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As your due date approaches, you’re probably picturing different scenarios of how labour will start. A dramatic movie-worthy splash when your water breaks? A contraction that has you gasping in pain? Or just a weird backache? It might be something in between. One scenario that you might not have considered is what happens if you need to be induced.
Labour induction means creating contractions in the uterus before labour starts on its own. According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), more than one in five labours is induced, so it’s actually a pretty common way to have a baby.
If you had a particular kind of labour and delivery in mind, like labouring at home as long as possible or having a home birth, it may no longer be possible with some induction methods. You might have a different birth experience than the one you’ve been envisioning for months, so take some time to process any emotions you may be feeling about the sudden change in plans. It's also helpful to educate yourself about all the terms and types of inductions that your midwife or OB-GYN will mention.
Jessica Dy, an OB-GYN based in Ottawa and co-author of the SOGC’s Clinical Practice Guidelines on Induction of Labour, says that when parents are having the induction conversation with their care provider, the most important things are knowing what the reason is for being induced and understanding the different methods of induction, along with the risks and benefits. The goal is, of course, a healthy delivery and good outcome for both you and your baby.
But Dy says it can feel like one of those decision-making flow charts, with various options that lead to more decisions. It can be overwhelming to process. “There isn’t one straight line in labour,” says Dy. “If you’re at this point, these are the things we can do. If you’re at that point, there are other things we can do. It always depends on how mom and baby are doing.”
There are a number of different reasons why your doctor or midwife may want to induce labour: if you are getting close to two weeks beyond your due date (usually the health of the placenta is the concern here) or if your water has broken but your contractions aren’t starting on their own. Medical conditions, such as an infection in your uterus, low amniotic fluid, high blood pressure and placental abruption (where the placenta peels partially or fully away from the uterus wall), are also reasons to induce.
If you have a midwife, she may be able to try some induction techniques, such as a cervical membrane sweep, in her own office or stay with you while you receive oxytocin in the hospital, depending on the province or territory you live in.
Also known as a “stretch and sweep,” cervical sweep or membrane stripping, the membrane sweep is a quick procedure where a doctor or midwife inserts one gloved finger into your cervix and uses a sweeping circular motion to separate the membranes that connect the amniotic sac to the walls of the uterus. This releases hormones called prostaglandins, which help prepare the cervix and lead to contractions. The “stretch” part is if your doctor or midwife is able to put two gloved fingers into the cervix to open it a little more. A lot of women find it uncomfortable or painful, but the pain is short-lived.
“In a normal, low-risk pregnancy, I usually start talking about a membrane sweep around 38 weeks,” says Kerry Harris, a midwife in Vancouver. “Evidence shows that if we give a stretch and sweep to eight women, that will prevent one induction past the due date. Some people want to start at 38 weeks and do it at every appointment, while others will decline and never have a sweep. It’s a personal thing.”
Some women may feel uncomfortably pregnant and are eager for their babies to arrive and willing to try anything to spur on contractions, while others are happy to wait and see if they go into labour on their own around their due date. If you are adamant about avoiding medical induction and feeling stressed about going overdue, a stretch and sweep might be the right choice.
A Foley catheter is a small balloon inserted by a doctor into the cervix and inflated about two or three centimetres in diameter. “This mechanically stretches the cervix but has a very minimal effect on causing contractions,” says Dy.
Your doctor may recommend this method if you’ve had a negative reaction to hormone-induced contractions in the past. It’s usually done in a hospital or an outpatient client, and you’ll be monitored for an hour or so to make sure that there isn’t any vaginal bleeding and the baby’s heart rate is normal. You can’t feel the balloon inside you, but the insertion can be uncomfortable and cause some menstrual-like cramping. Then you can head home for 12 to 24 hours before returning to the hospital (or sooner, if labour starts or if the balloon falls out, which means that it’s done its job of opening the cervix). If labour hasn’t started by the time you’ve returned to the hospital, your doctor may talk to you about using prostaglandins to dilate the cervix or recommend breaking the amniotic sac, which is another way to start labour (see “Amniotomy” section below).
Your body produces hormones called prostaglandins, and a synthetic form can be used to “ripen” your cervix, making it softer, more open and ready for labour. It comes in several forms.
The first form is a cervical gel placed in the vagina, near the cervix, by your doctor or midwife.
The second form is a prostaglandin called Cervidil, a medication on a tab with a string attached that’s placed near the cervix.
One disadvantage: These induction methods could lead to contractions that are too strong or too close together, which can affect the baby’s heartbeat, so your healthcare provider would remove prostaglandins or give you medicine to relax the uterus. Both of these can be administered in the hospital or an outpatient clinic, where you’ll be monitored to see if the baby is doing well, and then you can go home to see if labour is going to kick in.
