OB/GYN Explains Induction of Labor: Pros, Cons, and What You Need to Know

Hi, it is so great to see you again. Today, we are going to talk all about inductions of labor, why you might need one, how they happen, and kind of what to expect. Yeah, and over the course of this episode, we're going to be answering questions that you've asked us directly as well. Absolutely. So if this is your first time meeting us, I'm Sarah. I am a board certified OBGYN and a new mom. I'm Kurt. I'm a board certified pediatrician and a new dad. And we are the Doctors Bjorkman. Welcome back. We are the Doctors Bjorkman, as we mentioned, and we have detailed our own recent pregnancy and experience as new parents, trying to cover everything from trying to conceive through pregnancy and now parenthood, bringing our medical expertise and now new real life experience to you guys every week. Yes. So if you're not subscribed to our channel, please do so you can keep up with the great content we have coming for you. This week, we are talking all about inductions of labor. It's an episode we have gotten tons of requests for, so we're really excited to dive into that. There just seems to be a lot of buzz about inductions on social media. A lot of our friends and family have been induced. And so it seemed like the perfect time to go into it just because there can be a lot of angst and drama surrounding inductions of labor. So we want you to have the facts and the evidence. So maybe we could start by having you say what is an induction anyway? Sure. So an induction or an induction of labor or an IOL, we sometimes call it, is our goal is to induce labor, meaning to start labor. And so if you remember from our AMI and labor video, labor is when you start having regular strong uterine contractions that cause that cervix to change and dilate. And often that happens spontaneously. But up to 20, more than 22% of pregnant women will undergo an induction of labor here in the United States. And that's more than doubled since the 1990s. So the goal of an induction of labor is to kick you into labor to achieve a vaginal delivery. So an induction of labor is using medications to mimic the body's hormone to get the process of labor and childbirth started. Yes. Okay. But why doesn't everyone just do that naturally? That's a great question. And it's honestly something we don't have an answer to. Why do some women go into labor really, really early? We have a whole episode about what happens if my baby's born early. We don't understand why some women don't really kick into labor at all. We know there are a lot of things going on behind the scenes with your cervix and remodeling and changes in hormones, but we don't all exactly understand the timing and signal changes that are happening. Some women take a long time to kick into labor. Some women have super fast labors. We don't understand exactly why that happens, but it is a topic that is constantly being researched in OBGYN. So why would someone have an induction then? Well, there are really two big categories for why people get induced. And the first category is inductions that are medically necessary. Pregnancy generally is a state of wellness. However, some people have complex medical conditions or other things that make pregnancy a very high risk time for them. And pregnancy can complicate these medical conditions that people have at baseline. Other things that happen in terms of mom's health that we think about inductions for are things like preeclampsia, hypertensive disorders of pregnancy, uncontrolled gestational diabetes, or cholestasis. Sometimes it's also medically necessary for the baby's health to be born and have that labor induced. This could be either the baby is showing signs that it is not doing well, this could be poor growth, or that there's low fluid levels in the uterus. Also, going post dates can be dangerous for that baby inside mom too. We know that the risk of death in infants is twice that if they get to 42 weeks gestation as compared to babies born at 40 weeks. There's risk for infection in the uterus, there's risk for cord compression, and other things as that placenta is really kind of aging and meeting the end of its efficiency and supplying the nutrients that baby needs. The other big category, we have medically necessary inductions of labor, and then we have what we call elective inductions of labor. And so that means there is not a medical reason kind of pushing us to induce labor, but anyone after 39 weeks can choose to be induced. And so what is it about that 39 week mark, we might ask the pediatrician. Yeah, so full term in terms of full development of a developing baby is considered anytime after 37 weeks gestation. We know, however, that babies born at that 37-38 week mark have a slightly increased risk of some minor breathing issues. And then balancing that against the risks of going too long. And so week 39 seems to be this relatively sweet spot for baby's development avoiding some of the risks of going too long. So let's talk about how an induction works. So as we mentioned, we're using medications to mimic the body's natural process of getting that cervix to dilate and soften, and then getting those contractions started to push that baby out. Exactly. So let's talk about the cervix for a second. It is really an amazing organ. It goes from being closed and firm to keeping that baby in throughout your pregnancy to being soft and dilated to 10 centimeters to being able to let that baby exit the uterus. Sometimes