Induce labor

Contents

What is induction of labor

What is induction of labor

Induction of labor refers to the use of medications or other methods to induce or cause labor and childbirth. Induction of labor is used to make uterine (womb) contractions start so that delivery can occur ¹. Induction of labor is usually used only when a problem with the pregnancy risks the health of either the mother or the fetus or when the due date has passed ¹.

More than one in four pregnant women end up getting induced because:

Their baby is overdue but needs a little bit of coaxing out into the world;
They have a medical condition (most commonly diabetes) or pregnancy complication (most commonly premature rupture of the membranes) which creates health risks if they continue the pregnancy; or
There is something wrong with the baby for example it is not growing properly, and may be in danger if the pregnancy continues.

However even in these situations, your doctor may not induce labor. If, after having the risks and benefits of induction of labor explained, the pregnant woman does not agree to be induced the procedure will not be performed.

Induced labor for full-term pregnancy

A large study found that, for healthy women, inducing labor at full term rather than waiting for natural labor doesn’t increase the risk of major complications for newborns.
The findings also reverse the notion that inducing labor at full term increases the risk of needing surgical delivery.

In most cases, induction of labor is limited to situations in which there is a problem with the pregnancy or in which the pregnancy has continued past the infant’s due date. It is usually best to “let the baby set the delivery date” and allow labor to begin on its own, unless there is a medical reason to do otherwise.

Women who want labor induction for non-medical reasons should discuss it with their health care providers ².

Let baby set the delivery date

You can avoid or reduce many health risks for the mother and the baby by waiting until 39 weeks of pregnancy to deliver, if there is no medical reason to deliver earlier.
Research shows that the fetus goes through a significant amount of lung, liver, and brain development between 37 weeks and 39 weeks of pregnancy.
Your due date could be off by up to 2 weeks, which means if you have your baby before 39 weeks you could actually be having it early.
Research shows that delaying delivery until 39 weeks of pregnancy or later—if there is no medical reason to deliver earlier—is not associated with increased rates of stillbirths ³.

The American College of Nurse Midwives ² affirms the following:

Spontaneous labor offers substantial benefit to the mother and her newborn. Disruption of this process without an evidence-based medical indication represents a risk for potential harm.
Induction of labor should be offered to women only for medical indications that are supported by scientific evidence which indicate the benefit outweighs the risk of induction of labor, including the potential risks of prematurity or postmaturity.
Informed consent prior to labor induction should include discussion of the normal processes of labor and the benefits and potential harms of induction, including the optimal method to use during the induction process.
Development of the state of the science regarding the use of obstetric interventions for healthy childbearing women should continue, focusing on both the health outcomes associated with induction of labor and the context in which the decision for induction of labor occurs between healthcare providers and childbearing women.
Through a process of education and discussion, midwives can assist childbearing women to make informed decisions regarding induction of labor.

Monitoring your body’s preparation for labor

Several weeks before your labor begins, your cervix begins to soften (called “ripening”), thin out, and open to prepare for delivery. If your cervix is not ready, especially if labor has not started 2 weeks or more after the due date, a health care provider may recommend medication or other means to ripen the cervix before inducing labor.

Health care providers use a scoring system, called the Bishop score, to determine how ready the cervix is for labor. The scores range from 0 to 13. A score of less than 6 means that the cervix may need help to prepare for labor ¹.

Table 1. Modified Bishop score

Cervical features	Score
Cervical features	0	1	2	3
Dilation (cm)	< 1	1-2	3-4	> 4
Length of Cervix (cm)	> 3	2	1	< 1
Station (relative to ischial spines)	-3	-2	-1 / 0	+1 / +2
Consistency	Firm	Medium	Soft	–
Position	Posterior	Mid	Anterior	–

From the table above you can see that you will have a higher score if the cervix has already started to dilate, has shortened, is soft and has moved from a posterior to anterior position. For those women in which the cervix is already ‘ripened’ (a Bishop score of 7 or above) or have undergone cervical ripening, the next step of the process of inducing labor is artificial rupture of membranes and commencement of oxytocin infusion.

If your cervix is not ready for labor, your health care provider may suggest one of the following steps to ripen the cervix ¹:

