When you choose UCHealth for your labor and delivery, you have access to some of the top obstetric providers in the country, as well as specially trained nurses who provide expertise, compassion and comfort based on decades of experience. UCHealth is proud to welcome thousands of babies into the world each year.
Childbirth brings with it many questions. That is why we teamed up with UCHealth for this special edition of Ask an Expert: Elective Induction of Labor. Several of you submitted your induction questions and UCHealth maternal-fetal medicine specialist Mark Alanis, MD, provided expert insight and advice.
Here are his answers:
Q. What are the advantages and risks of elective induction?
Elective induction of labor may benefit patients in several ways. First, and most importantly, it essentially eliminates the possibility of stillbirth from that point forward, especially if fetal and uterine monitoring is done appropriately during the process. However, the overall rate of stillbirth is low, so this is a difficult statistic to demonstrate when looking at the published literature. Second, childbirth is a time when families often come together, and this can require travel and taking time off from work. An elective induction of labor allows patients and their families to plan ahead for this and the postpartum period. The risk of an induction of labor is an increased chance for overstimulation of the uterus. This is rare in uncomplicated, spontaneous labor. Overstimulation of the uterus can cause problems with adequate placental blood flow to the fetus that result in changes to the fetal heart rate pattern. If not resolved, this can, in turn, lead to the need for cesarean delivery. Another drawback to induction of labor is the increased time spent in the hospital prior to the active phase of labor. But every patient is different, and this can range from just a few hours to more than 24 hours.
Q. When is it safest to get induced? When is the earliest I can get induced?
There are two broad categories of induction of labor, medically indicated and elective. Medical indications can be for maternal or fetal reasons and including complications like preeclampsia, poor fetal growth, placental abruption, or maternal diseases like diabetes, cancer, or heart disease. The optimal timing of a medically indicated induction of labor depends on the specific indication and individual needs of the mother-fetus diad. An elective induction of labor means that there is no clear medical indication for induced labor. Elective induction of labor are performed between 39 and 41 weeks of gestation. The risk for perinatal mortality (combination of stillbirth and infant death within the first month of life) begins to increase significantly starting at 42 weeks of gestation and beyond. So, it is not advisable to continue pregnancy beyond this gestational time period.
Q. Does induction mean you will have a longer, harder labor than waiting to go natural?
Not necessarily. Different patients respond to different agents of induction of labor… differently. Some of the agents used do result in strong contractions that some women will experience as significant pain. Most women will feel the most pain in labor after entering the active phase of labor, regardless if this occurs after induction of labor or with spontaneous labor. The active phase of labor is when cervical dilation begins to occur rapidly and often, but not always, after the water is broken.
Q. How would you recommend a mom to go about inducing while still avoiding an epidural? What tips would you give?
Epidural is the most effective option for managing severe pain in labor, whether that is due to induction of labor or spontaneous labor. At Memorial, our patients control the amount of medicine they receive through their epidural using a safe, patient-controlled pump. However, many women do not want the limitations that an epidural can place on the mother, including more freedom of movement during labor. A variety or combination of techniques are useful for these patients. Use of a doula has been shown to reduce the utilization of epidural and improve the satisfaction of the labor process for many women. We have also had great success at Memorial managing pain in labor with inhaled nitrous oxide (“laughing gas”) and pain medications administered through the IV. It is important that the patient is making pain management decisions for herself and not pressured by peers or providers.
Q. Is it true that induction generally will lead to several interventions for mom during her labor?
No, this is not true. Part of this misconception is that most women who undergo an induction of labor are doing so for a medical indication. The medical indication itself is often the primary risk factor behind many of the interventions and complications that can occur with childbirth. Induction of labor in low-risk patients, however, is usually accompanied by three interventions: placement of an IV, artificial rupture of membranes, and increased fetal heart rate and uterine monitoring. This is because the agents we use to induce labor can cause overstimulation of the uterus in a minor percentage of cases. Artificial rupture of membranes is a painless intervention that helps women enter the active phase of labor and reduces the amount and time of medications used to induce labor.
