When it comes to childbirth, every expectant mother hopes for a smooth and natural labor process. However, there are instances when labor induction becomes necessary for the health and well-being of both the mother and the baby. Understanding the indication criteria for labor induction can help demystify this procedure and ensure that it is carried out at the appropriate time.
Labor induction is a medical intervention that involves stimulating contractions before they occur naturally. There are several reasons why a healthcare provider may recommend labor induction. Common indications include post-term pregnancy, maternal or fetal health concerns, ruptured membranes without contractions, and slow progress during labor. It is important to note that labor induction is always a carefully considered decision made by healthcare professionals based on individual circumstances.
By understanding the indication criteria for labor induction, expectant mothers can feel more empowered and informed about their birthing options. This knowledge can enable them to actively participate in the decision-making process and ensure the best possible outcome for themselves and their babies.
In this article, we will delve deeper into the various indications for labor induction, shedding light on when and why it becomes necessary. So, let’s explore the important factors that healthcare providers take into account when deciding to induce labor.
Trigger warning: stillbirth and suicidal ideations
What is Labor Induction?
Labor induction is a process of starting labor using pharmaceuticals and often other medical interventions.
A successful medical induction needs to initiate cervical dilation (opening of the cervix) and establish regular and effective contractions.
Reasons for Labor Induction
Motivation for a labor induction can range from medical indications to simply wanting to plan and control the labor process in a medical manner rather than a natural approach.
Indication Criteria for Labor Induction
Medical indications for labor induction can include:
fetal growth restriction
Fetal growth restriction means that the baby isn’t growing as well during pregnancy anymore and their estimated fetal weight is below the 10th percentile for gestational age [1].
Further indications of fetal growth restriction are commonly examined during a Biophysical Profile using ultrasound. These factors include examining if the blood flow in the umbilical arteries is sufficient and measuring the amniotic fluid index.
Additionally, ensure the amniotic fluid index (AFI) is measured more than once and that you are properly hydrated for the best accuracy. Otherwise, you could just have a temporarily low AFI due to dehydration.
estimated due date
Research has found that early ultrasound dating is the most accurate way to determine an estimated due date and decrease the risk of being labeled “postterm” having an unnecessary induction. To learn more, check out: The Truth About Due Dates in Pregnancy!
Ultimately, the choice of being induced for an estimated due date is yours. One high-quality study published in 2019 found the exact numbers of stillbirths for low-risk pregnancies to be 2 out of 10,000 at 39 weeks, 3 out of 10,000 at 40 weeks, 8 out of 10,000 at 41 weeks, and 9 out of 10,000 at 42 weeks [2].
Using this information, you can wait and see when you go into labor and use your intuition to decide what the best choice for you and your baby is.
Additionally, I highly recommend using kick counting during pregnancy to effectively monitor your baby daily and reduce the risk of stillbirth.
Reduced fetal movement
If you have been using kick counting during pregnancy and you notice reduced fetal movement, your OB or midwife may recommend getting a Non-Stress Test (NST). You can learn more about a NST here.
gestational hypertensive disorders
Gestational hypertension, preeclampsia, and eclampsia are all hypertensive disorders of pregnancy.
While there are some lifestyle factors that can be remedies for high blood pressure, if it can’t be controlled and is getting worse, this can pose a life-threatening risk to you and your baby.
intrahepatic cholestasis of pregnancy (ICP)
ICP can be life-threatening liver condition where bile from the liver does not flow properly in the body and bile acids build up in the blood, which can only be treated with the birth of the baby, sometimes through labor induction.
For more information, check out my blog post on Intrahepatic Cholestasis of Pregnancy
uncontrolled gestational diabetes mellitus (GDM)
If GDM is unable to be controlled with improving lifestyle facors, but is able to be controlled using a medication, the American College of Obstetrics and Gynecology (ACOG) recommends labor induction between 39-40 weeks [3].
Otherwise, if GDM cannot be controlled with lifestyle factors nor medication, ACOG suggests an even earlier labor induction. However, since prematurity carries its own risks, have an in-depth discussion with your OB or midwife to determine what is best for you and your baby.