the cervix is starting to soften as you get towards the end of pregnancy, but sometimes that cervix is still very firm and very close when you reach the end of pregnancy. And so there are things that your OB can do to help soften that cervix or ripen the cervix to get it ready for labor. And some of the things we can do are medications that you can either take orally or vaginally, they're called prostaglandins, and those help to soften the cervix. Sometimes they can cause contractions, sometimes they do not. And depending on the type of prostaglandin used, they can be every four hours or every 12, again, to help get that cervix soft and ready to go. Awesome. And then OBs often use things like Foley balloons too, right? Can you explain that? Yes. So a Foley balloon is just like it sounds. They are also used in the bladder to drain the bladder, but with a Foley balloon for inducing labor, it is a form of mechanical dilation. So what that means is your cervix is usually about one centimeter dilated, and you take a Foley balloon. It's kind of like a soft rubber straw that you pass through the cervix. And then you inflate that Foley balloon once it's up through your cervix in the uterus. And so you fill that Foley balloon with normal saline. And just by that Foley balloon being there in your uterus, it is causing the release of hormones and prostaglandins. So it's helping in that respect, but it's also kind of mechanically dilating often. There is some traction on that tail of the Foley balloon. And so it's also when that Foley balloon kind of works its way out of your cervix, you're three or four centimeters dilated. So often you may have to be a little bit dilated to get a Foley placed. So you may start out with some of those other medications. You may be able to do a Foley with those medications. You may start with a Foley. It depends on hospital policies and what your OBGYN prefers. Sometimes a Foley can be placed in the office and then you go home. Sometimes you do it as an inpatient in the hospital. Again, it just depends on your practices and hospitals policies and way they do inductions. So with all these different options about inducing labor, how do they choose what to do? Honestly, it depends on how your cervix feels and how dilated you are. So you will have a vaginal exam and then your OB will kind of make that choice. It's also very regional in how inductions happen and how your hospital does it. Also keep in mind that getting your cervix ready to go can take a long time. So hang in there. It can take more than 24 hours to get a cervix right or ready to go in someone who started out with a really unfavorable cervix that was very closed, very firm, very posterior. Okay. So then once the cervix is ripe, so it's softened a little bit, it started to dilate. What happens next? So you may be someone who comes in at two to three centimeters and is ready to go, or maybe you had to do some prostaglandins and a Foley to get your cervix right. But once you get to that point, now it is time to give you Pitocin to give you those strong uterine contractions to push that baby out. So Pitocin is synthetic oxytocin and oxytocin is the hormone that your brain makes to cause strong uterine contractions. And so now we need those strong uterine contractions. So baby's head is pushing down on that cervix to dilate it all the way to 10 centimeters. And then it's delivery time. Of course, if you are having an induction for a medical reason, it is important that you do that for your health or for baby's health or both. For whatever reason that is, your medical team has decided that is safer for you or baby or both of you for that baby to be on the outside. And that decision and recommendation is not made lightly by your team. But now let's talk about elective inductions or choosing to be induced at 39 weeks or beyond. Yeah, and so there's some historical older studies that compared women who came in in spontaneous labor already compared to women who came in and then had these elective inductions. And some of those older studies showed that women who had elective inductions had longer labor times and possibly a higher rate of c-sections. But when you think about these two groups that were in some of these older studies, they weren't really comparing apples to apples. And it's not surprising someone who comes in in labor already is going to have a shorter labor because they don't need the process of the extra medications and fluid bulbs to get things going. Right, that makes more sense that when you're coaxing labor to happen, it's going to take longer. So the big question though that wasn't addressed by these historical studies is what happens to women who have not gone into labor on their own by 39 weeks? Of course it is great to go into spontaneous labor, but if you've made it this far in pregnancy, is it better to be electively induced or is it better to just watch and wait and see what your body does? So this brings us to our discussion of the ARRIVE trial. This was a very well done randomized control trial that was completed in 2018 to look specifically at the question of how outcomes vary between women who undergo elective induction at 39 weeks versus those who continue that wait and see what happens approach. So before I go any further, a couple very important things to mention about this study. Number one, this study was looking at first-time moms who were healthy and otherwise low risk and whose babies were head down. Number two, there is a lot of