Our Induction of Labor Practices
At OB/GYN North we limit the process of labor induction to true medical indications only. We appreciate that this deviation from spontaneous labor is often not the ‘first choice’ of our clients, but we hope that you will be receptive to our recommendations. These decisions are made carefully based upon our collective experiences, training, and standards of care researched and developed by a variety of sources including, the American College of Obstetrics and Gynecology (ACOG) & the American College of Certified Nurse Midwives (ACNM). As a practice, we believe that induction should be reserved for medical indications but we also understand that induction is essential under certain conditions and circumstances to ensure a healthy birth process for mom and baby. We see each labor process as individualized, and rely on well-studied, trusted mechanisms to ensure a safe birth. We encourage open communication and promote sharing of information. Remember, our goals always have safety for both you & your baby in mind.
Most induction methods will require monitoring of your uterine and fetal activity, as well as consideration of your oral intake and activity. We make every effort to support the least amount of interference as your body makes itself ready for your baby’s birth; individual circumstances will dictate some of these considerations. There are a variety of ways in which induction can be accomplished and it is essential that your plan is customized to your specific circumstances, which we will share with you throughout the process.
If your cervix is firm, long, or closed, cervical ripening may be recommended before initiating labor. These options may vary and can range from natural approaches to more traditional methods *see handout ‘Natural Ways to Induce Labor’. Induction sometimes necessitates a cervical ripening phase, which is advisable if your cervix is not ready for active labor as a “ripe” cervix (2-3 cm open, 80+% effaced, soft, anterior) increases the likelihood for a successful induction and vaginal delivery.
An obstetrician or CNM can sweep or strip your membranes (pressing your bag of water off the cervix without breaking it) in the office at your regular OB appointments if your GBS swab is negative, you are beyond 38 wks and your cervix is open enough to permit it. This can stimulate the release of oxytocin from the pituitary gland helping to initiate contractions. This only work 50% of the time, and generally is effective within 48 hours. It should be noted, that minimal data has been published on membrane stripping, so we advise that you explore this technique and empower yourself so that you are able to ask questions and make decisions that you are comfortable with.
Cervidil or Cytotec
Cervidil is a hormone-infused string (like a thin tampon) that the OB, CNM or labor RN can place in the vagina. The Cervidil remains in the vagina approximately 12 hours and then is removed.
Cytotec is a tablet that is placed in the vagina and can be repeated every four hours until your cervix is ready for more active labor.
These ripening agents have been shown to ready the body for labor and can ‘prime the pump’ to encourage your body to respond to other measures such as Artificial Rupture of Membranes (AROM, or breaking the water) or Pitocin given intravenously. Ripening agents are often used the night before your induction. We will encourage you to sleep as much as possible during this preparatory phase. Your baby and your uterus will be monitored to ensure that these ripening agents are well-tolerated. On occasion, some women will begin active labor without further intervention.
Intracervical Foley Bulb/Cervical Ripening Balloon
Foley catheter balloons can be used to mechanically dilate the cervix and have been helpful to ready the cervix for induction. With this method, small rubber tubing is placed through the cervix and a balloon inside the tubing is inflated just inside the inner edge of the cervix. The balloon, given time and sometimes in conjunction with small amounts of Pitocin, gently opens the cervix. The balloon may come out on its own, or be removed with gentle traction. This process can take anywhere from a few hours to 12 hours, depending upon your body’s response, as well as your initial cervical dilation and effacement. Some women will be candidates for having the balloon placed in the office, and then go home overnight and proceed to the Labor & Delivery Unit at North Austin Medical Center to continue their induction the following morning. Rest is advisable during this time.
Induction of Labor
Artificial Rupture of Membranes (AROM)/Breaking the Water/Amniotomy
Breaking the bag of water may be used on its own to initiate labor or in conjunction with other mechanisms of ripening and induction. This is usually dependent upon your cervical exam, the firmness of the baby’s head on the cervix, and whether or not this is your first baby. While AROM can be used at any time after the cervix has dilated, it is often reserved for when the ripening phase has been completed. After the water bag has been broken, we do fewer cervical exams in an effort to minimize the likelihood of infection. There are no strict time limits that are associated with AROM and length of labor, but assessment of you and your baby are important to identify and treat an infection, in the unlikely chance that it should occur. The process of amniotomy is similar to a slightly longer cervical exam wherein a small hook is used to painlessly put a hole in the water bag which has no nerve endings. During the remainder of your labor, amniotic fluid will leak out intermittently. Some womens’ bodies respond quickly to this technique while others require additional measures to encourage their bodies into labor. If active labor (regular contractions that cause cervical change) does not ensue within 6 hours of AROM for induction, then pitocin will be necessary to initiate contractions.
Pitocin, a synthetic bioidentical hormone of oxytocin, has been used effectively for labor induction for many years and there is a vast amount of data that supports its safety in obstetric and midwifery practice. This hormone is infused, in a diluted form, intravenously. It may be the first-line medication used for induction, or may be used after a cervical ripening agent has been introduced or following amniotomy. Our intention is to mimic the natural pattern of labor; this is done by carefully managing the rate of the infusion. While typically small amounts have proven to be effective, more important is the evaluation of the fetal and uterine response to the Pitocin. We use as little as possible to create the desired effect of regular contractions that bring cervical change. Many are fearful that a pitocin labor will be much more painful, but this is false; when pitocin is initiated slowly and minimally, it allows the body to cope with the increasing intensity of contractions as in spontaneous labor. We work closely with the Labor & Delivery nursing staff to ensure that this process is both safe and effective.