If you’re interested, check out: 5 Ways You Can Help prevent Gestational Diabetes!
cancer treatment
During the first trimester of pregnancy, chemotherapy carries risks of birth defects or pregnancy loss [4].
However, the American Cancer Society states that, “Chemotherapy seems to be safe for the baby if given in the second or third trimester of pregnancy, but it isn’t safe in the first trimester. Other breast cancer treatments, such as hormone therapy, targeted therapy, and radiation therapy, are more likely to harm the baby and are not usually given during pregnancy” [5].
hyperemesis gravidarum (HG)
Hyperemess gravidarum is extreme, persistent nausea and vomiting during pregnancy. It can lead to dehydration, weight loss, and electrolyte imbalances.
Morning sickness is mild nausea and vomiting that occurs in early pregnancy.
Although hyperemesis gravidarum does not cause a physical need for labor induction, some women find it necessary for their mental health. HG has high risks of postpartum depression and postpartum post-traumatic stress disorder, with even 25.6% of women with HG in a study from 2022 experiencing suicidal ideations [6].
A woman with HG would have to weigh her benefits vs. risks of what she is feeling with HG and the possible increased risk of birth trauma that can come with induction of labor due to common hospital practices and how invasive the process can be.
Experiencing birth trauma has been found to also increase the risks for: [7-10]
- Postpartum depression (PPD)
- Postpartum Psychosis
- Anxiety
- Postpartum Post-Traumatic Stress Disorder (P-PTSD)
Criteria that Does NOT Indicate Labor Induction
The following are electively induced labors which do not improve the outcomes of mothers and newborns:
- Suspected big baby
- Suspected small baby or fetal growth restriction (FGR) with lacking evidence to diagnose. For example getting a biophysical ultrasound exam and non-stress test showing good doppler flow (good blood flow through the umbilical cord indicating nourishment and oxygen to the baby), healthy amniotic fluid index, and estimated fetal weight with ultrasound. Keeping in mind this can be +/- 1 lb off in either direction [11, 12].
- Induction for “due date” before 41 weeks
- 39-week induction to “decrease the risk of a cesarean birth”
- For “placental aging.” This is not an evidence-based concept. Your placenta doesn’t age.
- People with gestational diabetes mellitus (GDM) who have controlled blood sugar levels with diet and exercise. For these people, ACOG advises expectant management for up to 40 weeks and 6 days [5].
- Group B Strep (GBS) positive mothers. This would not be considered a need for an induction as the mother will choose if she wants to receive antibiotics in labor or not, regardless of an induced or spontaneous labor.
In the United States and some other developed countries, some mothers are led to believe their elective inductions were medically necessary due to the language and communication used by their OB or midwife.
Often these discussions lacked proper communication about the ‘benefits versus risks,’ including accurate information regarding evidence. You can read about how this happened to me when I had an OB-GYN in my birth story here.
Methods of Labor Induction
In 2020, the rates of labor induction were almost 32% (about 1 in 3 women) [13].
Two main things need to happen for an induced labor. Firstly, your cervix needs to begin to dilate (open). Secondly, your body needs to establish regular and effective contractions.
After being checked into the hospital for your induction, a nurse, midwife, or physician will likely request to do a cervical exam to check cervical effacement and dilation.
Effacement refers to how thin and soft your cervix is, while dilation refers to how open it is. These evaluations give them an idea on which interventions might best work for your body to effectively induce labor.
Pitocin
When you come into the hospital for labor induction, you will often have an IV for Pitocin (synthetic oxytocin) started.
Pitocin is usually started off on a low dose to see how you and your baby respond. Then, they will generally increase the dosage every 30-60 minutes until your contractions take on a regular pattern and are effectively changing your cervix.
foley bulb
Next, if your baby has not descended far enough into your pelvis, a dilation tool called a foley bulb is inserted into your uterus, blown up, and pressured on your cervix with Pitocin-induced contractions which begin dilating your cervix.
cervidil
Additionally, Cervidil may be used to help soften your cervix. This also makes it able to thin and dilate more effectively.
