Planned Inductions and the Cascade of Interventions

By: Aunt Doula (10/07/2022)

It sounds like a great idea, on the face of it, doesn't it? You go in for your regular 36 or 37 week appointment, everything looks great and the doctor ever so casually says "Alright, we'll just go ahead and get you scheduled for induction at 39 weeks!" They say it so confidently, so matter of fact, that you may not even think to ask "Is this normal?" "Do I need an induction?"

This is happening now to almost every new birthing person I speak with, unless they have a strong, empowered stance against induction, they understandably go along with the recommendation - after all their doctor is saying it's what to do, so it should be right.. right..? Well. Not necessarily.

The primary function biologically speaking of your cervix and uterus your entire pregnancy, is to protect and hold tight and only when they receive the correct hormonal signals that start with a hormonal signal from the baby, can they shift to a new function open and release - a "failed induction" is more often just a really strong and protective uterus that refuses to allow your baby to come into the world until it's ready. This concept is extremely important to understand, because the very first initiation of labor comes from your baby and modern medicine cannot replicate that - so they replicate all the other things it can to try an force your body into thinking it's time for labor in other ways - but your pituitary gland never got the very first go ahead, and that can mean all other attempts will be for not.

Now, inductions have their place in medicine, don't get me wrong. There are definite medical reasons to induce labor for the safety of the birthing person, child, or both. That will be discussed in another post. Here, I am speaking directly about healthy birthing persons, with healthy babies and low risk pregnancies being scheduled for an unnecessary induction of labor just because they are at 39 weeks gestation.

And it truly is, unnecessary. Labor in a healthy pregnancy is a natural and vital conclusion to an entire hormonal symphony that has an intricate and delicate interplay between the birthing person and the baby coming to a crescendo that is birth. Forcing a chemical labor upon both can be traumatic, difficult, and exceedingly painful - with no improvement in outcomes for either party. In fact, there are often poorer outcomes than allowing natural labor to come along. So, why do doctors continue to recommend it? Why 39 weeks? Why don't they ask what the birthing person wants? There are a whole lot of why's, and not a lot of science or evidence involved.

Medical induction of labor is a multi-step process, and once you step aboard the induction train, you are on an express bus with very few - if any - stops. If you are of the lucky induction lottery winners, your body will respond to the chemical replicants of hormones and eventually succumb to them and it will end with the vaginal delivery of your baby. If you are of the unlucky induction group, you get a participation trophy and a C-section you may or may not have been prepared for.

This post is not meant to diminish the validity of C-section births, which also have their definitive place in medicine and are in their own right necessary for a myriad of reasons. C-sections births are births, and they are beautiful in their own right - they are just another way a baby comes into this world, and those who live in areas with access and need are quite fortunate to live in a time where they are available.

What is induction, anyway? Here is a step-by-step process of an induction from admission to the pushing stage.

As stated above, induction is a multi step application of chemical replicant that are designed to mimic labor and essentially, trick your body into giving birth. The biggest problem with this process is, it short circuits some of the most important hormonal processes that happen when labor occurs naturally. The most vital of these hormonal processes is the oxytocin and beta-endorphin pulses that keep pace with your contractions and give natural pain relief that increases along side the strength of your labor. Natural labor starts low and slow, giving your body and uterus an ample "warm up" time to settle into the coming marathon. Oxytocin receptors in your uterus bud just hours before labor begins, allowing for the surges of oxytocin to naturally increase the strength of your contractions according to the muscles ability and the continuous conversation between you and baby on a hormonal level. A low and slow start to labor also allows baby to adapt to the contractions and prepare for entry to the breathing world. If this is done before they are truly ready, it can be all the more traumatic for the infant. It can lead to fetal distress and ultimately a C-section that may not have been necessary, had time, instead of intervention, been applied.

The first step of induction is to prepare the cervix. This is done with prostaglandins placed against the cervix to cause it to soften and thin so that the baby can exit the uterus. If the cervix is not open, there is nowhere for baby to go! Prostaglandins start the process of opening the doorway to delivery. Once the doorway starts to open, the bus has hit the freeway on ramp - you're in it for the long haul now.

One of two things will happen now that the cervix has softened and thinned (called effacement) It may have already started to dilate some, but often before that can really get going another chemical replicant will enter the game - pitocin - which is a synthetic form of oxytocin. If your cervix did not respond to the prostaglandins, you may have a Foley balloon placed to mechanically force your cervix open to convince it it's time for labor, and then the pitocin will start.

