Q&A: I want to know my options to induce labor.

My first question is: do you really need to have labor induced this time, or can you wait safely for nature to take its course? It can be hard to remember (or accept!) that the due date is actually the midpoint in a four-week window of time in which birth is likely to occur. Because of this recent research, induction before 39.0 weeks without a medical indication is no longer considered good obstetrical practice.

Several different options are available for induction of labor, but none are totally free of risks or side effects, and not one of them is 100 percent effective in all situations. In general, induction of labor should be reserved for when the benefits of induction outweigh its risks. You have already experienced side effects from medications used for induction. Induction of labor if the cervix isn't "ripe" can increase the chance of having a Cesarean. But sometimes the risks of remaining pregnant start to rise, like with prolonged pregnancy (41 or 42 weeks, depending on which recommendations you follow), or if the mom has diabetes or hypertension, or if the baby isn't growing well or the water has broken. In situations like those, induction may be necessary.

1. Assisted rupture of membranes (AROM): AROM can only be performed if the cervix is open and the baby's head is fairly low in the pelvis. This typically works best when you already contract a fair amount, and when the cervix is quite dilated and effaced. Risks include infection from prolonged rupture of membranes, if labor isn't fairly rapid. If labor doesn't start on its own after AROM, Pitocin is usually added.
2. The Foley balloon: Similar to the catheter sometimes used to drain urine from the bladder, the Foley balloon for induction is a small inflatable ball on the end of a tube that can be inserted through a slightly dilated cervix up just inside the uterus. The balloon is then inflated. The uterus tends to cramp to try to expel the balloon, and when it slowly pushes its way through the cervix dilation reaches 3 to 4 centimeters, the size of the balloon. At that point, the balloon falls out, and if labor hasn't started on its own, Pitocin is usually added.
3. Prostaglandins (PG): Prostaglandins are hormones that act on the cervix to make it more ready for labor. Synthetic forms of different prostaglandins can be used for induction, usually when the cervix isn't favorable enough for Pitocin. Several different formulations exist, including vaginal tablets (misoprostol, brand name Cytotec®), oral tablets (misoprostol/Cytotec®), vaginal gel (Prepidil®), vaginal suppositories (PGE2), and PG impregnated in a sterile string that is placed into the vagina (Cervidil®). Depending on type of PG and dose, some women experience nausea, diarrhea, or fever. If the uterus is very sensitive to the dose, extreme contractions can develop that may stress the baby, requiring another medication to stop contractions, or (rarely) an emergency Cesarean. One benefit of Cervidil® is that it can be removed if side effects develop, but induction may be a lot slower than some of the other formulations. Treatment with misoprostol/Cytotec® is "off label" use, because it is not FDA approved for pregnancy, although many institutions have protocols for use because it seems to be more effective than other options. PGE2 suppositories tend to have the greatest side effects and typically are only used for induction when needed in the second trimester.
4. Pitocin®: Pitocin is a synthetic form of the hormone oxytocin that can be given intravenously to induce or augment labor. Pitocin causes contractions that lead to dilation and effacement of the cervix, simulating normal labor. Since women have quite varied responses to Pitocin, the dose is started very low, and slowly increased over several hours to reach a level that causes strong regular contractions. Some moms find that Pitocin makes it more difficult to tolerate the contractions. Regardless of the initial method chosen for induction, Pitocin is often added in after the cervix has started to open.
   
   If the cervix is "ripe" (already somewhat dilated and effaced) any induction method can be effective. If the cervix isn't showing readiness for labor, rupture of membranes and Pitocin may not be good choices. Inductions can take several days if the cervix requires ripening before active labor begins. You can make a good argument that induction of labor just for convenience (or even for miserable pregnancy symptoms) should be avoided. Talk to your doctor or midwife and ask lots of questions so you can decide if induction is a good option for you or if "watchful waiting" might be a better course.