Induction of Labor

Labor can be induced for medical reasons or social reasons and is safe for the baby if done after 39 weeks. There are many agents that can be used for induction including Cervadil, Cytotec, pitocin, and cervical foley. There is a belief that inductions hurt more but I believe it has more to do with being in the hospital from the first contraction and therefore being less distracted. There is a higher chance for c-section in labors that are induced compared to going in to labor spontaneously.

Some times there are medical reasons to induce labor. If the mother gets sick, preeclampsia for instance, labor may need to be induced. Some types of high risk pregnancy are often induced at 39 weeks diabetes and hypertension are examples. It is possible the baby is showing signs of stress and this can be an indication for induction.

Social inductions are done for non medical reasons. Maybe the father is in the military and being deployed or a close relative is taking time off work. These types of inductions should not be done before 39 weeks as there is risk that the babies lungs may not yet be ready. Usually these inductions are done only if the cervix is favorable for induction, meaning there is a high chance of successes. When a social induction is done it is important that everyone is prepared to stop the process if the body is not responding to the medication.

Most people believe that induced labors have a higher c-section rate then spontaneous labors. This can be reduced by only doing social inductions with a favorable cervix and being willing to stop the process if it seems it is not working.

Prostoglandins are the chemicals the body secretes to initiate labor. They are thought to arise from the cervix probably from the pressure of the baby’s head against the cervix. The prostoglandins effect changes in the cervix to start the effacement process. They also cause changes in the uterus to make it more susceptible to oxytocin. Oxytocin is a protein the brain makes that causes uterine contractions.

Cervadil is one of the common medications that is used for induction. It is a prostoglandin that is placed on the end of a sting. This is placed in the vagina near the cervix. It is designed to stay in the vagina for 12 hours but can be removed earlier in certain circumstances. It is a cervical ripening agent and helps prepare the cervix and uterus for labor. It sometimes even puts women in to full labor by itself.

Cytotec is another prostoglandin, It is in pill form and can be put in the vagina, in the mouth under the tongue, against the cheek, or swallowed. It is the most effective agent for inducing labor. The most common way it is used is to be placed in the vagina and a repeat dose is placed in 4 hours. Like Cervadil,  Cytotec ripens the cervix to prepare for labor. Cytotec often places women in labor so that pitocin may not be necessary.

Cytotec has an interesting history. It was originally made as a drug to protect against ulcers while taking NSAIDs like Ibuprofen. It was noted that if used in pregnant women it would induce labor. This is why the FDA in the US  put the big scary warning “not for pregnant women”. And you certainly should not use this in pregnancy to prevent ulcers. Researches began studying its labor inducing properties and found that it is the most effective medication available for induction of labor. Early on the best dose was not known and most people were using 50 mcg in the vagina. At this dose it sometimes caused too many contractions and hyperstimulation. Now people use 25 mcg and hyperstimulation is uncommon. . Cervadil is the competing drug and it is still on patent. That means it is very expensive and drug companies are still making lots of money off of it. Cytotec costs less then 1% of cervadil, no one is making money off of it and therefore there is no voice to defend its use. To make matters worse, when Ru486, the abortion pill was introduced in the US Cytotec was part of the protocol to induce first trimester abortions. The company that makes Cytotec sent letters out warning doctors not to use Cytotec as it is ‘not for pregnant women”.  Cytotec definitely works better for induction then any other agent. When dosed properly the risk of hyperstimulation is very small. It should not be used in VBAC induction and maybe not in IUGR. In most other cases it is often the best choice.

Pitocin is chemically identical to oxytocin, the protein the brain makes to get the uterus to contract. It is given through the IV and the dose gradually increased. It works best if it is used after one of the prostoglandin agents or to augment labor that has already started. Contractions do not start immediately when Pitocin is given but rather gradually. This mimics natural labor.

A cervical foley is a catheter with a balloon on the end. It is put through the cervix and the balloon is filled with water.  The catheter is then taped to the leg so that the balloon applies pressure to the cervix mimicking the babies head. This can cause the release of prostoglandins and start the labor process. This is less commonly used in the US but it can be effective. It can be a little difficult to place and cause cramping but it is very safe and can be effective. This is the way we induced labor in Zimbabwe when I did a medical mission in that country.