Cerdivil is inserted somewhat like a tampon so that it sits right by the cervix.
misoprostol
Or, misoprostol (Cytotec) medication may be administered orally or vaginally. Misoprostol is effective for cervical ripening and inducing labor, thus softening your cervix, making it more easily opened with the foley bulb pressure induced by the Pitocin contractions.
Noteworthy, vaginal administration of misoprostol is not superior to oral. Many women prefer oral administration for their comfort. Additionally, some studies found that oral administration has a decreased risk of abnormal fetal heart tones in labor and “failure to progress” (which leads women to have cesareans) when compared to vaginal administration [3], but other studies see no difference [4].
The “main fear with this drug is excessive uterine contractions and uterine rupture in both scarred and unscarred uterus. These complications are dose-related higher the dose” [4].
However, if desired, you can start with only misoprostol and see how your body responds to progressing your labor with that and potentially avoid needing any other intervention to induce your labor in the hospital.
What is the Difference Between Pitocin and Oxytocin?
Pitocin is not the same as oxytocin. Pitocin cancels out the natural release of oxytocin and does not cross the blood-brain barrier, thus inhibiting the natural release of endorphins (natural pain relief) in labor. This is another reason Pitocin can make labor more painful than a non-induced and un-augmented (sped up) labor.
The hormones present immediately after an unmedicated birth include high levels of oxytocin, endorphins, catecholamines, and prolactin which are responsible for an easier birth of your baby, reduced risk of postpartum hemorrhage, and eager mama ready to meet her baby, and optimal hormones to begin a successful breastfeeding relationship.
Risks and Complications Associated with Labor Induction
The difference between an elective and medically indicated induced labor can directly affect your and your baby’s health.
Research studies have found that elective labor inductions compared to healthy pregnancies that begin on their own are at increased risks for: [15, 16]
- Epidural use (71% vs. 41.3%)
- Instrumental birth (28% vs. 23.9%)
- Cesarean (29.3% vs. 13.8%)
- Episiotomy (41.2% vs. 30.5%)
- Postpartum hemorrhage (2.4% vs. 1.5%)
- Not having skin-to-skin with their baby after birth which can negatively impact breastfeeding and bonding
However, if you have a medical indication for a labor induction, the criteria making the induction a valid option carries its own set of increased risks to you and your baby. Risks that are higher than those present with a healthy, low-risk, and low-intervention pregnancy and birth.
Therefore, the risks versus benefits comparison completely changes and that is why induction is a great “tool” to have access to for the people who need it and are accurately informed of the risks versus benefits.
Conclusion
Labor induction is a medical intervention that takes place in the hospital setting. Some women have induced labors for medically indicated reasons in attempt to prioritize health and well-being, while others accidentally or intentionally have an electively induced labor.
With a low-risk pregnancy birth is the safest when it begins on its own. This is why understanding the indication criteria for labor induction is so important. Plus, with our high numbers of unnecessary inductions and cesareans in the U.S., this is the time for women to take control of their health and experiences regarding labor and birth.
I hope you feel more encouraged, educated, and empowered after reading this article. Talk soon, mama!
– Katelyn Lauren
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References:
[1] Gutaj P, Wender-Ozegowska E. Diagnosis and Management of IUGR in Pregnancy Complicated by Type 1 Diabetes Mellitus. Curr Diab Rep. 2016 May;16(5):39. doi: 10.1007/s11892-016-0732-8. PMID: 26983627; PMCID: PMC4794518.
[2] Muglu, J., Rather, H., Arroyo-Manzano, D., Bhattacharya, S., Balchin, I., Khalil, A., Thilaganathan, B., Khan, K. S., Zamora, J., & Thangaratinam, S. (2019). Risks of stillbirth and neonatal death with advancing gestation at term: A systematic review and meta-analysis of cohort studies of 15 million pregnancies. PLoS medicine, 16(7), e1002838. https://doi.org/10.1371/journal.pmed.1002838
[3] American College of Obstetricians and Gynecologists (2018). “ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus.” Obstetrics and Gynecology 131(2): e49-e64.