Stripping the membranes. Your health care provider can separate the thin tissue of the amniotic sac with a finger, which contains the fetus, from the wall of the uterus. This process causes your body to release prostaglandins, which soften the cervix and cause contractions.
- Risks: This is a simple and easy procedure. It can be a bit uncomfortable but it doesn’t hurt. However, the procedure does not always work.
Giving prostaglandins. Prostaglandin E2 (dinoprostone) may be inserted into the vagina or given by mouth. Prostaglandin can be inserted if the Bishop score is 6 or less. Prior to inserting the medication into your vagina, you may be asked to empty your bladder. The position of your baby will be confirmed by palpating (feeling) the abdomen. A cardiotograph (CTG – recording of the baby’s heart rate and contractions of the uterus) will be performed to check the foetal heart rate pattern and the presence/absence of any contractions. If the bishop’s score is unknown an internal cervical assessment/vaginal examination must be made. Some women can find this uncomfortable as it involves the doctor or midwife inserting two fingers into the vagina in order to feel the cervix and make an assessment about the cervix’s dilatation, length, position and consistency (Bishop’s score).
- Your body naturally makes prostaglandins to ripen the cervix, but sometimes additional amounts are needed to help labor occur. Prostaglandin is available in the form of a gel (Prostin E2) or as a controlled release (the dose is released over a period of time) pessary (Cervidil) that is inserted into the vagina. Prostaglandin gel may be given in several doses, or a pessary, which releases the hormone over several hours. You will need to lie down for 30 minutes to allow the medication to be absorbed and stay in hospital after the prostaglandin is inserted. You may also need amniotomy or oxytocin too. A cardiotograph (CTG – recording of the baby’s heart rate and contractions of the uterus) will be recording your baby’s heart rate and any uterine contractions during this period. The fetal heart rate and maternal observations (any vaginal fluid loss/bleeding, temperature, pulse, blood pressure and oxygen saturations) will be checked 4-hourly thereafter. If you develop contractions you will need to have continuous CTG monitoring. A repeat internal exam will be performed six hours post dose to assess any cervical change. If the change is minimal then a second dose can be given.
- Risks: Some women find their vagina is sore after the prostaglandin, or they might experience nausea, vomiting or diarrhea. These side effects are rare and there’s no evidence that induction using prostaglandin is any more painful than a natural labor. Very rarely, the contractions can come too strongly, which can affect the baby’s heart rate. This can be controlled by giving you another medicine or removing the pessary. Tell your midwife or doctor straight away if you’ve had prostaglandin and you experience painful, regular contractions 5 minutes apart (for your first baby) or 10 minutes apart (for subsequent babies). Also tell them if your waters break, you start bleeding, or your baby is moving less.
- Complications can include:
  - Maternal gastrointestinal symptoms such as nausea
  - Uterine overactivity (the uterus contracting too frequently)
  - Postpartum hemorrhage (bleeding following the birth of your baby)
  - Fever
  - Amniotic fluid embolism
  - Vaginal irritation and/or
  - Back pain
- Some reasons why you shouldn’t have prostaglandins include:
  - Previous surgery involving the uterus, such as previous caesarean section
  - If you have had five or more babies in the past
  - Abnormal cardiotograph (CTG – recording of the baby’s heart rate and contractions of the uterus) or suspected fetal compromise
  - Known hypersensitivity to the medication
  - Any other conditions for which a vaginal delivery is NOT recommended
Inserting a balloon catheter. A small tube with an inflatable balloon on the end can be placed in the cervix to widen it. The balloon is inflated with saline, which usually puts enough pressure on your cervix for it to open. It stays in place for up to 15 hours, after which you’ll be examined again. You may also need artificial rupture of membrane (ARM) or oxytocin as well as a cervical ripening balloon catheter.
- Risks: Inserting the catheter can be a bit uncomfortable, but not painful. Tell your midwife or doctor straight away if the catheter falls out or you experience painful, regular contractions 5 minutes apart (for your first baby)or 10 minutes apart (for subsequent babies). Also tell them if your waters break, you start bleeding, or your baby is moving less.
Laminaria (a substance that absorbs water) can be inserted to expand the cervix.

Why should I wait until at least 39 weeks of pregnancy to deliver?

Babies born at or after 39 weeks of pregnancy face fewer health problems.
Babies’ brains, lungs, and liver continue important development until 39 weeks. Your baby’s brain, lungs, liver and other important organs are still developing in the last weeks of pregnancy.
Babies born too early may have more health problems at birth and later in life than babies born later.

If your pregnancy is healthy, it’s best to stay pregnant for at least 39 weeks. Wait for labor to begin on its own.

Scheduling means you and your provider decide when to have your baby by labor induction or cesarean birth.
If your provider recommends scheduling your baby’s birth, ask if you can wait until at least 39 weeks so your baby has time to fully develop.

Why does your baby need 39 weeks?

Babies born too early may have more health problems at birth and later in life than babies born later. Being pregnant 39 weeks gives your baby’s body all the time it needs to develop.

Your baby needs 39 weeks in the womb because:

Important organs, like your baby’s brain, lungs and liver, need time to develop. The brain develops fastest at the end of pregnancy. A baby’s brain at 35 weeks of pregnancy weighs only two-thirds of what it will weigh at 39 to 40 weeks.
She’s/He’s less likely to have health problems after birth, like breathing, vision and hearing problems.
She/He can gain more weight in the womb. Babies born at a healthy weight have an easier time staying warm than babies born too small.
She/He can suck and swallow and stay awake long enough to eat after he’s born. Babies born early sometimes can’t do these things.
She’s/He’s less likely to have learning problems and health problems later in life than babies born before 39 weeks.

Can scheduling an early birth cause problems for you and your baby?

Yes. Sometimes it’s hard to know exactly when you got pregnant. Even with an ultrasound, your due date can be off by as much as 2 weeks. If you schedule an induction or c-section and your date is off by a week or 2, your baby may be born too early. Ultrasound uses sound waves and a computer screen to show a picture of your baby inside the womb.

What are the risks to my baby and to me if I deliver without a medical reason before 39 weeks of pregnancy?

Risks to the baby:

May need to stay in the neonatal intensive care unit (NICU)
Birth complications, including breathing problems and cerebral palsy
Developmental disabilities, such as attention deficit/hyperactivity disorder (ADHD)
A 63% greater chance of death within the first year of life compared to babies born between 39 weeks and 41 weeks ⁴

Risks to the mother:

Postpartum depression ⁵
Stronger and more frequent contractions ⁶
Need for a cesarean delivery and its outcomes, including risk of infection, longer recovery time, and the possible need for cesarean delivery in future pregnancies ⁶

When does labor usually start?

For most women, labor begins sometime between week 37 and week 42 of pregnancy. Labor that occurs before 37 weeks of pregnancy is considered premature, or preterm ⁷.

Just as pregnancy is different for every woman, the start of labor, the signs of labor, and the length of time it takes to go through labor vary from woman to woman and even from pregnancy to pregnancy.

What is the differences between induced and natural labor?

An induced labor can be more painful than natural labor. In natural labor, the contractions build up slowly, but in induced labor they can start more quickly and be stronger. Because the labor is more painful, you’re more likely to need an epidural.

If your labor is induced, you are more likely to need other interventions such as the use of forceps or ventouse. You won’t be able to move around as much because the baby will need closer monitoring than during a natural labor.