nuanced discussion about the topic of elective induction. So please be sure to talk to your OB provider about this if it's something you're interested in because hopefully they know you, your medical history, and your goals for birth better than anyone. So as I mentioned, this ARRIVE study was really a good study. It was completed at 41 different centers in the United States and it has really helped to change the collective thought in the OBGYN community about kind of how we view inductions. So in this study, they recruited over 6,000 healthy first-time moms and half underwent induction at 39 weeks and the other half were in that wait and see group. And so they were allowed to go into labor naturally or ended up being induced for medical reasons, which also included making it to 40 and 5, at which time all the remaining women were induced. So what did they find? So they found that induction did not have a significant effect on death or serious complication in babies either way. For the moms who were electively induced, this was linked to lower c-section rates. So 18.6% in the elective induction group versus 22.2% in that wait and see group. For babies, the outcomes between the two groups were very similar, but those babies in the elective induction at 39 weeks group, they had a slightly lower rate of needing breathing help after birth. Overall, moms who were induced ended up spending more time in the hospital as you would expect. Again, if we're trying to coax you into labor, you might end up spending more time there, but they did spend less time kind of postpartum in the hospital. So the question, should everyone be induced at 39 weeks to lower the rate of c-sections? Although this study may be helpful with making informed decisions, it doesn't mean everyone should be induced. Also, it doesn't mean that elective induction at 39 weeks lowers the risk of c-section for every individual. There were more than 22,000 women who were eligible to be in this study and only 6,000 women volunteered to participate, which I think just goes to show that not every woman wants to have an elective induction and medical intervention in their pregnancy, and that's okay. So the American College of Obstetricians and Gynecologists did, however, release new practice guidelines that addressed the ARRIVE trial findings. They concluded that it's reasonable to offer elective inductions to low-risk, first-time moms at 39 weeks of pregnancy. However, they urge care providers to first consider three important factors. So number one, and most important, the values and preferences of the pregnant woman. Number two is the staffing and facility resources that are available, again, to assist with those possibly longer labors with an elective induction. And then number three, which is also really important, is they encouraged these providers to make sure they are re-evaluating and assessing their protocol for when they decide to call a failed induction. Again, not wanting to call an induction failed too early, and there are certain criteria that ACOG recommends OBGYNs use before making the decision to say, hey, this induction didn't work. We need to consider a C-section because we want to give moms a really good chance to have a safe vaginal delivery. Now, of course, some women want to have that experience of natural labor. That is totally understandable, whether it's having a non-medicated labor or, you know, definitely some people feel like they don't want to force their body maybe to do something that's not ready. I think it's interesting that the ARRIVE trial shows that, you know, sometimes it's actually better to help the body do the things it's naturally equipped to, but just doing it on a timeline that maybe is safer for mom and baby. Yeah. So whatever you decide, whether you want to be electively induced at 39 weeks or you want to wait and see what happens, it's just important to know that induction of labor at 39 weeks doesn't increase your risk of getting a C-section. It decreases your risk of some of the hypertensive disorders of pregnancy and may decrease your risk of your little one needing respiratory support. So very safe for mom, very safe for baby. Of course, you have to decide what is best for you and what feels important for you in terms of what you want for your experience. If you find yourself needing an induction, it means that you fall into one of two categories. One, you are in that medically necessary group, meaning that something is going on either with your health or with baby's that means you need your team thinks you should be delivered now. And that may be something that you knew was coming or it may be unexpected. And that can make, that can be kind of scary and make you very nervous. And there's a lot of emotion surrounding that. So again, want to make sure you're communicating with your OB team and your partner and your family and all of those things so you feel as supported as you can during that time. On the other side of it, there is the group of people who is considering elective induction. It means you, you're 39 or 40 weeks pregnant and you haven't gone into labor spontaneously. And that can, you know, that isn't also exactly what you imagined. And so that again can be a little bit scary and trying to decide what to do. So again, I, when you are being induced, it may not be that ideal situation that you had planned for. And so communication with your OB team is really important so that you feel like you understand what's going on with your care, what