Induction and Augmentation of Labour

Most people start labour naturally. However, for some specific reasons, your healthcare provider may recommend medical help to either start labour or strengthen your contractions during labour. Labour induction starts labour before it begins on its own, and labour augmentation strengthens labour already in progress. It is important to have a conversation with your healthcare provider about the risks and benefits of these procedures, before going into labour. This helps you to make an informed decision about your care.

• Pre-eclampsia
• Severe maternal illness

• Poorly controlled diabetes

• Poor growth of the baby (growth restricted)

• Early rupture of membranes and no labour, or when the mother has Group B Streptococcus

These are not all of the possible reasons, but they are the most common.

Benefits and Risks

The following are population level benefits and risks. It's important to speak with your healthcare provider to discuss how these may apply to your individual situation to make an informed decision for your care. "Induction should never be used for the convenience of the mother or the health care provider."¹

Benefits:

Induction

Induction of labour (starting labour) is a procedure that can be lifesaving if the risks, at any time, of continuing your pregnancy for either you or your baby are higher than giving birth.

Augmentation 

When labour is not progressing, augmentation can assist labour to progress and reduce your risk of a caesarean birth.

Risks:

Synthetic Oxytocin

We are just learning about some of the risks of using synthetic oxytocin during labour and birth. Naturally occurring oxytocin hormone levels are normally at their highest levels immediately prior to and right after birth.⁹ To learn more about how the use of synthetic oxytocin may interfere with your natural hormonal feedback and release of natural oxytocin from your brain, please read Dr. Sarah Buckley's blog: Synthetic Oxytocin (Pitocin, Syntocinon): Unpacking the myths and side-effects. These effects may cause:

• Lowered calming and pain-relieving effects for mother during labour²
• Increased risk of postpartum hemorrhage (excessive bleeding)²
• Need for more/increased synthetic oxytocin for labour to progress²
• Prolonged pushing stage²
• Increased use of vacuum or forceps at birth²
• Disruption/difficulty with newborn breastfeeding and bonding/attachment (oxytocin & prolactin hormones interference)²
• Potential short and long-term effects on infants²

Other Risks

• There is a risk of caesarean birth if your labour progress slows or your baby doesn't tolerate the induced labour (fetal distress).¹
• Excessive uterine activity (contractions too close together)¹²
• Bacterial infection of the uterus¹
• Umbilical cord prolapse (cord dropping down through the cervix)¹
• Birth of a preterm baby when dating was inaccurate¹
• Uterine rupture (tearing open)¹

Alternatives

Natural options to prepare your cervix &/or start labour

You can learn more about the evidence, benefits and risks for these options at the Evidence Based Birth Natural Labour Induction Series.

Be sure to discuss the use of any of these options with your healthcare provider prior to using them.

Waiting

It's important to discuss the N (Not Now) in the informed decision-making acronym, BRAIN (Benefits, Risks, Alternatives, Intuition, No or Not Now).

When weighing the benefits and risks of induction or augmentation procedures, ask the question: What if I wait a little longer?

• Induction: This is particularly important if your cervix has not begun to prepare for labour yet. Ask your healthcare provider about your Bishop's Score. This will help you understand the likelihood of induction success. Weigh your risks and benefits of doing the induction now or waiting. Waiting may improve the possibility of induction success or going into labour on your own without increasing risk.¹⁵ The healthiest choice most of the time is to let labour begin on its own.
• Augmentation: Labour may slow for several reasons, but stress, anxiety and fatigue can have a big impact. There are some things that you can try first to help your labour begin to progress again before going to medical augmentation:
• The environment you labour in and the support you receive during your labour plays a big part in optimizing your labour hormones. Having trusted labour support &/or a Doula and creating a safe, dark, calm, quiet, loving and respectful environment can help you relax and allow your body's natural hormonal physiology to make your labour more efficient and effective.
• Staying upright and changing positions or labouring in a deep tub can help your baby move into a better position for birth. Position changes and movement helps in the same way wiggling a ring off a swollen finger does. Moving your pelvic bones around your baby's head can help to wiggle the baby through your pelvis.
• Eating light foods to suit your appetite throughout labour. Labour and birth require a lot of energy.
• Drinking plenty of fluids (water, ice chips, popsicles, clear broth, tea or juice).
• Emptying your bladder often.
• Trying a variety of comfort measures throughout the duration of your labour.