There is also the risk that your baby won’t get as much oxygen or that their heart rate will slow down, or that the induction won’t work and you will need a caesarean. In rare cases, women lose more blood than normal after the baby is born, or their uterus tears.

How to induce labor

Once your cervix is ripe, your health care provider may recommend one of the following techniques to start contractions or to make them stronger ¹:

Amniotomy or artificial rupture of membrane (ARM). Your health care provider uses a small hook-like instrument to make a small hole in the amniotic sac, causing it to rupture (or the water to break) and contractions to start. Amniotomy is done to start labor when the cervix is dilated and thinned and the fetus’s head has moved down into the pelvis. Amniotomy can be performed to induce labor if the Bishop’s score is 7 or more. Before your membranes are ruptured, you will most likely be asked to empty your bladder. Following this, the position of the baby will be determined by palpating (feeling) the abdomen. Your baby’s heart rate will also be monitored. The membranes are ruptured while an internal exam is being performed. Once the membranes have ruptured you will experience fluid leaking out of the vagina, this is the fluid that surrounded your baby. Most women go into labor within hours after the amniotic sac breaks (their “water breaks”). However, some women will also need oxytocin to start their contractions.
- Situations where amniotomy should not be performed includes:
  - Low lying placenta (Placenta previa)
  - HIV infection
  - Active herpes lesions
  - Abnormalities of how the baby is lying
  - Any other conditions for which a vaginal delivery is not recommended
- Risks: There is a small increased risk of a prolapsed umbilical cord (where the umbilical cord comes out in front of the baby’s head), bleeding or infection. Amniotomy can be a bit uncomfortable, but not painful.
Giving oxytocin (also called Pitocin or Syntocinon). Oxytocin is a hormone the body naturally makes that causes contractions of the uterus. Synthetic forms of oxytocin (Pitocin or Syntocinon) are available and these can be administered intravenously (into the vein) to induce labor. This is typically as an infusion where a certain dose of the medication is delivered over a period of time. Oxytocin is given to start labor or to speed up labor that has already begun. Contractions usually start in about 30 minutes after oxytocin is given. Before starting oxytocin it is important that it has been 6 hours or more since your last dose of prostaglandins if you had any, that your membranes have ruptured either naturally or artificially (amniotomy) and that there are no abnormalities with the fetal heart pattern on cardiotograph (CTG – recording of the baby’s heart rate and contractions of the uterus). While you are receiving the oxytocin infusion you will need continuous CTG monitoring. This is to monitor your baby’s heart rate as well as determine how many, if any, contractions you are having. The amount of oxytocin given to you is adjusted depending on your response. The aim is to use the lowest dose of oxytocin possible to maintain 3-4 contractions in 10 minutes with each contraction lasting approximately 60 seconds.
- Situations where you shouldn’t have an oxytocin infusion include:
  - Any condition in which labor is not recommended
  - 2 or more previous caesarean sections
- Risks: Oxytocin can make contractions harder to cope with. You are more likely to need pain relief and the baby needs to be continually monitored. You won’t be able to move around much because of the drip in your arm. Sometimes the contractions can come too quickly, which can affect the baby’s heart rate. This can be controlled by slowing down the drip or giving you another medicine.
- Complications that can be associated with oxytocin infusion include:
  - Overstimulation of your uterus (Uterine hyperstimulation) – see below
  - Water retention
  - Low blood pressure (Hypotension)
  - Rarely abnormal heart rhythms (arrhythmias) and/or anaphylaxis reactions can occur

Oxytocin can be associated with uterine hyperstimulation. This occurs when:

Frequency of contractions is five or more within a ten minute period
Contractions last greater than 90 seconds
Contractions of a normal duration occur within 1 minute of each other
The uterus does not completely relax between contractions

If the baby seems unaffected by this it can simply be managed by turning off the oxytocin until the activity returns to normal. If the baby appears stressed (determined by its heart rate pattern) the oxytocin should be stopped promptly and consideration given to the use of medications to stop further contractions. Preparation for immediate vaginal delivery and/or possible caesarean section should be made in the event that the foetal heart rate does not return to normal. Where contractions return to normal and the baby is not stressed, the oxytocin should be restarted at half the rate of the last dose infused and adjusted accordingly.

What are the risks associated with labor induction?

With some methods, the uterus can be overstimulated, causing it to contract too frequently. Too many contractions may lead to changes in the fetal heart rate, umbilical cord problems, and other problems. Other risks of cervical ripening and labor induction include the following ¹:

Infection in the mother or fetus
Uterine rupture
Increased risk of cesarean birth
Fetal death

Medical problems that were present before pregnancy or occurred during pregnancy may contribute to these complications.

Is labor induction always effective?

Sometimes labor induction does not work ¹. A failed attempt at induction may mean that you will need to try another induction or have a cesarean delivery ¹. The chance of having a cesarean delivery is greatly increased for first-time mothers who have labor induction, especially if the cervix is not ready for labor.

What are signs of labor

The primary sign of labor is a series of contractions (tightening and relaxing of the uterus) that arrive regularly. Over time, they become stronger, last longer, and are more frequent. Some women may experience false labor, when contractions are weak or irregular or stop when the woman changes positions. Women who have regular contractions every 5 to 10 minutes for an hour should let their health care provider know.

It is important to discuss labor and signs of labor with a health care provider early in pregnancy, before labor begins. Some doctors may want a woman to wait until she has multiple signs of labor or is in “active” labor before coming to the hospital or birthing center.