the plan is and feel as empowered as possible for your birth, even if it isn't exactly what you expected. So to wrap this up, let's kind of talk about the pros and cons of an elective induction of labor. And the first thing I kind of put in the con category is that generally speaking, inductions take more time. We are trying to coax your body to do something. We have to get your cervix ready. We're giving you contractions. So your induction may be longer than spontaneous labor. You may spend more time in the hospital. Another potential con of an induction is that once you start a medication called Pitocin, which is given to help augment those contractions, your OBGYN is going to want you on a continuous monitoring to see how well the baby's tolerating those contractions that they're getting your uterus to do. And so if you're hoping to have intermittent monitoring throughout your labor process, maybe an elective induction isn't the best for you. Another con is that there is this idea that inductions are more painful. And there isn't great data on this either way. However, it makes sense that maybe induced contractions are different than spontaneous ones. Yeah. And as we already mentioned, it's kind of interesting in the ARRIVE trial that those women who underwent elective inductions actually reported lower levels of pain than those women who had spontaneous labor. That's very true. And I would guess maybe that is because the women who were being electively induced were in a hospital setting. And so when they realized they were at that point at the threshold where they wanted pain medication or an epidural, it was immediately available to them. And they had control over that as opposed to maybe women in spontaneous labor who are laboring at home. Their pain kind of starts to escalate as they're on their way to the hospital, kind of white knuckle, trying to get there, dying for that epidural. So maybe that is part of that difference. One other thing to keep in mind is that because elective inductions can sometimes take longer than spontaneous labor, hospitals aren't always able to accommodate every elective induction of labor. And so it's important to talk to your OBGYN sooner rather than later as your hospital may be booking these out weeks to months in advance. So with all of that, what were the pros of induction? So as we discussed with the ARRIVE trial, your risk of C-section was lower. The risk of hypertensive disorders of pregnancy is lower. And then that risk of baby needing respiratory support was also decreased. So definitely things for the pro column. Yeah. And there's also the potential to have a little bit more control over when baby comes with the ability to schedule your induction. Yeah, absolutely. That is awesome. It is so empowering for many women to feel like they have a little bit of control over a very uncontrolled process, it seems. And so knowing, just knowing that, hey, if I get to 39 weeks and we haven't spontaneously gone into labor, we can schedule an induction and evict this kid if that's something you want to do. And it's really great for people who have other little kiddos that have to arrange child care for if you take care of older parents and again, need help coordinating care and different things like that. It's very helpful. It is also really great for military families or spouses who travel in terms of timing and getting things scheduled. Definitely a pro to be able to potentially schedule when you're going to try to bring that baby earthside. So people ask me all the time, you know, what do you think about elective inductions? What would you do? And my answer is that I love elective inductions. I love the ARRIVE trial. If like you feel that's what's good for you, I personally knew that was the right move for me. I had my induction scheduled at 39 weeks. I knew that if I was still pregnant at 39 weeks, I was going to evict that sweet little girl and felt very confident that it wasn't increasing my risk of c-section. It was not going to do anything, you know, bad for babe. And so that was very much the right move for me in terms of it definitely gave you this like tiny shred of feeling like you had control over this situation that, you know. Yeah. It also made it pretty nice in terms of we both have pretty busy work schedules and for me to be able to tell my colleagues like, hey, by this date, I'm going to coverage. I can be home with Sarah and baby for those first couple of weeks. That was like a nice little extra little bit of peace of control in an otherwise uncontrollable situation. Yes. And so while my water did break when I was elsewhere, I did not kick into labor on my own, nor was my cervix even remotely favorable at that point. And so I did get to experience some of those lovely things we talked about. I had a Foley balloon that my uterus did not like at all and tried to cramp it out. I got Pitocin that sucked like the contractions were not a fun time. So I was very grateful to have immediately accessible pain meds when I was ready for those. So that's our overview of induction. Yeah. You all left us some amazing questions on our community page about induction. Hopefully we answered so, so many of them with this episode. We are going to go shoot a Q and a all about inductions just so this episode doesn't get super long. So please keep your eyes out for that. It was great having you this week. We are looking forward to more great content coming for you soon. Have a great week. See you next week guys. Bye.