At 6:30 A.M. on the dot, my patient, a first-time mom, and her husband, arrive on the labor and delivery floor for her induction.
As I settle them in and hook up the monitors to her belly, I explain the induction process.
When she asks me when I think the baby will come, I hesitate.
"Most likely, it will be a while," I say, as gently as I can. "With most first-time mothers, an induction can be unpredictable. Your baby may not come until tomorrow."
Shock registers on her face as she looks over at her husband.
"Well, do you think she could get some breakfast then? We were expecting the baby to come by lunchtime, so she didn't eat," he says quietly.
I shake my head. "No, I'm sorry, but we can't let you have anything right now -- not until we see how the baby responds to the medicine."
As they exchange silent looks, I know I am dealing, yet again, with a couple completely unprepared for what lies ahead. As a labor and delivery nurse, I want to make sure my patients are educated on the induction process before they come to the hospital. If you or your care provider is considering an induction for your labor, here's what you need to know.
Understand the reason for your induction. The primary reason for an induction should be a medical one, such as gestational diabetes or high blood pressure in the mother. Some patients, however, and even doctors, will choose an induction for "social" reasons, such as timing the birth for visiting family or to avoid having your baby on a holiday. "When there is a medical indication for a mother and baby, you have to do it," says Denise Huntley, MSN, RN, a labor and delivery nurse and childbirth educator at Brigham and Women's Hospital in Boston. "Often, though, patients choose an induction because they don't want to be pregnant anymore. I discourage that, especially with the first baby."
Unless you have a serious medical condition, no care provider should induce labor before 39 weeks. Even then, research shows, in the last weeks of pregnancy, every day counts for your baby's development.
So you should understand the reason for your induction. If your doctor says she wants to induce you, but you're not clear on the reason, speak up. If there is no clear medical reason for your induction, you do have the right to refuse.
Induction increases the risk for a cesarean section. "There are very good medical reasons to be induced," Huntley says. "But studies show that it does increase your risk for a cesarean." In fact, for first-time moms, an induction can double the risk for a C-section. Julie Marshall, of Fenton, MI, was induced for high blood pressure during her pregnancy. "But at some point during the induction, the baby flipped over, and I had to have an emergency C-section," Marshall recalls. A long labor, external drugs, bed rest, and stress on mom can each contribute to the increased risk.
You probably won't be allowed to eat much. This one comes as a shock to a lot of women. The prospect of not eating for even a few hours was frightening to me as a pregnant woman, so I understand why the thought of a day or more without much food might worry you. The reasons birthing centers may prohibit a woman from eating during labor include the nausea and vomiting that are a natural part of labor -- along with that increased risk for a C-section. (As in any surgery, patients headed to a caesarean aren't allowed to eat because stomach contents could wind up in the lungs during surgery, leading to serious complications like pneumonia.) If your doctor or midwife allows it, eat a hearty breakfast before your induction to keep your energy up. And ask your doctor what his or her protocol is for food during labor. "If we know it is going to be a long induction, we will 'break' a patient," says Michele Hakakha, M.D., FACOG, author of Expecting 411: Clear Answers & Smart Advice for Your Pregnancy. "So for example, after two doses of Cytotec or after a 12-hour dose of Cervidil, we will let a patient eat a light meal, like soup broth or some fruit, and shower before the pitocin portion is started. I find this a lot more humane."
There are different methods for an induction. Many women come in to the hospital for an induction expecting to be hooked up to Pitocin (oxytocin) to get labor going. But the OB staff can't start Pitocin until the cervix is "favorable," meaning that Pitocin won't be effective unless the body shows signs that it is ready for labor. A cervical-ripening agent, such as Cytotec, or misoprostol (which looks like a tiny pill and is placed behind your cervix), or Cervidil, or dinoprostone, a vaginal insert that is placed high into the vagina to start or continue the ripening of the cervix, may be used first to help your cervix stretch and open before Pitocin is administered. Alternatively, manual opening of the cervix can be achieved with a balloon catheter or even a rod made of seaweed that gradually expands.
