Inducing labor: Why and how providers induce labor

Why would my provider induce labor?

Your provider may recommend methods to bring on (induce) labor when the risks of waiting for labor to start on its own are higher than the risks of having a procedure to get your labor going. An induction can happen when you're full term, or it can happen earlier, in some cases, if the risks of continuing the pregnancy are greater than the risks of your baby arriving early.

Your doctor or midwife may recommend an induction if:

• You're still pregnant a week or two past your due date. Experts advise waiting no longer than that to give birth because it puts you and your baby at greater risk for a variety of problems.
• Your water breaks and your labor doesn't start on its own. Once your membranes have ruptured, you and your baby are at increased risk of infection. So your provider will help you weigh the risks and benefits of induction versus waiting to see if you go into labor on your own.
• You have tests showing your placenta is no longer functioning properly, that you have too little amniotic fluid, or that your baby isn't thriving or growing as they should.
• You develop preeclampsia, a serious condition that can endanger your health and restrict the flow of blood to your baby. Or, you develop gestational hypertension, a milder version of pregnancy-induced high blood pressure that may evolve into preeclampsia.
• You have a chronic or acute illness that threatens your health or your baby's health. Such conditions can include high blood pressure, diabetes, kidney disease, or cholestasis of pregnancy.
• You previously had a stillbirth.

You also might have an elective induction for logistical reasons – if you live far away from the hospital or know you have very rapid labors, for example. In those situations, your healthcare provider should wait until you're at least 39 weeks pregnant to schedule your induction (more on this below).

In the United States, just over 31 percent of labors were induced in 2020, more than triple the number (9.5 percent) in 1990. This may be explained in large part by the fact that there's a larger high-risk population now – with increased rates of obesity, advanced maternal age, and chronic diseases such as diabetes and hypertension.

Inducing labor at 39 weeks

In some cases, your provider may offer an induction at 39 weeks of pregnancy. The American College of Obstetricians and Gynecologists (ACOG) says that labor induction may be considered at 39 weeks for low-risk pregnancies.

Research suggests that induction at 39 weeks may reduce the risk of:

• Cesarean birth
• Preeclampsia
• Macrosomia
• Stillbirth
• Hypertensive disorders
• Infection in the mother
• Bad outcomes for the baby (such as respiratory problems and intensive care unit admission)

That's when comparing induction at 39 weeks with waiting for labor to occur on its own.

If you're interested, talk with your provider about whether induction at 39 weeks would be appropriate for your specific circumstances.

How to induce labor

How your provider induces labor depends in large part on your cervical dilation and effacement at the time. If your cervix hasn't started efface (become softer and thinner) or dilate (open), it's considered "unripe," which means you're not yet ready for labor. Your provider will check your cervix and plan accordingly.

If your cervix isn't ripe, your provider will use either medication or "mechanical" methods (see below) to ripen your cervix before starting the induction. This often shortens the length of labor, and may end up jump-starting labor as well.

To ripen your cervix and induce labor, your healthcare provider may:

• Use prostaglandins. You may have medicine that contains synthetic prostaglandins inserted into your vagina, or you may be given an oral dose of misoprostol (a form of prostaglandin). Prostaglandins act like hormones, and this medication helps ripen your cervix and sometimes stimulates contractions so you don't need oxytocin.
• Use a Foley catheter or cervical ripening balloon. Instead of using medication, your provider may ripen your cervix by inserting a thin tube with one or two tiny, uninflated balloons on the end. When these balloons are filled with fluid, the pressure on your cervix stimulates your body to release its own prostaglandins, which can make your cervix soften and open. (When your cervix begins to dilate, the balloon falls out and the tube is removed.)

  

  If your labor doesn't start from these methods alone – which is common – you'll eventually be given an IV infusion of oxytocin. This drug (often referred to by the brand name Pitocin) is a synthetic form of the hormone that your body produces naturally during spontaneous labor.

  If your cervix is already somewhat dilated, your provider may:

• Strip or sweep your membranes. Your provider inserts a finger through your cervix and manually separates your amniotic sac from the lower part of your uterus. This causes the release of natural prostaglandins, which may help further ripen your cervix and possibly get contractions going.
  
  

  In most cases, membrane stripping is done during an office visit. You're then sent home to wait for labor to start, usually within the next couple of days. Many moms-to-be find this procedure uncomfortable or even painful, although the discomfort is short-lived.

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• Rupture your membranes. If you're at least a few centimeters dilated, your provider can insert a small hooked instrument through the cervix to break your amniotic sac. This procedure (called an amniotomy) causes no more discomfort than a vaginal exam. This would only be done after you've been admitted to the hospital, before or after you're given oxytocin (see below).

  

If your cervix is very ripe and ready for labor, there's a small chance that rupturing the membranes alone will be enough to get your contractions going. If that doesn't happen, your provider will:

Use oxytocin (Pitocin). Oxytocin is the hormone that causes your uterus to contract. Your provider may give you oxytocin through an IV pump to start your contractions or to speed up your labor, if necessary, once contractions have begun. They can adjust the amount you need according to how your labor progresses.

It usually takes about 30 minutes for oxytocin to start working.

How long does induction take?

It depends. The amount of time it takes to go into active labor after the start of induction varies widely.

Here are some reasons why:

• If your cervix is riper, you'll probably have a shorter time from the start of induction to active labor and delivery.
• Once your membranes are ruptured, either artificially or spontaneously, you'll probably progress faster, especially if you're already having contractions and your cervix is ripe.
• You'll likely progress to active labor more quickly if you've had a baby before.

Your provider will usually continue giving medication or using mechanical ripening methods, such as a balloon in the cervix, for up to 12 hours, unless active labor begins before that or there's a problem with your baby's heart rate. After 12 hours, they should be able to give you a rough estimate of how much longer you can expect to wait before active labor begins.