Signs That You Are Approaching Labor
Sign	What It is	When It Happens
Feeling as if the baby has dropped lower	Lightening. This is known as the “baby dropping.” The baby’s head has settled deep into your pelvis.	From a few weeks to a few hours before labor begins
Increase in vaginal discharge (clear, pink, or slightly bloody)	Show. A thick mucus plug has accumulated at the cervix during pregnancy. When the cervix begins to dilate, the plug is pushed into the vagina.	Several days before labor begins or at the onset of labor

Other signs of labor include ⁸:

“Lightening.” This term refers to when the fetus “drops,” or moves lower in the uterus. This may happen several weeks or only a few hours before labor begins. Not all fetuses drop before birth. Lightening gets its name from the feeling of lightness or relief that some women experience when the fetus moves from the rib cage to the pelvic area. It allows some women to breathe more easily and more deeply and may provide relief from heartburn.
Increase in vaginal discharge. Called “show” or “the bloody show,” the discharge can be clear, pink, or slightly bloody. This discharge occurs as the cervix begins to open (dilate) and can happen several days before labor or just as labor begins.

Labor contractions before 37 weeks of pregnancy are a sign of preterm labor. Women who notice regular, frequent contractions at any point in pregnancy should notify a doctor or go to the hospital. Your doctor can check for changes in the cervix to see whether labor has begun. As needed, doctors can also give women in preterm labor specialized care. Among women who experience preterm labor, only about 10% go on to give birth within a week.

Other signs of labor include ⁹:

Change in vaginal discharge
Pain or pressure around the front of the pelvis or the rectum
Low, dull backache
Cramps that feel like menstrual cramps, with or without diarrhea
A gush or trickle of fluid, which is a sign of water breaking

Sometimes, if the health of the mother or the fetus is at risk, a woman’s health care provider will recommend inducing or causing labor using medically supervised methods, such as medication ¹.

Unless earlier delivery is medically necessary or occurs on its own, waiting until at least 39 weeks before delivering gives mother and baby the best chance for healthy outcomes. During the last few weeks of pregnancy, the fetus’s lungs, brain, and liver are still developing ¹⁰.

What is false labor?

Your uterus may contract off and on before “true” labor begins. These irregular contractions are called false labor or Braxton Hicks contractions. They are normal but can be painful at times. You might notice them more at the end of the day. Usually, false labor contractions are less regular and not as strong as true labor. Sometimes the only way to tell the difference is by having a vaginal exam to look for changes in your cervix that signal the onset of labor.

One good way to tell the difference is to time the contractions. Note how long it is from the start of one contraction to the start of the next one. Keep a record for an hour. It may be hard to time labor pains accurately if the contractions are slight. Listed as follows are some differences between true labor and false labor:

Differences Between False Labor and True Labor
Type of Change	False Labor	True Labor
Timing of contractions	Often are irregular and do not get closer together (called Braxton Hicks contractions)	Come at regular intervals and, as time goes on, get closer together. Each lasts about 30–70 seconds.
Change with movement	Contractions may stop when you walk or rest, or may even stop with a change of position	Contractions continue, despite movement
Strength of contractions	Usually weak and do not get much stronger (may be strong and then weak)	Increase in strength steadily
Pain of contractions	Usually felt only in the front	Usually starts in the back and moves to the front

[Source ⁸ ]

What are the stages of labor?

Labor has three stages. In the first stage of labor, the body prepares to give birth. There are two phases: early and active.

Stage 1

The first stage of labor happens in two phases: early labor and active labor. Typically, it is the longest stage of the process.

During early labor:

The opening of the uterus, called the cervix, starts to thin and open wider, or dilate.
Contractions get stronger, last 30 to 60 seconds, and come every 5 to 20 minutes.
The woman may have a clear or slightly bloody discharge, called “show.”

A woman may experience this phase for up to 20 hours, especially if she is giving birth for the first time.

During active labor:

Contractions become stronger, longer, and more painful.
Contractions come closer together, meaning that the woman may not have much time to relax in between.
The woman may feel pressure in her lower back.
The cervix starts dilating faster.
The fetus starts to move into the birth canal.

Stage 2

At this stage, the cervix reaches full dilation, meaning that it is as open as it needs to be for delivery (10 centimeters). The woman begins to push (or is sometimes told to “bear down”) to help the baby move through the birth canal.

During stage 2:

The woman may feel pressure on her rectum as the baby’s head moves through the vagina.
She may feel the urge to push, as if having a bowel movement.
The baby’s head starts to show in the vaginal opening (called “crowning”).
The health care provider guides the baby out of the vagina.

This stage can last between 20 minutes and several hours. It usually lasts longer for first-time mothers and for those who receive certain pain medications.

Stage 3

Once the baby comes out, the health care provider cuts the umbilical cord, which connected the mother and fetus during pregnancy. In stage 3, the placenta is delivered. The placenta is the organ that gave the fetus food and oxygen through the umbilical cord during the pregnancy. It separates from the wall of the uterus and also comes out the birth canal. The placenta may come out on its own, or its delivery may require a provider’s help.

During stage 3:

Contractions begin 5 to 10 minutes after the baby is delivered.
The woman may have chills or feel shaky.

Typically, it takes less than 30 minutes for the placenta to exit the vagina. The health care provider may ask the woman to push. The provider might pull gently on the umbilical cord and massage the uterus to help the placenta come out. In some cases, the woman might receive medication to prevent bleeding ¹¹.

Pain relief options during labor and delivery

The amount of pain felt during labor and delivery is different for every woman. The level of pain depends on many factors, including the size and position of the baby, the woman’s level of comfort with the process, and the strength of her contractions.

There are two general ways to relieve pain during labor and delivery: using medications and using “natural” methods (no medications, also called natural childbirth). Some women choose one way or another, while other women rely on a combination of the two.

A woman should discuss the many aspects of labor with her health care provider well before labor begins to ensure that she understands all of the options, risks, and benefits of pain relief during labor and delivery before making a decision. It might also be helpful to put all the decisions in writing to clarify things for all those who might be involved with delivering the baby.

Pain-Relieving Medications

Pain-relief drugs fall into two categories: analgesics and anesthetics ¹².

