and maternal sepsis. However, Hannah wanted a vaginal birth, since her mother and grandmother had had vaginal births with all of their children. She was very afraid of c-section surgery.
Per her doctor’s orders, Hannah hadn’t eaten or drunk anything since the induction began. Even her access to ice chips was limited. She was exhausted from the pain of the contractions. So once the epidural was in place, the nurses turned out the lights, and Hannah took a nap while the synthetic oxytocin drip continued to gradually increase, in hopes that her cervix would dilate fully and she would give birth vaginally.
For the doctors and nurses assisting Hannah with her induction at the hospital, the process was normal and went exactly to plan. They perform these types of procedures for nearly a third of all pregnant women they see. This reflects the US national average: between 1990 and 2018, induction rates rose from 9.6% to 25.7% for all women and to 31.7% for first-time births (Declerq, Belanoff, and Iverson 2020). But for Hannah, a first-time mother, the experience was abnormal, unplanned, and intensely frightening.
Hannah is a happily married school-teacher who planned to have a family and was delighted to find herself pregnant in her late twenties. She prepared for her birth by reading Your Pregnancy Week-by-Week by Judith Schuler and Glade Curtis. For her prenatal care, she chose a female Ob/Gyn whom she liked and trusted and whose services were covered by the healthcare plan she had through her job.
After trying one class of a Bradley series, she dropped out of it, because the teacher said something that her conservative husband felt was inappropriate. Instead, Hannah educated herself on her own, paid close attention to all of her doctor’s instructions, and talked about birth with her family members, including her sister, who is a doula. For a first-time mom, Hannah was very familiar with pregnancy, birth, breastfeeding, and the care of infants from growing up in a large family. She felt confident during her pregnancy and was looking forward to giving birth naturally.
The induction of labor process, however, caught her completely off her guard. The possibility of a threat to her baby’s life hijacked her birth plan. She didn’t know that late ultrasounds cannot always accurately measure low amniotic fluid. She did not know that fluid levels sometimes drop shortly before birth naturally. When her fluid measured low, her doctor advised her to re-hydrate and get induced rather than get re-checked to see if the fluid levels had risen. She didn’t know she could ask for a re-check. Yet during the induction process, when her doctor performed an AROM, plenty of water came gushing out hours after the ultrasound. The baby did have enough amniotic fluid after all, and the low amniotic fluid index (AFI) measurement at the time of the ultrasound was either inaccurate or a temporary state, not an indication of placental insufficiency.
During her labor, Hannah’s doctor came to tell her that she was considering taking her to the operating room for a cesarean. Since this was exactly what Hannah did not want, she asked for a little more time. She then called her family and asked for them to pray that she would be able to dilate completely and push her baby out naturally.
Fortunately for Hannah, her cervix was ready upon her next vaginal exam, and her friendly OB allowed her to push for the whole two hours that her protocols allowed. Even though she was a first-time mom on an epidural, and she could not feel her contractions, Hannah managed to push out her baby with tremendous effort just in the nick of time. She did not have to have a cesarean and she was able to breastfeed her baby shortly after birth.
To Induce or not to Induce?
In the United States, induction of labor in pregnant women has risen to nearly 30% in 2020, more than tripling since 1990 (Grobman 2022). While rates have risen worldwide as well, they have not risen at nearly this rate. Many inductions of labor fail to lead to vaginal birth and instead result in cesareans (Goer and Romano 2012). Induction and cesarean surgery come with risks to the health of both the mother and the baby.
ACOG recommends medical induction of labor for various causes. These include a pregnancy being at 41–42 weeks; maternal health problems with heart, lungs, or kidneys; placental problems; problems with the fetus, such as poor growth; decrease in amniotic fluid; infection of the uterus; gestational diabetes or diabetes mellitus; chronic hypertension, preeclampsia, or eclampsia; or pre-labor rupture of membranes. They also support elective induction of labor, as when a mother wants to induce because of “physical discomfort, a history of quick labor, or living far away from the hospital” (ACOG 2022).
There are other social pressures that can make a mother feel like she ought to induce, as well. Sometimes a mother has taken time off from work prior to the actual birth, only has a certain number of days or weeks to stay home with her baby (usually the standard six weeks for a vaginal birth and eight weeks for a c-section birth), and she wants that time with the baby in her arms, perhaps breastfeeding, rather than continuing in utero. This is paid time off to care for the baby as guaranteed by the federal Family Medical Leave Act. Although maternity leave can be extended while a job is held for the mother (or father), it is often unpaid, and unpaid leave is not an option for many families. In addition, some families like to pick the date of their baby’s birth, for convenience or in hopes of an auspicious birthday, and there are other reasons why women choose induction as well. Without obtaining her fully informed consent, a doctor may recommend induction and a mother may accept it, as Hannah did, without a full understanding of what induction entails or what risks it involves.
Risks of induction include low fetal heart rate due to adverse effects of medications, fetal distress, infection of the mother or baby, uterine hyperstimulation and possible amniotic fluid embolism (fortunately, rare), placental or uterine rupture, cesarean section, birth of a premature baby lacking proper lung development, and maternal hemorrhage (Mayo Clinic 2022; Goer and Romano 2012). These are serious risks that can lead to maternal and fetal morbidities and even mortality, though modern medicine fortunately has many ways of treating these complications when they arise.
