By Ali Weatherford

There have been a lot of pregnant people desiring early induction or being advised by their doctors to consider induction at 39 weeks. Especially in the last few years, these inductions are often done without medical necessity. These are also called elective inductions.

Maybe you like the idea of inducing labor a little early for any number of reasons.

Or maybe your doctor is suggesting an early induction, but you do not understand the reasons or if that’s something you want. This happens a lot. It’s okay to question this and want some more information.

It’s normal and important to be curious about what induction is and how it’s done

It’s hard to say exactly why your doctor is recommending an induction. But for people who do not have a medical problem that needs to be solved by induction, it’s common now that doctors refer to the results of the ARRIVE trial as evidence in support of elective induction at 39 weeks. Induction rates have gone up significantly in the last few years, possibly in response to these study results.

An elective induction is one done without any medical necessity. It’s a choice that’s not directly related to need or safety. The goal of the ARRIVE trial was to determine differences in outcomes between a 39-week elective induction or expectant management (waiting until labor begins on its own) in low-risk pregnancies.

The results of this study were published in 2018 and provide a lot of useful information for discovering the safest window of time to induce labor. The study also points out that inductions done at the right time and in the right way can be very safe and could potentially lower certain risks, such as cesarean rates and preeclampsia. However, it would be flawed to think that the results of this trial mean that ALL people would benefit from induction at 39 weeks.

There are many factors to consider when deciding whether to induce labor or to allow labor to begin spontaneously. Also, a follow-up study of data from before and after the ARRIVE trial showed that while induction rates have risen significantly since the study was published, the cesarean and preeclampsia rates have not significantly fallen.

It’s important to consider YOUR individual preferences for medical care and birth experience.

I’m a childbirth educator, and I get A LOT of questions about induction. Many students are faced with the decision and want to know the right thing to do. I am NOT a medical professional. I can not advise someone about how to manage their health care. Most importantly, I am not THEIR doctor. I try to gather as much information as I can, but I can only offer general information.

After doing a lot of reading, it seems pretty clear that as long as you are low-risk, the evidence can support either DOING or NOT doing an elective induction! That’s not helpful, right? It does not seem to be significantly more or less SAFE to have an elective induction for most people. It IS important though, to consider what you want for yourself.

What makes you feel safe and peaceful when you think about your birth?

Keeping stress levels low helps keep you safer and healthier. That means that the way you feel about different options for birth matters.

If your goal is to have an unmedicated birth, labor induction might make that less accessible. If your plan includes a lot of freedom of movement, the ability to eat and drink as desired, less time in the hospital, and fewer interventions, then allowing labor to begin spontaneously might be the way to go.

OR, you might like to have a smaller window of potential birth dates. The idea of sitting around WAITING for the baby to come can cause some people to stress which is never helpful! You might have special circumstances in your life that mean having your baby sooner will be helpful. Some people have partners who are on a short leave from a military deployment, or a parent who can only stay to help for a small window of time. You might have started your maternity leave and want to spend as much time as possible with your baby before going back to work. If you have some of these or similar circumstances, elective induction at 39 weeks is most likely a safe option.

If your goal is to avoid a cesarean, the results of the ARRIVE trial did show a 3% decrease in cesarean rates with elective induction. So far though, it doesn’t seem to be playing out this way in the real world. But it doesn’t seem that induction at 39 weeks is increasing cesarean rates either.

However, pay close attention to the reasons that the cesarean rates in the study might be lower. It might have something to do with the way participating doctors and hospitals were asked to handle each labor in the study. It was a well-designed and well-run trial. The doctors who participated in the trial were asked to follow a particular study protocol for HOW to perform the inductions and when to classify an induction as failed before continuing to a cesarean. For the people who were waiting for labor to begin on its own, there were also some guidelines for how to proceed with their care.

The way the doctors induced their patients in the trial is not necessarily the way that all doctors practice in the broader community or in all regions of the U.S. There are a lot of different ways to induce labor. Some are more successful than others for certain patients. Some providers have much higher cesarean rates than others. Those are all important questions when looking for ways to lower your chances of having a cesarean.

Also, consider that there are other ways to lower your cesarean risk by even bigger percentages. For example, having continuous labor support from a doula has been shown to decrease cesarean risk by as much as 35%!

It’s very important to understand that the results of studies can often be interpreted in different ways and it’s a great idea to dig a little deeper or ask questions before using the numbers to make a decision for yourself.

Here are a few articles that were written to help interpret and recommend how to implement the study results for the ARRIVE trial:

Ultimately, when induction is offered and the reasons are not explicit or medically necessary, you have a right to find out more and make that decision for yourself. Make sure to ask all the questions and get all the answers you need to make a decision that feels right for you and your family.

Remember also that the people who participated in the study CHOSE to do that. A lot more people were asked to participate but refused. We can’t know why, but we can probably assume that the people who said ‘yes’, felt comfortable with BOTH the idea of induced labor AND expectant management. That’s not true for everyone, and it’s important to know where you stand.

Is induction right for you?

Induction might be the path you’d like to choose, but for others, it is not. When you have conversations and feel empowered to make your own decisions without judgment, you gain trust in your care providers, confidence in your body, and in your ability to parent your children. This is a very big gain and should not be ignored.

