Step-by-step from Admission to Pushing - Induction / Induced Birth

By: Aunt Doula (11/06/2022)

More and more pregnant people are being offered elective inductions and also undergoing medically necessary inductions. This post covers the general outline of a US hospital based induction from the time of admission until the pushing stage of labor so that you can be familiar with the general process of what to expect in your upcoming induction. Different facilities have different procedures and different medications, however the general process remains the same. This is a broad-stroke overview that includes options your facility may not provide, or have different medication brand names for. This is not medical advice or a guarantee of how your induction will go, it is intended as a way for you to understand the general outline of an induction to empower you to ask questions of your provider and facility to find out what their specific policies, procedures, and medications are. It is also intended to help you understand aspects of the process you may not have realized were going to happen so you can clarify them with your doctor and avoid confusion or delays.

While inductions follow a fairly standard progression you may run into some common hiccups along the way which will be covered in a separate post. As stated above listed are the most common things that usually happen but understand that some things are not offered everywhere or some things will not be indicated for your particular medical picture. This is educational information only. You will have to speak to your doctor to determine what your facility uses and what their particular induction procedure entails from this list.

Admission and Baseline Exams

When you arrive at the hospital, you will either be taken to a triage room to do all the intake and initial exams or taken directly to your delivery room. Different facilities have a one-room setup for labor, delivery and postpartum, some will have you moved to a postpartum floor (a second room) after you deliver. If you aren't sure what your facility provides, it's good to learn as soon as you get there so you are able to unpack and relax fully into the space or know that you will have to move again.

Most inductions take on average anywhere between 12 and 72 hours. These are the extreme examples, the average is 36 hours from admission until delivery when you have no cervical changes and no labor signs upon admitting.

For the initial intake exams, you will change into your labor gown or their gowns and they will get an IV placed - if you have a preference for where this goes, speak up! It is usually placed in the back of the hand, so if you want your partner on a specific side, pick the other hand. They will do their best to accommodate your request. They may take blood from the IV line for initial blood work and hang IV fluids. An IV for an induction is typically not optional and cannot be declined in almost all cases.

Next you will be given an abdominal exam to determine the relative position of the baby and a cervical exam to ascertain your current cervical state. This will help determine your "Bishop Score" which is used by the medical staff throughout your stay in almost every hospital. It is a number designation that can change according to your progression that is used to assess the likelihood of a vaginal delivery as your labor progresses.

Next you will have two stretchy bands wrapped around your belly, one to monitor the baby's heart rate, one to monitor your contractions - this is the baseline exam, but if you want to be able to move around for labor, ask for a wireless monitor! Most inductions, especially for any high-risk designations such as IUGR, have a facility policy for continuous external fetal monitoring. I won't step too high on a soap box, but you can refuse continuous monitoring if the baby is doing well and ask for intermittent monitoring if a wireless monitor isn't an option. This is completely up to you, and a discussion worth having with your doctor and/or nurses to help you maintain freedom of movement for comfort if that is what you want. For the intake baseline exam however, it will be about 30 minutes on the monitor where you will need to remain relatively still and in bed - use the restroom before they start!

Once all this initial intake is out of the way and your baby's position and your cervical state has been determined, the most likely first step is cervical induction - this is achieved with either hormonal analogs or mechanical methods. You can read about these here.

The First Stage of Induction - Cervical Induction

If hormonal analogs are chosen Synthetic Prostaglandins will be administered. One of two will be chosen, (again facility and your medical situation dependant) either Misoprostil aka Cytotec or Dinoprostone aka Cervadil. Misoprostil may be given to you in the form of an oral pill that you swallow, or the oral pill may be broken into pieces and placed inside your vagina in contact with your cervix. Cervadil is most often used as a vaginal insert and looks a bit like a tea bag, which would also be placed in contact with your cervix.

The other possibility is a mechanical cervical induction where a foley or cook catheter is inserted into your cervix and the end is inflated slowly to put expansion pressure on your cervix which encourages it to open as well as triggers your body to produce natural prostaglandins due to the pressure. There is a possibility that instead of a catheter they may use dilation rings, but the idea is the same as the catheter, pressure to open mechanically and encourage natural prostaglandins to release.

This process takes anywhere from 3-24 hours to see changes. They may have to try both synthetic analogs to see change, they may use a Foley catheter to start, it could be any order of things listed above, however before the second stage of induction can begin, your cervix must be ready to let the baby out, otherwise contractions would be like pressing on a blocked door - fruitless.

It is important to note that sometimes, the cervical hormonal analogs are enough to engage early contractions to begin, and that's a good thing! Don't worry if you don't feel anything happening tho, your cervix changes without your ability to feel it actively. Your team will regularly assess your progress and the position of the baby. Each person's response to medications, routes of administration and just plain time all play a role in the induction process.

Once your cervix has reached a prescribed state of softness, effacement and dilation, the second stage of induction will begin - IV pitocin. Ask when you arrive what the goal posts of cervical changes are before the pitocin can begin if this is something that will reduce your anxiety to know. If knowing the numbers and the progress or lack of it would stress you out, you can also ask not to be informed! It's up to you. They may give you a Bishop Score or individual numbers for each cervical change and baby's station in the uterus. It is good to bring a binder with you to the hospital to have a place for multiple copies of your birth plan (if applicable) blank paper to take notes as well as a place to keep all the papers you will be given over your stay.