Once you reach active labor (about 6 centimeters dilated), you'll likely continue to dilate for another four or five hours before delivering your baby, if you're a first-time mom.

While women who are induced typically spend more time laboring in the hospital – possibly because they're admitted before they're in active labor – the active labor stage lasts about the same time in induced and spontaneous labors.

Is it risky to induce labor?

Although induction is generally safe, there are some risks, which may vary according to your individual situation. Here are possible risks and inconveniences:

• Overly strong and frequent contractions. Oxytocin, prostaglandins, and nipple stimulation occasionally cause contractions that come too frequently or are abnormally long and strong. This, in turn, may stress your baby. To assess the frequency and length of your contractions as well as your baby's heart rate, you'll need to have continuous electronic fetal monitoring during an induced labor. You'll probably have to lie down or sit still while being monitored, but some hospitals offer telemetry, which means you can walk around during the process with a small version of the fetal monitor attached to you.
• Rupture. In rare cases, prostaglandins or oxytocin can cause placental abruption, or even uterine rupture – although ruptures are extremely rare in women who have never had a C-section or other uterine surgery. Commonly used prostaglandins such as misoprostol and cervidil (dinoprostone) are associated with a relatively high rate of rupture in women attempting a vaginal birth after a cesarean (VBAC) and should never be used in women with a scarred uterus. Some experts don't think women attempting VBAC should be induced with oxytocin either.
• Infection in the baby. This may happen if the amniotic sac is ruptured for a long time.
• Long wait time. Inducing labor can take a long time, especially if you start with an unripe cervix, and this process can be hard psychologically and physically. Sleep deprivation and dealing with pain for long periods may exhaust you and make it harder to push your baby out when the time comes. (On the other hand, the long wait for labor to begin may be even more trying among women who go past their due date.)
• You might still need a C-section. If induction doesn't work, you'll need a C-section. Having a C-section after a long labor or unsuccessful induction is associated with higher rates of complications than you might have with a planned C-section.
• You may have an increased risk of postpartum depression. According to a study of more than 46,000 women who gave birth between 2005 and 2014, the risk of postpartum depression and anxiety disorders within the first year postpartum was higher in women who received oxytocin during delivery. In women who had a history of prepregnancy depressive or anxiety disorder, the increase was 36 percent when compared to those not exposed to oxytocin. In women with no history of prepregnancy depressive or anxiety disorder, the risk was increased by 32 percent.

Your healthcare provider should recommend inducing your labor only when they believe that waiting for labor to begin would be riskier for you and your baby than intervening.

When should labor not be induced?

Labor shouldn't be induced before 39 weeks, unless it's safer for you and your baby than continuing the pregnancy.

You'll need to have a C-section rather than an induction whenever it would be unsafe to labor and deliver vaginally. You might need a C-section if:

• You have tests that show your baby can't tolerate contractions or otherwise needs to be delivered immediately.
• You have placenta previa, a condition that means your placenta is positioned unusually low in your uterus, either next to or covering your cervix.
• Your baby is in a breech or transverse position, meaning they're not coming headfirst.
• You had a previous C-section with a "classical" (vertical) uterine incision or another uterine surgery, such as a procedure to remove fibroids (myomectomy).
• You're having twins and the first baby is breech, or you're having triplets or more.
• You have an active genital herpes infection.
• You have a prolapsed umbilical cord (the cord has dropped ahead of the fetus into the vagina)

Dos and don'ts before being induced

These tips can help make the induction process more enjoyable:

Don't try natural methods of starting labor at home without talking with your doctor or midwife first. Some of them – such as mild exercise or having sex (if it's safe for you now) are harmless. But others – such as drinking castor oil or administering an enema –  can cause side effects such as nausea and diarrhea. And other methods – such as herbal remedies and nipple stimulation – can overstimulate your uterus and be unsafe.

Do ask your doctor or midwife what to expect on induction day. You may have already been to the office for cervical ripening procedures, but when it's time for you to receive Pitocin, you'll head to the hospital. Your doctor will give you directions about when to arrive.

Bring your hospital bag and head to the labor and delivery department. Your doctor will meet you there, either immediately or after you've been admitted and tended to by the hospital labor and delivery team.

The delivery nurses will get you situated, start an IV, and draw some blood for lab work. A provider (an in-house doctor or midwife at the hospital or your doctor or midwife) will perform an exam and determine how to best get your induction started.

Do bring entertainment. Some inductions take a very long time to get going, particularly if your cervix isn't ripe at the outset. In this case, you may be in the hospital for many hours before you even feel your first contraction.

It's a good idea to bring something to keep yourself entertained, such as books or a tablet. Consider making a labor playlist on your phone – soothing music that distracts and relaxes you. In the early phase of the induction, before contractions get strong and regular, try lowering the lights and minimizing noise so you can nap as much as possible.

Don't be in a hurry. You'll be more comfortable if the induction happens gradually. If you're given Pitocin, it's easier on you if the dosage starts low and is slowly increased (every 30 to 45 minutes). This allows you to adjust emotionally and physically as your labor progresses.

Do use relaxation techniques. Once your contractions get going, you can use comfort measures like relaxation, aromatherapy, massage, and position changes.

Don't hesitate to ask for pain meds or an epidural if you choose. If you want, you can still labor without pain medications. But you may prefer to have an epidural started before you get Pitocin. Especially in a scheduled induction, where you're likely to be in labor for a long time, an epidural can allow you to get much-needed sleep.

Learn more:

• Labor positions
• What happens to your baby right after birth
• How long do you stay in the hospital after giving birth?