If an induction is recommended for:

1. Prolonged pregnancy, it's important to learn more about what this means. Rachel Reed describes this well in her post about Post-Dates Induction of Labour: balancing the risks.
2. A big baby, it's important to learn more about what this means. Rebecca Dekker describes this well in her post about  Evidence on: Induction or C-section for a Big Baby? The following evidence should be discussed with your Healthcare Provider:

• "Both physical exams and ultrasounds are equally bad at predicting whether a baby will be big at birth."³
• Estimated weight results at the end of pregnancy can fall anywhere from 15% above or below the baby’s actual weight.³ 
• "The suspicion of a big baby leads many care providers to manage a woman’s care in a way that increases the risk of Cesarean and complications."³

Induction and Augmentation Procedures

Induction of Labour

There are various methods for induction.

Sweeping of the Membranes

Sweeping, or stripping, the amniotic membranes after 38 weeks gestation is a simple intervention, which can be a first step to try to start your labour. The process of separating the amniotic membrane from the uterus stimulates the production of prostaglandins. This may trigger contractions and labour.⁶ Studies have shown that it may avoid the need for induction for post-dates^6 14 and to increase the chance of spontaneous birth in the first two days after, for first time pregnancies.¹⁴

If your cervix is open a little, this step can be done in your healthcare provider's office or during a prenatal home visit by your midwife. "It involves the care provider inserting one or two gloved fingers into the vagina and through the cervix, and then using a continuous, circular, sweeping motion to gently separate the bag of water that surrounds the baby from the lower part of the uterus."⁶ Many people find the procedure quite painful⁶ and it may make you feel uncomfortable for a period of time afterward. You may have some bleeding and irregular contractions. There is also a 9% chance of your membranes rupturing during the procedure.⁶

It's important to be aware that some healthcare providers consider membrane sweeping part of their routine care. Since it is a medical intervention, it's important to discuss membrane sweeping with them before the end of your pregnancy so that you can make an informed decision if this procedure is best for you.

Ripening (softening) of your cervix:

Before labour begins the cervix makes some physiological changes to be ready to respond to the contractions. It lines up with the vagina, softens, thins and starts to open. If your healthcare provider has assessed that your cervix has not begun its preparation for labour yet, you will be asked to come into the hospital the evening before your induction for a procedure that will enhance the effectiveness of your induction. The following options: Foley Catheter and Prostaglandins, both ripen (soften) and prepare your cervix for labour and may start labour contractions. Your healthcare provider will have a discussion with you to decide which will be the best option for you.

Foley Catheter

A soft rubber catheter (tube) with an inflatable balloon at the end is placed through your cervix and then the balloon is filled with sterile water and pulled back against the cervix.⁴ The end that extends out of your vagina is taped to your thigh.⁴ It is left in place until it falls out on its own (usually overnight) or after 24 hours. This method stretches the cervix and releases naturally occurring prostaglandins. The procedure is performed the evening before your induction. You will experience some cramping after the procedure. Your baby will be monitored with an external fetal heart rate monitor for at least one hour after insertion to make sure they are coping with the procedure. You will then be sent home with instructions for when to return to the hospital. The benefits of this procedure are that it is a simple procedure and has less risk of side effects such as excessive contractions.

Prostaglandins

Synthetic versions of naturally occurring chemicals, prostaglandins, are applied by gel or a tampon-like device to your cervix. Prostaglandins will not be used if you have had a previous caesarean birth. You will experience some cramping as the prostaglandins begin to work. Your baby will be monitored, with an external fetal heart rate monitor, for at least one hour after insertion to make sure they are coping with the procedure. You may need more than one dose.⁴ If additional doses are needed, they will be given every 6 hours.⁴ You will then be sent home with instructions for when to return to the hospital.

Return to hospital if:

• your contractions become painful and occur regularly every 5 minutes. ^{4 10}
• your contractions are painful and last more than 2 minutes each.⁴
• your water breaks.^{4 10}
• you have bright red vaginal bleeding.^{4 10}
• you feel less than 6 movements of your baby in 2 hours.^{4 10}
• you are unable to manage your contractions at home.
• there is any other reason you feel you need to return to the hospital.¹⁰

If you go home and labour doesn’t begin by the following morning, or within 12 hours after insertion, a nurse will call you to plan the time of your return. You should eat light meals and drink plenty of fluids while at home. Once you come back to the hospital, your healthcare provider will discuss with you the next steps.

These may include one or more of the following options.