[4] M van Gerwen M, Maggen C, Cardonick E, et al. Association of Chemotherapy Timing in Pregnancy With Congenital Malformation. JAMA Netw Open. 2021;4(6):e2113180. doi:10.1001/jamanetworkopen.2021.13180
[5] Treating Breast Cancer During Pregnancy
[6] Nana, M., Tydeman, F., Bevan, G., Boulding, H., Kavanagh, K., Dean, C., & Williamson, C. (2022). Termination of wanted pregnancy and suicidal ideation in hyperemesis gravidarum: A mixed methods study. Obstetric medicine, 15(3), 180–184. https://doi.org/10.1177/1753495X211040926
[7] Dekel S, Ein-Dor T, Dishy GA, Mayopoulos PA. Beyond postpartum depression: posttraumatic stress-depressive response following childbirth. Arch Womens Ment Health. 2020 Aug;23(4):557-564. doi: 10.1007/s00737-019-01006-x. Epub 2019 Oct 25. PMID: 31650283; PMCID: PMC7182486.
more references:
[8] Munk-Olsen T, Laursen TM, Pedersen CB, Mors O, Mortensen PB. New parents and mental disorders: a population-based register study. JAMA. 2006 Dec 6;296(21):2582-9. doi: 10.1001/jama.296.21.2582. PMID: 17148723.
[9] Rodríguez-Almagro J, Hernández-Martínez A, Rodríguez-Almagro D, Quirós-García JM, Martínez-Galiano JM, Gómez-Salgado J. Women’s Perceptions of Living a Traumatic Childbirth Experience and Factors Related to a Birth Experience. Int J Environ Res Public Health. 2019 May 13;16(9):1654. doi: 10.3390/ijerph16091654. PMID: 31085980; PMCID: PMC6539242.
[10] About Hyperemesis Gravidarum: Post Traumatic Stress Disorder
[11] Worried about having a big baby? Four things to know about birth weight
[12] Dittkrist, L., Vetterlein, J., Henrich, W., Ramsauer, B., Schlembach, D., Abou-Dakn, M., Gembruch, U., Schild, R. L., Duewal, A., & Schaefer-Graf, U. M. (2022). Percent error of ultrasound examination to estimate fetal weight at term in different categories of birth weight with focus on maternal diabetes and obesity. BMC pregnancy and childbirth, 22(1), 241. https://doi.org/10.1186/s12884-022-04519-z
[13] Simpson, Kathleen Rice PhD, RNC, CNS-BC, FAAN. Trends in Labor Induction in the United States, 1989 to 2020. MCN, The American Journal of Maternal/Child Nursing 47(4):p 235, July/August 2022. | DOI: 10.1097/NMC.0000000000000824
more references:
[14] Jindal, P., Avasthi, K., & Kaur, M. (2011). A Comparison of Vaginal vs. Oral Misoprostol for Induction of Labor-Double Blind Randomized Trial. Journal of obstetrics and gynaecology of India, 61(5), 538–542. https://doi.org/10.1007/s13224-011-0081-0
[15] Dahlen, H. G., Thornton, C., Downe, S., de Jonge, A., Seijmonsbergen-Schermers, A., Tracy, S., Tracy, M., Bisits, A., & Peters, L. (2021). Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ open, 11(6), e047040. https://doi.org/10.1136/bmjopen-2020-047040
[16] Espada-Trespalacios, X., Ojeda, F., Nebot Rodrigo, N., Rodriguez-Biosca, A., Rodriguez Coll, P., Martin-Arribas, A., & Escuriet, R. (2021). Induction of labour as compared with spontaneous labour in low-risk women: A multicenter study in Catalonia. Sexual & reproductive healthcare : official journal of the Swedish Association of Midwives, 29, 100648. https://doi.org/10.1016/j.srhc.2021.100648
DISCLAIMER: This post is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding you or your baby’s health. Please read my Medical Disclaimer for more info
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