More of What to Expect When You're Induced
It could take a while. An induction is a lot like trying to start a car with a dead battery. You can try and try, but until you get a jump-start, it won't take off. The goal of an induction is to kick a woman into starting natural labor and then help her along the way. Because no one really understands how labor starts, an induction can be a guessing game. "I recently had a patient who was complaining that she wasn't in active labor after two days of being induced," Huntley recalls. "But honestly, that's not a long time when you're being induced, especially for a first baby and an induction before 40 weeks."
So don't go in with the mindset that you'll arrive in the morning and have a baby by lunchtime. The far more likely scenario is that your induction will take at least a day, and maybe even longer. In some cases, labor simply can't be started. After three unsuccessful attempts at her overnight induction, Tracey Howland-Szczepanski of North Branch, MI, was surprised when her doctor sent her home. "They didn't even tell me that being sent home could be an option," she says.
So you should come in prepared for the possibility that you'll be in labor for at least 24 hours and bring a laptop or tablet to keep yourself entertained.
Your contractions may feel more intense. Be prepared for this and adjust your pain management methods accordingly.
Although I planned for a drug-free birth with my first child, a stalled labor and the addition of Pitocin equaled pain I couldn't manage. Stephanie Tuttle of Coldwater, MI, has had two induced and two noninduced labors, and the contractions in her induced labors were, she says, "more intense."
"They never mentioned the intensity of an induced versus a natural labor," Tuttle says. "They're more intense -- you can feel the difference. The contractions last longer, and sometimes they're harder because they aren't as productive."
The other factor that may cause an induction to be a bit more intense is the fact that it is so controlled. "Natural labor will have some breaks in it," Huntley says. "You may have five minutes between contractions to catch your breath; with Pitocin, contractions often are every two to three minutes."
You may be more closely monitored. Many women hope to have some degree of freedom to move around during early labor, perhaps to use a birthing ball or walk the halls. If you're being induced, however, you may be more restricted. For example, if you're given Cytotec, you need to remain in bed for at least an hour after the medicine is placed so it doesn't get dislodged.
If you're given Pitocin, the baby must be monitored continuously, which may mean bed rest for you. And if your contractions prove difficult to pick up with external monitors, your doctor may have to place an internal monitor to get an accurate reading of your contractions, further restricting your activity.
It's a mental thing. "Labor is labor," Huntley says. "It's always uncomfortable, but an induction can be more difficult because it's longer and in a hospital setting, so there is nothing to distract you from what's going on." It can be challenging for women to put themselves in the right frame of mind for labor, especially if the induction takes a considerable amount of time. Not knowing how the body will react may be stressful, and some women find that the process of waiting in an unfamiliar environment tires them out before active labor even begins. "Just coming to a hospital makes you more anxious," Huntley explains. "And then add in pain and you're likely to respond more intensely."
To quell anxiety, bring in elements of home. "Most people are afraid of hospitals," Huntley says. "But labor is a personal experience that a woman needs to make her own." She recommends making the birth experience as homey as possible and encourages patients to bring in their own pillows, snacks, toiletries, and clothes to help them relax. When I had my third child in July, I slathered myself in my favorite lotion to drown out the scent of hospital. Now, the smell of Moonlit Path conjures up that precious time I spent getting to know my new son.
Education is vital. The key to a successful induction -- and a smooth labor and delivery -- is preparation. "I familiarized myself with the process of induction, then I made it a point to ask every question in the book before I went through it," says Ruth Logan, a freelance writer in Trumbull, Connecticut. "At my final weekly checkup, I made sure that my doctor walked me through the steps of the entire induction process. He told me what to expect and gave me the pros and cons of induction itself. If not for that, I probably would have been a nervous wreck!"
Don't be afraid to ask your provider detailed questions about your induction and, if you can, speak to a labor and delivery nurse at the facility where you will deliver -- she will often have inside information that your care provider may overlook.
Remember that every woman is different. Inductions are more unpredictable than a non-induced labor, but every pregnancy, labor, and delivery is unique. Your induction may last a day or two, or you could have a textbook induction that places your baby in your arms in four hours from start to finish. Do your homework and prepare as best you can -- and keep an open mind about your labor and delivery. And don't forget to bring the snacks. Even if you have to wait to eat them until after the baby is born, you will thank me.
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