Options: Induction of Labor



What are some reasons a caregiver might recommend induction?

What factors affect whether I have an induction?

Are the risks of induction more of a concern for certain women?

If I choose not to have labor induced, what are my other options?

How is labor induced?

What are some non-medical (elective) reasons for induction of labor?

What are some situations in which caregivers vary in how often they recommend induction of labor?

How do informed consent and refusal and shared decision making relate to these matters?



What are some reasons a caregiver might recommend induction?

A caregiver may recommend induction of labor for three types of reasons.
  • pregnancy complications or preexisting medical problems: In a small proportion of pregnancies, problems arise that pose a serious threat to the woman's health, the baby's health, or both. For example, if the woman develops preeclampsia (a disorder involving high blood pressure in pregnancy), induction of labor can protect the woman and her baby from serious illness or even death. In addition, women who have chronic health problems before pregnancy, such as heart disease, diabetes, or certain autoimmune diseases, may consider induction of labor to prevent complications associated with these conditions.
  • risk factors that are not diseases or complications: More commonly, a care provider may recommend induction because a risk factor has developed. A risk factor is not a true complication or disease process, but rather a test result, clinical observation, or other factor that increases the chance of health problems or labor complications. Examples include ruptured membranes (broken water) before labor, which may increase the chance of infection; pregnancy that has reached 41 weeks, the point in pregnancy when risk of stillbirth or neonatal death increases; and the caregiver's suspicion that the baby is large, which may increase the chance of difficult labor or newborn injury. In these cases, a caregiver may offer induction to lower that risk, although the best evidence does not always support its use. For example, the best evidence suggests that inducing labor when the baby is thought to be big increases the chance of cesarean section without improving outcomes for the baby. It is important to make an informed decision with full understanding of the risks and benefits involved. The Best Evidence: Induction of Labor page in this section can help.
  • non-medical reasons: Some caregivers offer induction, or agree to a woman's request for induction, for reasons that are unrelated to the mother's or baby's health. For example, the caregiver may offer induction on a day that she or he will be on call to enable the woman to give birth with her familiar caregiver. Although caregivers often suggest induction in such cases, and many women consider having labor induced for convenience or to get the pregnancy over with, best evidence suggests that inducing labor in these cases can be risky for both woman and baby.

What factors affect whether I have an induction?

The health needs of you and your baby can certainly influence whether you have an induction of labor, but some other key factors include:
  • your choice of caregiver and birth setting.
  • how determined you are to avoid induction that does not offer you or your baby clear health benefits.

Induction rates vary widely across hospitals and across different providers within a single hospital. This variation occurs for many reasons. One is that caregivers differ in the ways that they inform and support women at the end of pregnancy and in their judgment about when to recommend induction. Induction rates also vary from one birth setting to another due to differences in policies and practice styles. Because of this variation, your choice of caregiver and choice of birth setting can have a major impact on the type of birth that you will have.

In addition, your commitment to letting labor begin on its own affects your chance of induction, because some caregivers agree to induce labor when women request it, even if there is no medical reason. It is common to have physical discomfort and emotional ups and downs at the end of pregnancy. However, understanding that the baby needs these final days and weeks to prepare his or her lungs, digestive system, and other organs for a safe transition to life outside the womb can you help resist the temptation to induce labor.

Are the risks of induction more of a concern for certain women?

Induction of labor is a major medical intervention that poses the potential for risk for all women and babies. However, in some cases the potential for risk is small and in other situations the risk is greater. The following are some situations when the risks of induction of labor may be a special concern, based on a systematic review of the evidence conducted in 2010 and other recent studies.
  • Women having their first baby are more likely to have induction lead to a cesarean section than women who have already given birth vaginally.
  • If the cervix has not already begun to thin out and dilate ("ripen") or if the baby has not settled low in the pelvis, induction is more likely to lead to a cesarean. A caregiver can do a simple vaginal exam and calculate what is known as a "Bishop score" based on the qualities of the cervix and the position of the baby. The lower the Bishop score, the higher the chance the induction will lead to a cesarean section. A Bishop score below 6 (out of 13) signifies an increased likelihood that the induction will lead to a cesarean, whether or not medicines or other techniques are used to "ripen" the cervix.
  • If the woman is less than 39 weeks pregnant, induction can result in a baby born with significant health problems, especially breathing difficulties. When labor is induced before 39 weeks, the baby is more likely to admitted to the neonatal intensive care unit.
  • Women who have given birth previously by cesarean section may face additional risks if labor is induced. Best evidence suggests that risks are not increased with the use of synthetic oxytocin (Pitocin) or with induction before 41 weeks. The risk of having the scar give way (rupture) may increase with induced labor from 41 weeks on or when using Prostaglandin E2 and, especially, misoprostol, to get labor going. Some care providers or hospitals are unwilling to try to induce labor in women with past cesareans. (You can find more information about birth options for women with prior cesareans in VBAC or Repeat C-Section).