You might also like to know what’s involved in an induction before deciding. Not all doctors or regions use the same methods, so be sure to talk to your doctor about how they anticipate your induction will be done so you can get prepared. It can be handled differently depending on your body’s level of readiness for labor and other factors.

If your cervix is already beginning to prepare for birth by softening, thinning, and/or opening, your induction might be handled a number of ways and may be shorter and easier than others. If your cervix has not begun to change for labor, an induction may involve several different steps and could take a very long time to initiate labor, even multiple days.

How is induction of labor done?

  1. Cervical Ripening – The cervix is part of the uterus. It’s the baby’s exit. It’s made of different tissue than the rest of the muscular uterus. It’s very firm while it’s trying to keep tightly shut and keep a baby inside. As the baby grows, your body starts to prepare for birth. The cervix will soften in response to hormones, called prostaglandins, which your body begins to release at the end of pregnancy. If you’re considering induction, your doctor will probably check your cervix to assess its readiness for labor.

The Bishop Score is a numerical calculation to rate the readiness of the cervix for induction based on what they feel during an examination. If you have a low Bishop score, and your cervix has more softening to do, you may be given cervical ripeners or prostaglandins as part of an induction. These on their own can sometimes get labor started, but are most often just a first step in the process. These medications might be:

    • Oral medications – Sometimes prostaglandins are given orally.
    • Vaginal medication – More often, the medication is put directly onto the cervix. It is inserted vaginally as a tablet, a gel, or an insert that can be removed when it’s no longer needed.
  2. Manual Opening – Sometimes a different method is used instead of OR in addition to the prostaglandins for cervical ripening. Manual methods for opening/softening the cervix involve putting an object into the cervix to force it open. Sometimes, this stimulation can get labor started without a need for further intervention, but it’s usually just a step in the process. Most of the time, these are done in the hospital and you stay until the baby is born. Some providers will insert the device and send the patient home to sleep and wait for progress. These manual methods might be:
    • Foley or Cook Catheter – This is a device like a balloon that is inserted into the cervix. It is then inflated with sterile fluid so it stretches the cervix. Once the cervix softens and opens, the device falls out or can be easily removed.
    • Laminaria sticks – These are small stick-like objects that are made of rolled-up seaweed! There is a string attached much like a tampon. They are inserted into the cervix and they begin to swell with moisture. As they swell, they stretch the cervix.
  3. Membrane Sweep – This involves the doctor or midwife inserting fingers into the vagina to disconnect the amniotic sac from the cervix. It can be done once the cervix is a little dilated (open) already. It can be a little uncomfortable, and there may be some bleeding after. It’s not as effective as some other strategies, and it can be done multiple times. Some providers might offer to do these at prenatal visits when you are approaching your due date.
  4. Rupture of Membranes – This means breaking your bag of water. The amniotic sac that your baby is inside of is full of fluid. Usually, the sac breaks on its own at some point during labor, releasing the water (MY WATER BROKE!!). Sometimes breaking it artificially can stimulate labor. A doctor or midwife will insert a long plastic stick (which looks sort of like a crochet hook) into the vagina to make a hole in the amniotic sac to release the fluid.
  5. Oxytocin – Oxytocin is a hormone that our bodies make to help us feel connected to each other, and it’s also responsible for uterine contraction! For labor induction, artificial oxytocin can be given by IV to start or intensify uterine contractions. Sometimes a small amount can jump-start labor and it can continue on its own. Other times, oxytocin is given continuously to keep labor going. Sometimes oxytocin is given after other methods for cervical ripening are done first. This might make oxytocin more effective.

Although inductions of labor done around 39 weeks are shown to be very safe in most cases, there are some risks. A lot of artificial oxytocin can cause the uterus to work too hard. Those stronger and more frequent contractions might cause some distress for the baby. During an induction, you, your baby, and your contractions will be monitored continuously so a problem can be caught and addressed if it happens. Those stronger and more frequent contractions can also sometimes lead to an exhausted uterus. If that happens, the risk of hemorrhage may be higher because the uterus can’t properly contract to stop the bleeding after the placenta is delivered. Risks for infection and uterine rupture can be slightly higher.

One more thing to recognize is that sometimes labor inductions don’t work. It might just be that sometimes your body is not ready, and all the efforts fail. If this happens, you might get sent home to come back and try another day as long as the amniotic sac is not broken. In other cases, a cesarean birth might be the next best option.

Whatever you decide, it’s always a good idea to get information and get prepared! People are often surprised at how long and involved an induction can be. You may not prepare to be in the hospital for so many days, which can cause stress and even boredom. As long as you have all the information, you can make the right choice for you.

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Resources:
https://www.nejm.org/doi/full/10.1056/NEJMoa1800566
https://www.ajog.org/article/S0002-9378(18)30661-6/fulltext
https://www.acog.org/womens-health/faqs/labor-induction
https://www.tommys.org/pregnancy-information/giving-birth/what-membrane-sweep
https://www.tommys.org/pregnancy-information/giving-birth/inducing-labour
https://evidencebasedbirth.com/arrive/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821557/#:~:text=The%20recent%20ARRIVE%20trial%20helped,induction%2C%20compared%20to%20expectant%20management
https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2014/03/safe-prevention-of-the-primary-cesarean-delivery
https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2018/08/clinical-guidance-for-integration-of-the-findings-of-the-arrive-trial