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Induction of Labor: When Is It Right?

One of the questions often asked of me in my private obstetrical practice concerns the process of induction of labor. Induction of labor is any process that initiates labor before it might spontaneously begin. It may seem unnatural, the best way to have a baby still being for a woman to go into labor on her own and have her baby vaginally. But it is a completely legitimate technique that is often necessary to bring a pregnancy to a happy conclusion when medical complications in the mother might make continuing a pregnancy dangerous to herself or to her unborn child. This reason for induction is the only medically indicated reason, and it is determined by an obstetrician based on many factors.

Delivering Early for Health Reasons

Toxemia (also called Pre-eclampsia, or Pregnancy-Induced Hypertension) is a common legitimate indication. A worrisome slowing of the baby’s growth might alert a doctor that the outside environment may be less hostile to a baby than the inside environment, or womb (uterus). When these or a host of other dangerous things happen, it’s time to have a baby before disaster strikes. Of course, this is really common sense and is usually an obvious conclusion to the mother as well as to her doctor.

Choosing to Deliver Early

But there are also elective inductions. Although it’s not the “natural” way to have things go, it is quite acceptable if the prospective mother is within one week of her due date, and her cervix (mouth of her womb) is “ripe” for induction. This “ripening” is determined by how dilated it is, how thinned out it is, and how far down is the baby’s head. Certainly a baby within a week of the due date is not a prematurity risk. And a baby who goes beyond the due date may in fact be what’s called a post-maturity risk–at risk for fetal distress.

If a patient asks, many doctors will grant a patient’s request to induce one week before the baby’s due if the cervix is ripe, and most doctors really want to induce if the baby goes much beyond the expected date of delivery. Before the due date is convenient for the patient; after the due date is wise for the sake of the pregnancy.

Many feel that nature should take its course no matter what, but some patients have domestic situations that justify a safely timed induction. When the father might be available from his work, when a grandmother might be in town to help out, timing delivery before school starts–all of these reasons and innumerable more can cause a patient to ask for an induction. And if she’s within that magic week of the due date, a physician will usually consider it, but only if the cervix is ripe. Because if it isn’t, a doctor can induce away at an unripe cervix all day, fighting stubborn anatomy. This can increase the risk of resorting to C-section, so it’s always wise to follow the rules of ripeness, which are satisfied by a numerical score of dilatation, thinning (effacement), and head descent. This numerical score is called the Bishop’s Score and gives obstetricians a raw number value to determine whether induction is feasible or not.

Pain & Induced Labor

Questions regarding inductions being harder labors than natural labors are valid. The answer is that if an induction, for either medical reasons or personal reasons, is done with a good Bishop’s Score and within a week of the due date or beyond, it should be no “harder” than a natural labor. Indeed, the patient’s own natural contraction mechanism takes over in these cases, allowing a doctor to turn the drip down or even off altogether. On the other hand, an elective induction without an inviting Bishop’s Score is a bad idea, as it is liable to be a long drawn out affair, with the shadow of C-section looming continuously overhead when the war against the laws of physics is lost.

Unfortunately, rupture of membranes (breaking the “bag of water”) usually necessitates induction, regardless of the Bishop’s Score, and these patients are at particular risk for failure to dilate and C-sections. This is unfair but at times unavoidable. And although a C-section is a disappointment to those who hoped for an uncomplicated vaginal delivery in these cases, it’s not the worst thing that could happen–it’s just second choice. But an obstetrician can aim higher than second choice when considering elective inductions merely by following a few easy rules.

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