Q. Do elective inductions generally lead to an increase in C-Sections?
We used to think this was true in the past, but as mentioned above, we now know that elective induction of labor does not increase the risk for cesarean delivery. This misconception was due to older studies that were just plain wrong in how they looked at the question. These older studies compared women who underwent induction of labor and those who presented in spontaneous, active labor. Since then, we have had multiple, prospective, randomized controlled trials that have compared women undergoing induction of labor to a more appropriate control group- women not undergoing induction of labor and instead continuing pregnancy until 41 weeks of gestation. All of these studies prove that induction of labor does not increase the risk of cesarean delivery when faced with the only other option- continuing your pregnancy for another week or two.
Q. What is the induction process like?
An induction of labor starts with knowing the status of the cervix. A “ripened” cervix is one that is soft, shortened, and a little dilated before labor begins. The amount of cervical ripening can be semi-quantified by the Bishops score. The higher the Bishop score, the shorter the labor course, the less medication necessary, and the higher the likelihood of vaginal delivery. Cervical ripening is a natural process but can also be stimulated by an office procedure called membrane sweeping. This involves a pelvic exam in which the clinician “sweeps” the membranes away from the wall of the uterus and cervix, which causes the release of natural cervical ripening molecules. In patients with a high Bishop score, artificial rupture of membranes (a.k.a. amniotomy) is sometimes the only induction of labor intervention that is necessary. Some patients require medicines that help ripen the cervix, and this is usually the first intervention in the process. These agents also cause uterine contractions, and so fetal heart rate and uterine activity monitoring are typically performed frequently or continuously during an induction of labor. Patients with a low Bishop score often require a long time during this cervical ripening phase, sometimes 24 hours or longer. This period is the often the hardest part for patients because it can feel like nothing is happening.
Q. I saw you completed your residency in NC, go Tarheels! Do you have any speculation about what has contributed to why America is falling behind so many other first world countries in terms of maternal outcomes? What can we do as birthing women to have good outcomes for ourselves and our new babies? What do YOU do in your practice to avoid becoming part of that statistic in the US?
Thank you for raising this extremely important topic. The increasing rate of maternal mortality in the US is alarming. I’m not sure anyone truly has a full explanation for it. There have been many academic publications on this topic over the past 4 years, and a national spotlight has recently been placed over this issue in the lay press as well. While it is true that our patients have become more medically complex over the last 2 decades or so, it is also true that some states and institutions have taken proactive measures and are seeing decreased rates of maternal mortality and morbidity. California, for example, has a diverse racial and ethnic population with the same kinds of medical complexity we see in other states, but they have seen a 55% decrease in maternal mortality since 2006! How do we copy their success? The answer to this question is not a simple one either. A culture of patient safety is not achieved by simple changes in practice or increasing the numbers of nurses or through government mandate and oversight. But certainly, it is important to incorporate patient safety bundles, formalize training in teamwork and communication for healthcare members, and improve our partnerships between clinical advocacy groups and legislators. And yes, a patient should advocate for herself as well by speaking up when she is concerned that something is not right or she is uncomfortable with her management. Trust between a woman and her care provider is definitely a critical component to a successful pregnancy outcome. But an unintended message is sometimes communicated and received, in either direction. Please, let us know if we are not on the same page!
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About Mark Alanis, MD
Dr. Alanis joined the UCHealth Maternal-Fetal Medicine team and cares for patients at 1400 E. Boulder in Colorado Springs.
He is excited to be a part of a team-based approach that is centered on excellence, quality, and patient satisfaction. “This highly specialized field of medicine allows me to stay on top of a knowledge base that is ever increasing and then help those patients who find themselves facing challenges in their pregnancy,” he said.
He earned his medical degree from University of Texas Health Science Center, Texas. He completed his residency in Obstetrics and Gynecology at Carolinas Medical Center in Charlotte, North Carolina, and his fellowship in Maternal-Fetal Medicine from the Medical University of South Carolina, Charleston, SC.