The third form is a pill called misoprostol, which is swallowed with water or placed under the tongue. Some people’s bodies metabolize it better than others, so it may work better for some women. It may be used if your water has already broken and your care provider has concerns about introducing bacteria into the uterus through vaginal exams. Misoprostol has the highest risk of causing too many contractions, says Dy, so you would stay at the hospital so the baby can be monitored with an external monitor (you will still be able to move around). All of these methods may cause faster or more intense contractions than if labour started naturally.
If the prostaglandins work to soften and shorten your cervix (this is often called a “favourable” cervix), your care provider can give you oxytocin through an IV line. Oxytocin is naturally produced by your body to help the uterus contract. It may also be called by its synthetic name, Pitocin. (Oxytocin is generally not used on its own before the cervix is considered favourable because it’s associated with a higher rate of C-sections.) “When you’re given oxytocin, you’re monitored continuously with an external monitor because some people can be quite sensitive to it,” says Dy. “Usually, by that point, you’re having more frequent contractions, every two or three minutes.” Both oxytocin and prostaglandins can reduce your baby’s heart rate, which is also why monitoring is used to make sure that all is well.
An amniotomy is where your care provider uses an instrument that looks like a crochet hook to break the amniotic sac, allowing amniotic fluid to leak out. This is uncomfortable but not painful. Again, this is usually done once the cervix is favourable, and oxytocin is used to keep labour consistent.
“Once your water is broken, there’s no turning back,” says Dy. “You’ve got to keep labour moving forward because there’s a risk of infection [because].” With this method, there is also an increased risk of cord prolapse (where the umbilical cord drops into the vagina), so it’s done in a hospital or clinical setting where you can be monitored to make sure that your baby is safe.
Each induction method carries some specific potential risks, so you and your care provider have to weigh the risks and benefits against the risks and benefits of continuing the pregnancy without inducing labour. Some uncommon but serious risks include uterine rupture and heavy bleeding after delivery.
One big question that many expectant couples have is whether induction leads to a higher rate of C-sections—and the answer isn’t quite clear.
“The association between inductions and C-sections doesn’t seem to hold as strongly as it used to,” says Dy. New research suggests that an induction at 39 weeks actually leads to a lower C-section rate, lower infant mortality and fewer blood pressure problems for women. Some of those studies point to a lower rate of admission to the NICU, while others found a slightly higher rate.
Some women are wary of induction because of wanting to “avoid that cascade of intervention, where one intervention can potentially kick-start another, like continuous monitoring,” says Harris. Women who are experiencing stronger, more intense contractions than they'd anticipated may change their minds and elect to have an epidural.
Induction may not be right for you if you have had a previous C-section or other major uterine surgery and are attempting a vaginal birth after Caesarian (VBAC) due to the risk of uterine rupture; if your placenta is blocking the cervix (known as placenta previa); if you have an active genital herpes outbreak; or if your baby is breech or transverse (bum down or lying sideways in the uterus).
If you have a midwife, she may have some approaches that she would like to use first, including the stretch and sweep (described above). “We sometimes offer our clients a ‘labour cocktail,’ which is castor oil, verbena oil, apricot juice and almond butter blended into a smoothie,” says Harris. “That can sometimes get labour going without needing oxytocin. We don’t have published evidence around dosage or safety, but anecdotally we see that it’s quite safe and that’s why we offer it.” (This kind of smoothie also gets the bowels moving, which is thought to trigger contractions. But it can also lead to vomiting and diarrhea, so some midwives don’t recommend castor oil to their patients at all.)
Some traditional midwives, like Indigenous midwives, may use an herbal tea called blue cohosh to induce labour, but talk to your care provider beforehand. Blue cohosh tea should only be used under a midwife’s supervision.
Harris may also refer patients for acupuncture because some studies have found that it’s a low-risk, painless way to help with cervical ripening.
Nipple stimulation, either manually or with a breast pump, is another anecdotal approach. “Nipple stimulation causes the release of oxytocin, which is the hormone that causes contractions, and it can sometimes kick-start labour,” says Harris. “We may recommend it if someone’s water has broken but they haven’t had contractions yet or in a labour that’s slowed down a bit.”
Everyone’s approach to labour is a little different. Destinee Heikkinen, a mom of four, knows a fair bit about trying to get labour started—all her pregnancies were close to 42 weeks. “With my oldest two kids, who were 10 and 12 days past due, my midwife did multiple stretch and sweeps in the days leading up to and past my due date,” she says. “When these didn’t start labour, I was referred to an OB-GYN, who used the prostaglandin gel. That was enough to start contractions, and I didn’t need the oxytocin.” With her fourth baby, who was five days post-term, Heikkinen tried all kinds of natural ways to kick-start labour (sex, daily walks, spicy food), but she credits a smoothie of castor oil, lemon tea, almond butter and apricot juice for starting labour six hours after she drank it.
The bottom line: Labour, like parenting, is unpredictable and messy. The best thing you can do is arm yourself with information to help with decision-making every step of the way.