Artificial Rupture of your Membranes (ARM or "breaking your water")

If your cervix has started to dilate, your healthcare provider uses a long plastic tool with a tiny plastic hook on its end to nick the amniotic sac, and release the fluid inside the membranes (the sac surrounding the amniotic fluid around your baby).¹³ This will feel like a vaginal exam. The baby must be well engaged in your pelvis to perform this procedure to avoid the risk of a cord prolapse (umbilical cord falling through the vagina ahead of the baby).¹³

In combination with Synthetic Oxytocin, it can help increase your chances of having a vaginal birth within 24 hours.¹³ You will be encouraged to go for walks around the hospital to wait for/assist labour to begin on its own. If your contractions do not start after rupturing your membranes, then your healthcare provider will discuss the use of synthetic oxytocin to help your contractions to begin.

Once your membranes have been ruptured, you and your baby become more vulnerable to infection. One important way to reduce the risk of infection once your membranes are ruptured is to minimize the number of vaginal exams during labour.¹³

An alternative to consider, if your cervix is favourable (i.e., has a good Bishop's score) is to start with synthetic Oxytocin infusion first and wait to rupture membranes until active labour is achieved. This way if the induction is not working, you can stop it and try it again another day. If your membranes are ruptured, this isn't an option because of the risk of infection. ¹⁵

Synthetic Oxytocin (synthetic hormone)

An artificial form of the naturally occurring hormone oxytocin is given by an intravenous (IV) infusion. This medication will cause your uterus to contract. The dosage is precisely controlled with an infusion pump so that your contractions occur regularly and at a moderate to strong intensity.

The baby’s heart rate will be continuously monitored when Oxytocin is used to ensure the baby can tolerate the increase in frequency and strength of contractions. One way to reduce the risks is to turn off the Oxytocin drip once the active phase of labour is reached. It can always be turned back on if needed. ¹⁵

Contractions started with synthetic oxytocin become intense much more quickly than natural onset labours. The latent (first) phase of the 1st stage of labour can also last longer with induced labours.¹⁴ In addition, the limitations on your movement and ability to change positions and access comfort measures such as warm water (shower or bath) reduces your ability to work with the pain of contractions. This may increase the need for medical pain management such as an epidural.

Uninterrupted skin to skin with your baby immediately after birth, until after the first breastfeeding (1-2 hours) and regularly into the postpartum period, is beneficial if you require synthetic oxytocin in labour and birth. This is because skin to skin contact increases your production of naturally occurring oxytocin.

Augmentation of Labour

Augmentation of labour may be needed if you are in labour and are already having contractions, but your labour is not progressing towards the birth of your baby (i.e., your cervix dilating and the baby descending in your pelvis).

The primary reasons for prolonged labour may be related to one of the following 4 Ps:

• Power of the contractions (strength, length, frequency)
• Passenger (the baby's position & size in relationship with your pelvis)
• Passageway (your pelvis size and shape in relationship with the baby) 
• Psyche (your anxiety &/or pain perception and resources to manage it).

Identifying the specific reason(s) causing the delay, and steps to correct it, may allow labour to move forward. See the Alternatives section for non-medical ways to help your labour progress if it has slowed.

Medical augmentation may be done with one or both of the following two methods. These procedures are described, above, in the Induction of Labour section.

Artificial rupture of your membranes

• This method is the same process used for induction of labour. Rupturing your membranes may reduce the risk of needing Ocytocin augmentation later on if this is not your first pregnancy, but it has not been shown to shorten the length of your labour.¹³. "It does not have any benefit in shortening labor if it’s your first time giving birth and you have a spontaneous or non-induced labor."¹³ Additionally, it's important to be aware that the longer your labour takes, the higher your risk of infection if your membranes are ruptured.¹³

Oxytocin (synthetic hormone)

• Used to increase the strength and frequency of your contractions if your labour has slowed. This method is the same process used for induction of labour.

For more information, decision aids & tools

• Ottawa Personal Decision Guide
• Association of Ontario Midwives: When your pregnancy goes past your due date
• Association of Ontario Midwives: In Due Time...Pregnancy Beyond 40 and Induction of Labour
• Partner to Decide: Your Choice: Spontaneous Labor or Labor Induction?
• Making Informed Decisions About Your Care - other decision aids & tools

If you have specific questions

• Speak with your healthcare provider.
• If you are giving birth at LHSC, speak with the nurse at the London Health Sciences Centre (LHSC) Preadmission Clinic. A pamphlet is available at the LHSC Women’s Health Clinic for more information on induction and augmentation of labour.