If I choose not to have labor induced, what are my other options?

If you are considering induction of labor that is not clearly medically needed, you want to weigh the option against two others:
  • Wait for labor to begin on its own. Going into labor on your own is safer than having labor induced or having a c-section. However, not all women who plan to wait for labor will go into labor on their own. That's because the additional days or weeks, while giving your baby time to develop fully, also create the potential for mild complications in the pregnancy to become more serious or for new problems to develop. These problems are more likely if you already have a mild complication (such as mild high blood pressure or well controlled diabetes) or if you are already a week or more past your estimated due date.

    To watch for problems that may develop at the end of pregnancy, your care provider may recommend more frequent prenatal visits, tests to check on the well-being of your baby, or both. They also occasionally detect complications early enough to deliver the baby safely before the situation worsens. Unfortunately, however, none of the testing methods is perfect. "False positive" results, when the test indicates a problem that doesn't really exist, are common and may lead to unnecessary inductions or c-sections. Research has not proven whether or under which circumstances these tests lead to better health outcomes. The tests that are used to monitor fetal well-being at the end of pregnancy include:
    • a fetal nonstress test: monitoring the fetal heart rate for a period of 20 minutes or longer to observe for accelerations (heart rate goes up, a reassuring sign) or decelerations (heart rate goes down, a sign that baby may be compromised)
    • a biophysical profile: an ultrasound measuring the fetal movements, breathing, and muscle tone and estimating the amount of amniotic fluid. The results are usually combined with nonstress test results to provide an overall score from 0-10. A score of 8, 9, or 10 is reassuring and a score of 4 or below requires delivery. The best option when the score is below 8 but above 4 will depend on the judgment of the caregiver and the preferences of the woman
    • fetal movement counting: There are various methods involving the woman counting fetal movements either throughout the day or during a certain time frame (such as the 1-2 hours directly after eating a meal). Decreased fetal movement may be a sign that the baby is not getting enough oxygen.
  • Have a scheduled cesarean section. In a few cases, the best alternative to induction of labor is a scheduled c-section. Your caregiver may recommend a c-section instead of an induction of labor if there are severe complications that make labor unsafe for you or your baby. Because induction in some situations (see above) increases risks in women who have had prior cesareans, a woman who originally planned for a vaginal birth after cesarean may opt for a repeat c-section if she faces a complication that requires delivery.

How is labor induced?

Scientists do not fully understand how labor begins. As a result, methods used to induce labor are directed at only part of the complex process. For instance, the commonly used drug Pitocin is an artificial version of oxytocin, a hormone that causes contractions. But contractions are not always enough to cause labor, so other methods may also be used. These include other hormone medicines, methods to stimulate women's own hormones, mechanically opening the cervix, and breaking the bag of waters. The Best Evidence page describes the safety and effectiveness of these methods.

What are some non-medical (elective) reasons for induction of labor?

Evidence suggests that inducing labor without a medical reason increases the risk of problems during and right after birth. (See Best Evidence: Induction of Labor.) Despite these risks, many women have labor induced for non-medical reasons. These include:
  • Desire to get the pregnancy over with. This is most common non-medical reason women ask for or agree to an elective induction. Aches and pains, sleep problems, and emotional ups and downs are common in the final days and weeks of pregnancy. Although induction of labor may seem like the best option for dealing with those problems, these discomforts can often be addressed with proper education, support, or less risky medical interventions.
  • Preference for a certain care provider. Most care providers share the responsibility of being "on call" for births with one or more other care providers. You may strongly prefer one care provider over the others, or fear that you will end up with a care provider you don't know. However, choosing labor induction is likely to have a much greater impact on how your labor and birth unfold than the presence of a particular care provider in labor. In addition, it is common for labor induction to take longer than a typical care provider's shift. You may end up beginning your induction with one person but giving birth with a different one.
  • Convenience of scheduling the baby's birth. It's not easy to predict when labor will begin. The uncertainty can make it difficult to arrange logistics such as scheduling maternity leave from your job or making sure you have plenty of help after the baby comes. Many women who understand that induction for convenience could result in health problems for themselves or their babies (e.g., avoidable cesarean or baby in intensive care unit) prioritize safety over convenience.