However, given their seriousness, the risks ought to be significant enough to justify induction. Elective induction in a healthy woman poses unnecessary risks to the health of the mother and baby, and the mother ought to be informed of this so that induction will not be undertaken with false expectations of ease of delivery. All mothers, but especially first-time mothers, need fully informed consent about the benefits, risks, alternatives, and timing of induction.
A Midwife’s Perspective
I spoke with Hannah after her first birth and learned about her negative feelings regarding her experience of induction of labor with her first child. Because of how strong her negative feelings were, she did not want to have another child. Yet she unexpectedly became pregnant again and had difficulty adjusting. She then suffered a miscarriage, which was heartbreaking for her. After this, she decided that she did want to have another child after all, but in a more peaceful way.
Whereas she did not want a cesarean for her first birth, for her second, Hannah did not want either a cesarean or an induction. Although she decided to keep the same doctor and hospital for her second birth, and turned down her sister’s offer to be her doula due to her husband’s preference that he be her only family support during the labor, Hannah steadfastly declined all offers of induction before labor and augmentation during labor. She accepted an epidural in labor even though she did not feel she needed one, simply because she had one the first time, but she pushed her baby out easily after a very short labor with no complications. For Hannah, this was a healing experience.
Medical induction of labor can be a painful, fearful process for mothers and babies that presents unnecessary risks to their health. Induction comes with its own risks, such that it ought only to be undertaken if the benefits outweigh the risks. Induction can be beneficial if it leads to a vaginal birth instead of a major abdominal surgery in cases where an underlying condition in the mother (such as diabetes or preeclampsia/eclampsia) or in the fetus (such as poor growth) may be alleviated by an earlier birth.
However, it should be noted that not all underlying conditions listed by ACOG as reasons for induction are equal. In my view, elective medical inductions of labor in healthy women should not be offered or performed when requested because the risks outweigh the benefits. Low amniotic fluid, as we saw in Hannah’s case, is a questionable reason. Goer and Romano have provided extensive data to show that “postdates” pregnancies should rarely be induced, either (2012).
A diagnosis of “postdates” assumes that all women are due at 39–40 weeks. Yet in talking with older midwives, I have learned that in some families, the women used to regularly carry pregnancies for 42–44 weeks. Few women do so anymore, however, because this is not allowed in the obstetrical model of care and state regulations often do not allow midwives to continue caring for “postdates” pregnancies, either at home or in out-of-hospital birth clinics.
In my own personal experience, when I served as a midwife to the Acholi people in a rural area of northern Uganda, an estimated due date was often difficult to calculate because women rarely kept track of their menstrual periods and no working ultrasound was available in our rural clinic at the time to assess dates. Therefore, no one was ever induced in our practice. This was to avoid inducing a premature baby’s birth. Notably, there were no unfavorable outcomes from induction or lack of it. Induction is, in fact, rare across the whole country of Uganda, and this is only one example of many African countries that have low induction rates for most pregnant woman. As noted above, rates of induction are far higher in America than internationally.
This suggests that many of inductions of labor are being performed in the US unnecessarily. While there are many social and economic reasons for this, this trend should change. If it does, the physical and emotional health of mothers and their babies will improve in the future.
- ACOG. “Labor Induction: Frequently Asked Questions.” Acog.org. Accessed July 19, 2022. www.acog.org/womens-health/faqs/labor-induction.
- Cunha, John P. “Side Effects of Pitocin.” MedicineNet. Accessed July 27, 2022. www.medicinenet.com/side_effects_of_pitocin_oxytocin/side-effects.htm#what_drugs_interact_with_pitocin_oxytocin.
- Declerq, E, C Belanoff, and R. 2020. “Maternal perceptions of the experience of attempted labor induction and medically elective inductions: analysis of survey results from listening to mothers in California,” BMC Pregnancy and Childbirth 20: 458. bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03137-x.
- Goer, Henci, and Amy Romano. 2012. Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle: Classic Day Publishing. See esp. Chap. 7 “Inducing Labor: Patience is a Virtue,”129–80.
- Grobman, William. “Induction of Labor with Oxytocin.” UpToDate. Accessed July 18, 2022. www.uptodate.com/contents/induction-of-labor-with-oxytocin.
- Mayo Clinic. “Healthy Lifestyle: Labor and delivery, postpartum care: inducing labor: when to wait, when to induce.” MayoClinic.org. Accessed July 18, 2022. www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/inducing-labor/art-20047557.
- Moberg, Kerstin Uvnas. 2016 Oxytocin: The Biological Guide to Motherhood. Amarillo, Texas:Praeclarus Press.
- Wiberg-Itzel, E, M Soderstron, and K Uvnäs-Mober. 2021. “The correlation between synthetic oxytocin given during labor and women’s personality traits according to the SSP survey: A pilot study.” Front Women’s Health 6. www.oatext.com/the-correlation-between-synthetic-oxytocin-given-during-labor-and-womens-personality-traits-according-to-the-ssp-survey-a-pilot-study.php.