Each category has different forms of medications. Some of these medications carry risks. It is important for women to discuss medications with their health care provider before going into labor to ensure that they are making informed decisions about pain relief.

Analgesics

Analgesics relieve pain without causing total loss of feeling or muscle movement. These drugs do not always stop pain completely, but they reduce it.

Systemic analgesics affect the whole nervous system rather than a single area. They ease pain but do not cause the patient to go to sleep. Systemic analgesics are often used in early labor. They are not given right before delivery, because they may slow the baby’s breathing and reflexes. They are given in three ways:
1. Injected into a muscle or vein
2. Administered through a small tube placed in a vein. The woman can often control the amount of analgesic flowing through the tube.
3. Inhaled or breathed in with a mixture of oxygen.2 The woman holds a mask to her face, so she decides how much or how little analgesic she receives for pain relief.
Regional analgesics relieve pain in one region of the body. In the United States, regional analgesia is the most common way to relieve pain during labor.3 Several types of regional analgesia can be given during labor:
- Epidural analgesia, also called an epidural block or an epidural, causes loss of feeling in the lower body while the patient stays awake. The drug starts working about 10 minutes to 20 minutes after it is given. A health care provider injects the drug near the spinal cord. A small tube (catheter) is placed through the needle. The needle is then withdrawn, but the tube stays in place. Small amounts of the drug can then be given through the catheter throughout labor without the need for another injection.
- A spinal block is an injection of a much smaller amount of the drug into the sac of spinal fluid around the spine. The drug starts working right away, but it lasts for only 1 to 2 hours. Usually, a spinal block is given only once during labor, to help with pain during delivery.
- A combined spinal-epidural block, also called a “walking epidural,” gives the benefits of an epidural block and a spinal block. The spinal part relieves pain immediately. The epidural part allows drugs to be given throughout labor. Some women may be able to walk around after a combined spinal-epidural block.

Anesthetics

Anesthetics block all feeling, including pain.

General anesthesia causes the patient to go to sleep. The patient does not feel pain while asleep.
Local anesthesia removes all feeling, including pain, from a small part of the body while the patient stays awake. It does not lessen the pain of contractions. Health care providers often use it when performing an episiotomy, a surgical cut made in the region between the vagina and anus to widen the vaginal opening for delivery or when repairing vaginal tears that happen during birth.

Natural Pain-Relief Methods or Natural Childbirth

Women who choose natural childbirth rely on a number of ways to ease pain without taking medication. These include ¹³:

The company of others who offer reassurance, advice, or other help throughout labor, also known as continuous labor support ¹⁴
Relaxation techniques, such as deep breathing, music therapy, or biofeedback
A soothing atmosphere
Moving and changing positions frequently
Using a birthing ball
Massage
Yoga
Taking a bath or shower
Hypnosis
Using soothing scents (aromatherapy)
Acupuncture or acupressure
Applying small doses of electrical stimulation to nerve fibers to activate the body’s own pain-relieving substances (called transcutaneous electrical nerve stimulation, or TENS)
Injecting sterile water into the lower back, which can relieve the intense discomfort and pain in the lower back known as back labor

When is induce labor dangerous?

There are also some situations when labor will not be induced because it is too dangerous (no matter how much mum is ready and willing to do just about anything to get baby out of there). These are usually situations in which a vaginal birth is not possible, and a caesarean section is the recommended method of bringing baby into the world.

Labor will not be induced unless the baby is doing everything just right. For example, if baby is not in the right position for vaginal birth (malpresentation) or the position of the umbilical cord poses a danger during vaginal birth, induction of labor is contraindicated meaning it’s a big no-no in doctor speak.

Similarly if the placenta or umbilical vessels are covering your cervix, (conditions referred to as placenta previa and vasa previa respectively) getting induced is out of the question. If baby experiences sudden changes that indicate it may be distressed, for example if its heart rate slows down or it is not getting enough oxygen, induction is too dangerous.

Mums also needs to be just right to undergo induction of labor and vaginal delivery of their baby. Doctors won’t induce women with cephalopelvic disproportion (which means there’s not enough room for baby’s head to pass through their pelvic bone). For those with viruses (like HIV and genital herpes) that may infect their baby during normal medical procedures carried out for induction of a vaginal delivery such as breaking the waters, , induction of labor also poses too great a risk.

Ripening the cervix for induction of labor

Your cervix also needs to be just right or the cervix must be ripe. The cervix is the entrance to the womb and it’s usually closed off to prevent all but the tiniest of particles (think sperm) entering the womb. However before the baby can move from the uterus through to the vagina to be born, the cervix needs to open up, or dilate to make room for baby’s head to pass through. The ripeness of the cervix is assessed by calculating the Bishop’s score.

As the cervical canal becomes wider it shortens and softens in preparation for baby’s passage. If all’s going well and baby’s in the correct position, this means the cervix is ready for childbirth, and labor can be induced.

If the cervix is not ripe, induction of labor is not out of the question. But the cervix must be ripened, by applying a gel or pessary containing chemicals called prostaglandins which help the cervix dilate, or by transcervical foley catheter, a procedure in which a catheter is inserted into the cervix to encourage it to soften and dilate. That usually takes at least six hours with prostaglandin gel and 12-18 hours with a transcervical foley catheter.

Childbirth after induction

Sometimes there are complications, for example uterine contractions fail to start or gain sufficient momentum for labor, uterine contractions occur too quickly or the baby’s heart rate changes. In these cases the hormones used to induce labor may be withdrawn, and sometimes an emergency caesarean section needed.

However, most women go on to deliver their baby vaginally after induction of labor. It is a common procedure performed in more than one in four pregnancies. As the procedure will only be performed when the benefits for both mum and bub outweigh the risks, you can rest assured that there’s a good reason, if your doctor asks you to consider induction of labor.