It is important to note, that pitocin does not work on your brain, it only works on your uterus. It is happy to make your uterus contract, but you won't be getting any good feelings back! Naturally occurring oxytocin made in the body contracts the uterus but at the same time comes with pain relief, and comes in waves. Pitocin comes with no pain relief and rolls constantly, bombarding your uterus with a signal to contract so hard and so often that it can, and often does, become unbearable. This is because the strength of the contractions is not being governed by your natural labor process - there is no hormonal conversation going on between your brain and your uterus, there is only a chemical acting upon your uterus telling it to contract at all costs - and neither you nor your baby are likely to find it pleasant, or tolerable. You're on the freeway now, and the driver may be going a bit too fast for comfort!

Enter, the epidural. Needing an epidural is common in an induction because you have been forced into labor before your body and your baby's body were necessarily ready, and your body isn't making the pain relief it needs to to keep up. Again this is because the pitocin isn't acting on your brain to tell it to release oxytocin along with beta endorphins to keep this ride bearable. You will understandably, probably be asking if not begging for an epidural. The bus has hit 95 in a 60 zone, but the epidural is coasting it down to a nice 70. Wait. 50. 30? What's happening? Why is the bus stopping? - Your labor has stalled. This is common with epidurals and inductions, but now that you can't feel the pain, they'll just increase the pitocin! (How convenient) The bus begins to pick up speed again.

You might be 5 or 6 cm now, but staying there. Stuck. So the doctor drops in and suggests that they break your waters. They may do it without telling you during your cervical exam - but what's done is done! Let's have a baby! They say, and then leave. You aren't sure what just happened, but they're the doctor, and your water has to break before you can have your baby.. right..? What they may not tell you is that you are now on a clock - your baby must arrive earth-side within 12-24 hours (depending on facility) or you are having a C-section. There may not have been a discussion, but now there is no decision to be made - it's baby in a set amount of time, or surgery. Were you ready for that?

If you are on the lucky induction lottery winner bus tho, your chemical labor will be well on its way now, and you'll be meeting your baby soon. Complications at this stage will be covered in another post.

If you are on the unlucky induction bus, your labor stays stalled after the epidural and waters being broken. Nothing seems to be working. You will be rudely labeled with "failure to progress" as if you had anything to do with the outcome, quite likely your baby will start to show signs of fetal distress or you will become too exhausted to continue. By this time you will be happily entertaining the idea of a C-section to get this all over with.

Did you see the cascade of interventions unfolding from the moment at your 37 week appointment when your doctor so smoothly suggested this induction? Let's walk it through. There will also be a post on more in-depth examples of the cascade of interventions in a future post.

Typical induction cascade of interventions by step

-1) Casual suggestion of induction without discussion of pros, cons, or alternatives.

-2) Scheduling as if there is not choice in the matter

-3) Arrival on induction day - very little is explained to you, you probably won't be told what's happening as it happens.

-4) Cervical induction begins with prostaglandins, if that fails, they might insert a Foley ballon

-5) Your body hasn't gotten the message from the prostaglandins that it's supposed to be going into labor - Pitocin drip is started.

-6) Epidural because the pain is crazy - your uterus is contracting beyond it's voluntary limits.

-7) Waters broken (this may happen really anytime you show up whether for an induction or not, be aware, they do not always get your consent.)

Assuming you are on the lucky bus, you will reach 10cm dilation, 100% effacement, zero station and begin to push and then meet your baby! (See corresponding post about what all of these things mean, and how they relate to "The Bishop Score")

If not, you are still on the intervention bus and

-8) Labeled rudely with "Failure to progress" the nurses will try to turn down your epidural, or shift your positions, maybe tweak pitocin but ultimately you will run out of time and end up at

-9) C-section birth due to failure to progress, fetal distress, infection risk due to waters being broken more than allotted time.

Is this how you imagined your birth would go? Is it how your birth HAS to go? No.

An induction is a multi step process, where each intervention is inevitably leading to the next intervention, which causes more interventions when all of this could have been avoided if the very first intervention of suggesting an induction was never made.

Read that again. All of these interventions lead to one another, that may have all been avoided if an induction had never been suggested. There are very few inductions that aren't failed inductions, when you consider a vaginal birth without complication a successful induction.

So what is the answer? Education. What did you learn from reading this (very brief) overview of the process of induction? What else do you want to know? After reading this, would you still want or go through an induction? Let me know in comments below. If you've had an induction, was it like this? Was it different? How much did you know going in? Would you do it again?