What are some situations where care providers vary in whether or how often they recommend induction of labor?

Care providers may disagree about whether to induce labor in certain situations. These include:
  • Prelabor rupture of membranes (PROM). If your water breaks and your pregnancy has reached full-term (at least 37 weeks), this is a usually a sign that your labor is about to begin. For some women, labor contractions kick in within the first few hours, but for other women the process takes longer. If your water is broken for many hours, the risk of infection increases. Your care provider may suggest inducing labor to lower this risk, however providers disagree about how long to wait before inducing. Some may suggest inducing right away while others recommend inducing if labor hasn't begun after 12 hours, 24 hours, or longer. The Best Evidence: Induction of Labor page reviews the research findings related to labor induction for PROM.

    If your water breaks at term before labor has begun, inducing labor or waiting for it to begin on its own both may be reasonable choices. Your provider's recommendation may reflect her/his routine practice or it may be an individualized recommendation based on your specific circumstances. If you choose to wait for labor to begin on its own, avoid vaginal exams, sexual intercourse, or placing anything in your vagina to prevent infection.
  • Pregnancy lasting beyond the woman's estimated due date. Many women remain pregnant past their "estimated due date" at the 40 week mark. If a woman remains pregnant until 42 weeks or longer, the risk of stillbirth or newborn death increases significantly. To prevent women from remaining pregnant that long, most care providers will recommend induction before 42 weeks. Some will recommend induction on the woman's due date or even earlier, while others wait until the woman is more than 41 weeks pregnant. The Best Evidence: Induction of Labor page reviews the research related to induction of labor between 41 and 42 weeks of pregnancy.
  • Care provider concern that the baby is large. "Suspected macrosomia" is a very common reason some care providers recommend induction. A large baby may be more difficult to deliver, leading to a c-section or injury to the baby during vaginal birth (an uncommon outcome). However, studies have shown that inducing labor does not reduce the chance of newborn injury and in fact seems to increase the likelihood of a c-section. (The Best Evidence: Induction of Labor page describes that research.) In addition, many babies delivered early because of concern about their size are born weighing considerably less than the care providers had suspected. That's because both ultrasound and hands-to-belly estimates of fetal weight are unreliable, and both methods are more likely to overestimate than underestimate the baby's size. It's also difficult to know whether a large baby will pose challenges during labor. Many women do not experience extra difficulty giving birth to larger babies.

How do informed consent and refusal and shared decision making relate to these matters?

Every pregnant woman has the right and responsibility to make informed maternity care decisions on behalf of herself and her baby. This may involve making an informed choice to accept (consent to) or decline (refuse) an intervention or procedure. Every care provider has the responsibility to provide accurate, unbiased information to support informed decisions.

Whether, when, and how to induce labor are rarely clear-cut decisions. They often involve uncertainty about benefits and harms. It is important to make this decision on the basis of complete, accurate, and unbiased information and to consider your own preferences and priorities. As the person receiving care and the mother of your baby, you are in the best position to decide what risks are important to you.

Ideally, your care provider will be able and willing to provide unbiased and complete information and you can engage in shared decision making together. However, care providers may face financial incentives to encourage induction of labor, or may have a preference for induction of labor based on its convenience. Further, busy care providers face challenges in staying up to date with the large, continually growing research literature about best practices. (Learn more about informed decision making.)




References

Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol. 2009;200(2):156.e1-156.e4.

Glantz JC, Guzick DS. Can differences in labor induction rates be explained by case mix? J Reprod Med. 2004;49(3):175-181.

Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: New insights. Evid Rep Technol Assess (Full Rep). 2010;(191)(191):1-397.

King V, Pilliod R, Little A. Rapid review: Elective induction of labor. Portland: Center for Evidence-based Policy; 2010 Accessed January 5, 2011 at http://www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/med/index.cfm.

Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: A best-evidence review. BJOG. 2009;116(5):626-636.



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Best Evidence: Induction of Labor

Most recent page update: 6/10/2014


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