The Second Stage of Induction - Uterine Induction

Once the pitocin is administered, the contractions can come on fast, hard, and back to back - do not be afraid to tap out and ask that your drip be turned down! Pitocin contractions are not like spontaneous natural labor contractions - spontaneous natural labor contractions come with your body's natural feedback loop of pain relief. Pitocin only works on your uterus, not your brain, and your uterus will go from 0-100 in terms of contraction strength and frequency so in addition to the fact that the pitocin does not trigger your brain to release oxytocin and beta-endorphins, the contractions do not slowly build in the same way such that your body adjusts to the pain in the ramping up process of a normal labor, it just goes from nothing to everything all at once and that is immensely difficult to handle! You can ask for the pitocin drip to be turned down, started at low dose and turned up, or ideally request that it be given in a pulsed manner that more closely mimics natural labor so your body is less likely to get slammed fiercely.

Pitocin causes contractions that are much stronger than spontaneous labor contractions because the uterus and your brain are not talking, the pitocin is forcing your uterus to contract stronger and more often than your uterus would otherwise in spontaneous labor which has a gradual wind up with a wave like rhythm that allows you to adapt to the changes and increases gently.

Having an epidural with a pitocin drip is common, but knowing how to ask for a less intense administration (low dose, start low and ramp up over a few hours, or pulsed administration) can make a huge difference in your chances of avoiding an epidural if you don't want one. If you need an epidural but don't want to be completely numb, ask if your facility provides 'walking epidurals' or 'patient controlled administration epidurals' this will allow you to have pain control but retain some feeling and feedback of labor. A walking epidural doesn't always allow for full mobility, be forwarned that despite its name, you will still probably have wobbly sea legs and need support to get out of bed. It is important to note that with an epidural almost always comes a urinary catheter, a frequently hugging blood pressure cuff and the monitoring bands for the baby and contractions will be placed until delivery.

Once your pitocin drip is started, it's really a waiting game to get to the pushing stage goal of a fully effaced (100%) and fully dilated (10cm) cervix with the baby at a zero station.

Depending on your progress and response to the above induction methods or epidural, they may offer to break your water. Read about it here. I encourage you to ask a lot of questions about this one and to decline without them providing you ample evidence and reason to do it - As covered in the post linked just above, first of note is that most hospitals have a policy of birth must occur within 12 to 24 hours after the waters are broken, and that may mean a mandatory C-section if you pass the facility time allotment, so if things have been slow or become slow, to progress, I would think twice and ask how long you have to deliver vaginally if they break your water. Also ask about how breaking your waters may affect the baby's tolerance for labor - it is their cushion against the rigors of the early and mid labor uterine contractions of spontaneous labor, and pitocin induced labors are generally much more gruelling for a baby so breaking the waters artificially can lead to unnecessary fetal distress. There is very little evidence that breaking the amniotic sac does anything to speed up labor, in fact it can slow things down and create more pain for you both, as the cushion that protects your baby from the contractions also protects your pelvic outlet from being unduly compressed by the baby's head while they are still working their way down into the pelvis and vaginal canal. It is generally regarded as unnecessary to have the waters broken artificially as it has no proven benefits and definite drawbacks, none the least of which is umbilical cord prolapse where the umbilical cord comes through the cervix ahead of the baby which is an absolute emergency and would require an immediate emergency C-section.

The Pushing Stage

Once you have reached full cervical readiness and your contractions are timing correctly along with baby at at least a zero station you will begin to push - now I highly recommend that you read this post on the 4 primary styles of pushing and be well informed about which you want to stick with. This will ideally also be on your birth plan.

The primary pushing stage can be anywhere from 30 minutes to 3 hours - You may note the "laboring down" as listed in the pushing methodologies, however because of the pitocin driven contractions you will not likely have the period of rest a natural labor gives at this time to labor down and wait for baby to reach a lower station - you will need to power through, you got this!

Induction Notes & Other Important Choices to Consider

Other things to keep in mind is that you are in the driver's seat - remember that this entire experience is yours. You are a client being given a service by providers - if you are not getting the answers you want, the services you were promised, or the experience you expected - speak up. Your labor room is not and should not feel like a prison.

There are a lot of twists and turns of delivery during an induction that arent listed above, so if it seems like your induction is veering quite a ways off the path, be sure to grab a nurse and get a solid understanding of where you are in the induction process, what the next steps are, and what happens if those steps don't get you progressing. Remember, you are in the driver's seat - know where you are going!

Remember that if something doesn't feel right, tell them to stop and explain what is happening. If you don't like what is happening, tell them to stop and explain what is happening. You have every right to block your body from a procedure you do not consent to. If you say you want an epidural and change your mind when the anesthesiologist comes in the room, just say you changed your mind. If you change it back in an hour, they can return in an hour. It isn't rude to ask for what you want or change your mind! Consent is revocable at any time.

As a side note, it is highly likely, practically guaranteed, your labor team will tell you that you cannot eat, they may even tell you to fast before you arrive. This is an old rule that hospitals have held onto for so long it's sinful. The one group of people who cares - your anesthesiologists - have said time and again that women should be allowed to eat during labor. The doctors and nurses will tell you you can't, the nurses will not provide you food, but what you do in the privacy of your labor room is up to you. If it turns out you need a C-section, disclose to your anesthesiologist what you last ate and when so they are aware.

Because more c-sections are done conscious, it's even less of a concern for aspiration. Even if you needed to go under general anesthesia, the risks of aspiration now vs 75 years ago when this rule was created is completely different. People come into the ER needing surgery every single day on full stomachs and they aren't having issues. Anesthesiologists are amply trained to handle the extremely rare event of vomiting during surgery. So think about if you want to eat during labor and check out the American anesthesiologists stance on eating during labor for yourself. Eating during labor especially an induction, improves your stamina, your tolerance for a prolonged induction, and keeps you fueled and ready for the exhausting pushing stage.