Risks of inducing labor

Risks of inducing labor include:

Your due date may not be exactly right. Sometimes it’s hard to know exactly when you got pregnant. If you schedule an induction and your due date is off, your baby may be born too early. If your pregnancy is healthy, wait for labor to begin on its own. If you need to schedule an induction for medical reasons, ask your provider if you can wait until at least 39 weeks.
Oxytocin and medicines that ripen the cervix can make labor contractions too close together. This can lower your baby’s heart rate. Your provider carefully monitors your baby’s heart rate when inducing labor. If your baby’s heart rate changes, your provider may stop or reduce the amount of medicine you’re getting.
You and your baby are at higher risk of infection. The amniotic sac normally protects your baby and your uterus from infection. If labor takes a while to start after your membranes rupture, infections are more likely.
There may be problems with the umbilical cord. If the amniotic sac is broken, the cord may slip into the vagina before your baby does. This is called umbilical cord prolapse. It’s more likely to happen if your baby is breech. This is when your baby’s bottom or feet are facing down before birth instead of being head-down. Umbilical cord prolapse can cause the umbilical cord to get squeezed during birth. If this happens, your baby doesn’t get enough oxygen, which can be life-threatening.
Induction may not work so you may need a c-section (also called cesarean birth). C-section is surgery in which your baby is born through a cut that your provider makes in your belly and uterus.
You may have a uterine rupture. This is when the uterus tears during labor. It happens rarely, but it can cause serious bleeding. If you’ve had a c-section in a prior pregnancy, you’re at higher risk of uterine rupture because a c-section leaves a scar in the uterus.
You may be at higher risk of serious bleeding after birth (called postpartum hemorrhage). Inducing labor increases the chances that your uterine muscles don’t contract the right way after you give birth, which can lead to bleeding.

Labor complications

Even if you’re healthy and well prepared for labor and giving birth, there’s always a chance of unexpected difﬁculties or problems may arise.

If complications occur, providers may assist by monitoring the situation closely and intervening, as necessary.

Some of the more common complications are ¹⁵:

Labor that does not progress. Sometimes contractions weaken, the cervix does not dilate enough or in a timely manner, or the infant’s descent in the birth canal does not proceed smoothly. If labor is not progressing, a health care provider may give the woman medications to increase contractions and speed up labor, or the woman may need a cesarean delivery ¹⁶.
Perineal tears. A woman’s vagina and the surrounding tissues are likely to tear during the delivery process. Sometimes these tears heal on their own. If a tear is more serious or the woman has had an episiotomy (a surgical cut between the vagina and anus), her provider will help repair the tear using stitches ¹⁷.
Problems with the umbilical cord. The umbilical cord may get caught on an arm or leg as the infant travels through the birth canal. Typically, a provider intervenes if the cord becomes wrapped around the infant’s neck, is compressed, or comes out before the infant ¹⁸.
Abnormal heart rate of the baby. Many times, an abnormal heart rate during labor does not mean that there is a problem. A health care provider will likely ask the woman to switch positions to help the infant get more blood flow. In certain instances, such as when test results show a larger problem, delivery might have to happen right away. In this situation, the woman is more likely to need an emergency cesarean delivery, or the health care provider may need to do an episiotomy to widen the vaginal opening for delivery ¹⁹.
Water breaking early. Labor usually starts on its own within 24 hours of the woman’s water breaking. If not, and if the pregnancy is at or near term, the provider will likely induce labor. If a pregnant woman’s water breaks before 34 weeks of pregnancy, the woman will be monitored in the hospital. Infection can become a major concern if the woman’s water breaks early and labor does not begin on its own ²⁰.
Perinatal asphyxia. This condition occurs when the fetus does not get enough oxygen in the uterus or the infant does not get enough oxygen during labor or delivery or just after birth ¹⁷.
Shoulder dystocia. In this situation, the infant’s head has come out of the vagina, but one of the shoulders becomes stuck ¹⁸.
Excessive bleeding. If delivery results in tears to the uterus, or if the uterus does not contract to deliver the placenta, heavy bleeding can result. Worldwide, such bleeding is a leading cause of maternal death ²¹.

Delivery may also require a provider’s special attention when the pregnancy lasts more than 42 weeks, when the woman had a C-section in a previous pregnancy, or when she is older than a certain age.

Slow progress of labor

Your midwife or doctor can tell how labor is progressing by checking how much the cervix has opened and how far the baby has dropped. If your cervix is opening slowly, or the contractions have slowed down or stopped your midwife or doctor may say that your labor isn’t progressing. It’s good if you can relax and stay calm – anxiety can slow things down more. Ask what you and your partner or support person can do to get things going.

Your midwife or doctor may suggest some of the following:

change to a position you’re comfortable in
walk around – movement can help the baby to move further down, and encourage contractions
a warm shower or bath
a back rub
have a nap to regain your energy
have something to eat or drink.

If progress continues to be slow your midwife or doctor may suggest inserting an intravenous drip with Syntocinon to make your contractions more effective. If you’re tired or uncomfortable, you may want to ask about options for pain relief.

When the baby is in an unusual position

Most babies are born headﬁrst, but some are in positions that may complicate labor and the birth.

Posterior position

This means the baby’s head enters the pelvis facing your front instead of your back. This can mean a longer labor with more backache. Most babies will turn around during labor, but some don’t. If a baby doesn’t turn, you may be able to push it out yourself or the doctor may need to turn the baby’s head and/or help it out with either forceps or a vacuum pump. You can help by getting down on your hands and knees and rotating or rocking your pelvis – this may also help ease the backache.

Breech birth

This is when a baby presents bottom or feet ﬁrst. About 3-4% of babies are in the breech position by the time labor starts. Sometimes a procedure called ‘external cephalic version’ will be discussed – this is where a doctor gently turns the baby in late pregnancy by placing their hands on your abdomen and gently coaxing the baby around so it can be born headﬁrst. This turning is done at around 36 weeks, using ultrasound to help see the baby, cord and placenta.

The baby and the mother are monitored during the procedure to make sure everything is OK. There’s a small risk that turning the baby may tangle the cord or separate the placenta from the uterus. This is why the procedure is done in hospital, in case an emergency cesarean is needed.

Your midwife or doctor will discuss with you the best way of managing a breech labor and birth. If the baby is still in the breech position at the end of pregnancy, a cesarean may be recommended.

Multiple pregnancy

When there is more than one baby, labor may be preterm. When the last baby has been born, the placenta (or placentas) is expelled in the usual way. If the babies are premature, they are likely to need extra care at birth and for a few days or weeks afterwards.

At term, you may be induced if your babies are in the correct position. Often the obstetrician will suggest that you have an epidural. This is because after the ﬁrst twin is born the second twin can get in an unusual position and the obstetrician may need to maneuver the second twin into position for birth.

Concern about the baby’s condition

Sometimes there may be concerns that the baby is distressed during labor. Signs include:

a faster, slower or unusual pattern to the baby’s heartbeat
a bowel movement by the baby (seen as a greenish-black ﬂuid called ‘meconium’ in the ﬂuid around the baby).

If a baby is not coping well, its heart rate will usually be monitored. If necessary, the baby will be delivered as soon as possible with vacuum or forceps (or perhaps by cesarean).

Postpartum hemorrhage

Postpartum hemorrhage is a complication that can occur after a baby is born. Postpartum hemorrhage is uncommon. Losing some blood during childbirth is considered normal. Postpartum hemorrhage is excessive bleeding from the vagina after the birth.

There are two types of postpartum hemorrhage, depending on when the bleeding takes place:

primary or immediate – bleeding that occurs within 24 hours of the birth
secondary or delayed – bleeding that occurs after the first 24 hours, up to 6 weeks after the birth.

Depending on the type of postpartum hemorrhage, the causes include:

poor contraction of the womb after the baby is born (uterine atony)
part of the placenta being left in the womb (known as ‘retained placenta’ or ‘retained products of conception’)
infection of the membrane lining the womb (endometritis).

To help prevent postpartum hemorrhage, you will be offered an injection of Syntocinon as your baby is being born, which stimulates contractions and helps to push the placenta out.

Your midwife will check your uterus regularly after the birth to make sure that it is ﬁrm and contracting. Postpartum hemorrhage can cause a number of complications and may mean a longer stay in hospital.

Retained placenta

Occasionally the placenta doesn’t come away after the baby is born, so the doctor needs to remove it promptly. This is usually done with an epidural or a general anesthetic in operating room.

How to induce labor naturally

Natural ways to induce labor include the use of herbal supplements, castor oil, enemas, sexual intercourse, breast stimulation and/or acupuncture. These are discussed in more detail below.

These techniques may be used either to ripen the cervix (help the cervix soften and dilate so it is ready for labor) and/or induce labor (stimulate uterine contractions).

These methods may be used in an attempt to avoid medical induction of labor, or may be used in combination with medical methods.

In any case it is important that you inform your doctor or midwife if you are using any complementary medicines or treatments so that they can be aware.

Herbal supplements

The use of herbal remedies to promote health and treat disease is increasing in general, and their use in pregnancy is no exception. So if you’re looking for information about herbal remedies for induction of labor, you’re probably not alone.

A range of herbs have been used to induce labor, amongst which evening primrose oil is probably the most commonly administered by midwives. Although it has a long history of use as a labor inducing agent, there is no clear evidence how evening primrose oil works, or if in fact it does. There is also no information about the potential risks of using it. And yes, even though they occur naturally, herbal remedies often come with risks just like medicines.

There is also limited evidence about the effectiveness and safety of other herbs used for induction of labor, including:

Black haw and black cohosh: both of which are said to have a uterine tonic effect, that is it helps tone the uterine muscles;
Blue cohosh: which is thought to stimulate uterine contractions (labor contractions).
Red raspberry leaves/extract: which are also thought to encourage uterine contractions but only after a woman has started labor.
Castor oil: which is sometimes used for ripening the cervix or inducing labor.

Currently there is very little evidence on how effective and how safe the use of herbal supplements, castor oil, and/or enemas are.

Sexual stimulation and intercourse

Sexual stimulation including intercourse and stimulation of the breasts and nipples are commonly recommended techniques for inducing labor. Stimulation of the breasts and nipples promotes the release of oxytocins – the same hormone which is released (or administered by doctors in medical induction of labor) to stimulate uterine contractions.

Having actual intercourse stimulates the lower uterus which releases chemicals called prostaglandins, another substance produced naturally by your body and administered artificially in medical induction of labor to prepare the cervix. If the man ejaculates, the semen he releases provides an additional dose of prostaglandins. A woman’s orgasm causes uterine contractions, which also occur during labor.

While it sounds reasonable that the hormones your body releases while you’re getting sexy induce labor, there’s no evidence that women who have lots of sex have gone into labor any earlier than those who don’t. A review of the scientific literature ²² showed that while all of the above possible mechanisms may play a role, the one study of 28 women had very little data, which meant that no reasonable conclusions could be drawn. But if you’re waiting for your baby and you’re in the mood, it could be a great, intimate way to pass the time.

Breast stimulation

Stimulation of the breasts is known to facilitate the release of oxytocin – the hormone that is responsible for causing the uterus to contract during labor as well as post-partum facilitating the letdown of breast milk. When this method is used it may include either massage or the application of warm compresses to the breasts for one hour three times per day. However this has been associated with increases in the fetal heart rate and it is unclear if this is due to reductions in the blood supply to the baby, leading it to have lower oxygen levels.

A review of the scientific literature ²³ has shown that breast stimulation was associated with a significant reduction in the number of women that hadn’t gone into labor within 72 hours. However an important point is that this reduction does not apply to women whose cervix was unfavorable (i.e. the only beneficial effect was seen in women who already had a favorable cervix). It was also found that breast stimulation was also associated with lower rates of post-partum hemorrhage (bleeding after you have had your baby).

Importantly this review also highlighted that there were several perinatal deaths (a death that occurs while the baby is still in the uterus and over 20 weeks gestation or within the first 28 days of life) that occurred during the studies. It is for this reason that until safety issues have been fully evaluated breast stimulation should not be considered for use in a high risk population.

Acupressure to induce labor

Acupuncture is a Chinese medicine procedure which involves inserting fine needles at particular points in the body. Different points are targeted for different conditions. There is a belief in both Chinese and Western medicine that the process of inserting needles, which stimulates nerves, may trigger the release of prostaglandins (which prepare the cervix for labor) and oxytocin (which stimulates contractions). However no scientific studies have yet been conducted to produce evidence of whether the process actually helps induce labor, or whether or not there are any risks involved.

Other techniques

Hot baths and enemas have also been proposed as techniques for preparing the cervix and/or inducing labor. There’s no evidence that a bath or an enema actually works when it comes to ripening to cervix or inducing labor. Some doctors recommend avoiding baths all together as they increase the core body temperature, which isn’t good for the baby and baths may increase the risk of infection.

Alternative techniques for inducing labor

There are a number of alternative techniques that have been used traditionally and may still be recommended for inducing labor. Unfortunately there is no scientific evidence to show that they work, and little is known about the risks these techniques may involve. While having sex or a relaxing hot bath are probably safe, herbal remedies and acupuncture may involve risks. If you’re considering using herbal remedies to induce labor, have a good chat with your doctor before you do.

Labor Induction. https://www.acog.org/Patients/FAQs/Labor-Induction[↩][↩][↩][↩][↩][↩][↩][↩][↩]
American College of Nurse-Midwives. Position statement 2016: Induction of labor. http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000235/Induction-of-Labor-2016.pdf[↩][↩]
National Institute of Child Health and Human Development. (2015). Press Release: U.S. stillbirth rates unchanged after move to discourage elective deliveries before 39 weeks. https://www.nichd.nih.gov/newsroom/releases/110915-stillbirth-rates-unchanged[↩]
Fleischman, A.R., Otnuma, M., & Clark, S.L. (2010). Rethinking the Definition of “Term Pregnancy.” Obstetrics & Gynecology, 116(1), 136–139. https://www.ncbi.nlm.nih.gov/pubmed/20567179[↩]
Koroukian, S.M. (2004). Relative risk of postpartum complications in the Ohio Medicaid population: Vaginal versus cesarean delivery. Medical Care Research and Review, 61(2), 203–224. https://www.ncbi.nlm.nih.gov/pubmed/15155052[↩]
Why at least 39 weeks is best for your baby. https://www.marchofdimes.org/pregnancy/why-at-least-39-weeks-is-best-for-your-baby.aspx[↩][↩]
Fleischman, A. R., Oinuma, M., & Clark, S. L. (2010). Rethinking the definition of “term pregnancy.” Obstetrics and Gynecology, 116(1), 136–139.[↩]
How to Tell When Labor Begins. https://www.acog.org/Patients/FAQs/How-to-Tell-When-Labor-Begins[↩][↩]
Preterm (Premature) Labor and Birth. https://www.acog.org/Patients/FAQs/Preterm-Premature-Labor-and-Birth[↩]
National Child and Maternal Health Education Program. (2013). Moms-to-be: Let baby set the delivery date. https://www1.nichd.nih.gov/ncmhep/initiatives/is-it-worth-it/Pages/moms.aspx[↩]
Labor and birth. https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/labor-and-birth[↩]
Medications for Pain Relief During Labor and Delivery. https://www.acog.org/Patients/FAQs/Medications-for-Pain-Relief-During-Labor-and-Delivery[↩]
Makvandi, S., Roudsari, R. L., Sadeghi, R., & Karimi, L. (2015). Effect of birth ball on labor pain relief: A systematic review and meta-analysis. Journal of Obstetrics and Gynecology Research, 41(11), 1679–1686[↩]
Approaches to Limit Intervention During Labor and Birth. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth[↩]
Elixhauser, A., & Wier, L.M. (2011). Complicating conditions of pregnancy and childbirth, 2008. HCUP Statistical Brief #113. Rockville, MD: Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.pdf[↩]
Shields, S. G., Ratcliffe, S. D., Fontaine, P., & Leeman, L. (2007). Dystocia in nulliparous women. American Family Physician, 75(11), 1671–1678. https://www.aafp.org/afp/2007/0601/p1671.html[↩]
American College of Obstetricians and Gynecologists. (2016). Ob-gyns can prevent and manage obstetric lacerations during vaginal delivery, says new ACOG Practice Bulletin. https://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations[↩][↩]
World Health Organization. (2007). Managing complications in pregnancy and childbirth: A guide for midwives and doctors. http://apps.who.int/iris/bitstream/handle/10665/43972/9241545879_eng.pdf;jsessionid=73AD4A7212BC83DAF9EA1114424C0E75?sequence=1[↩][↩]
Episiotomy. https://medlineplus.gov/ency/patientinstructions/000482.htm[↩]
Premature rupture of membranes. https://medlineplus.gov/ency/patientinstructions/000512.htm[↩]
ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006 Oct;108(4):1039-47. https://www.ncbi.nlm.nih.gov/pubmed/17012482[↩]
Sexual intercourse for cervical ripening and induction of labour. Cochrane Database Syst Rev 2001; (2): CD003093 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003093/full[↩]
Breast stimulation for cervical ripening and induction of labour. Cochrane Database Syt Rev 2005; (3): CD003392 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003392.pub2/full[↩]