Episode Transcript
Dr. Lacey Krebsbach:
Even though it’s sometimes a surprise that an induction is coming it doesn’t necessarily mean that, you know, it’s a bad experience. It certainly can be a very positive, healthy experience.
Courtney Collen (host):
Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We are starting new conversations about age old topics from pregnancy to postpartum, managing stress, healthy living, and more. “Her Kind of Healthy” is here to bring you the honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.
In this episode, we are talking about labor induction and some of our most common questions when it comes to inducing labor, either planned or unplanned. And I have two guests joining me for this conversation. Dr. Lacey Krebsbach is an OB/GYN, and Paige Neameyer is a labor nurse who spends a lot of her days now educating nurses for labor and postpartum – both at Sanford Health in Fargo, North Dakota. Dr. Krebsbach, Paige, thank you so much for taking the time to join me.
Both:
Thank you. Yes, thanks for having us.
Courtney Collen:
So we’re going to start with this question for you, Dr. Krebsbach. What does it mean when we talk about inducing labor? And please feel free to chime in, Paige. I’d love to know why a woman would be induced and when is it recommended?
Dr. Lacey Krebsbach:
So, the process of an induction of labor is essentially getting the uterus to start contracting before the spontaneous onset of labor. And there are different methods to do that. And there are different indications with which we do that as well.
They’re often medical indications, which is the most common cause that we induce labor. And those can fall under the category of maternal issues. If mom has underlying medical concerns such as hypertension or diabetes those could be baby issues. If there’s a concern for growth restriction or other issues as to why baby would maybe need to have a timed delivery instead of waiting for the onset of labor.
And then there are more elective type of inductions where medically the pregnancy is healthy and mom and baby are fine, but for other reasons between the provider and the patient, it’s decided upon to move towards delivery sooner than waiting for labor.
Courtney Collen:
What methods are used to induce labor?
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Photo by: Sanford Health
Dr. Lacey Krebsbach:
The labor induction process can be just that. It can be a process. It can be a few days of a process. And the determination of what we use to induce labor all depends on the starting point for the patient. So there is a process that kind of kickstarts labor when the cervix maybe hasn’t quite started to soften or dilate, and that’s called cervical ripening. And then there’s the more active labor process where we’re using medications through the IV or potentially breaking the bag of water around baby to help kickstart those contractions.
Courtney Collen:
Paige, why would a patient need an induction, or why would they opt for one by planning ahead?
Paige Neameyer:
Yeah, so we do have what’s called an elective induction will call list. So these are people that do not medically need an induction, but they want one. And in order to get on this list, their cervix has to be ready. So that will be determined by what’s called a bishop score that the provider will do in the clinic.
They have to be at least 39 weeks, and once they meet this criteria, they can get their name put on a list. So this doesn’t give them a specific day that they will be induced, but it does put them on a list so that the birth center knows, hey, these people would like to come in to be induced and their cervix is ready.
I think the difference with this is that for one, they don’t medically need to get in, but if there’s enough staff or the birth center is looking good, and we would like some patients, we can bring them in. And so that’s really nice because we know that their cervix is ready.
So that induction process does look a lot different than somebody who’s starting at a closed cervix or a not ready cervix. And so the process for induction, just like Dr. Krebsbach said, there are so many different ways to induce, and it really depends on the patient and the start of their cervix.
Courtney Collen:
Yeah, I certainly think that is one overarching theme when it comes to these conversations – that every patient’s journey is going to look a little bit different. Every labor and delivery is going to look a little bit different.
So obviously if you have specific questions about your journey, your care journey, then you know, ask your provider, ask your physician, ask your nurse. These are all such wonderful conversations to have and we’re so grateful for your insight and your expertise to help just us learn a little bit more about what this is all about.
Paige Neameyer:
Yeah. And I do feel like a lot of people like to share their birth story, so it’s easy to compare yourself to somebody else. And I think that can be hard too, because you may be talking to a friend who was induced and her cervix maybe started at five centimeters. So her induction only took a couple hours where maybe you are being induced for a medical reason, or your water broke early and your cervix is starting at closed or one centimeter.
It’s important to know and not compare yourself to others because that induction process could take days. And if you think about it, we are doing what your body would naturally be doing over maybe a week, two weeks, and we’re doing that in one to two days. So really just letting patients know they’re not behind.
I think that expectation if they go into it knowing like, OK, we’re going to take this step by step. I’m not behind because my labor is taking longer. That’s OK. And the end goal is a healthy mom, healthy baby, and we can absolutely take our time if that’s what is necessary to do. And I think with cervical ripening, just knowing that, hey, it might take one to two days to even get my cervix to open and then another day to get it to dilate.
And just knowing that really sets the mom up for success knowing, OK, like, this might take some time, and that’s OK. That doesn’t mean they’re going to be in pain that whole time either. I think that’s important to know too. You’re not going to be in excruciating pain for three days. The actual labor part comes later.
Courtney Collen:
Yeah. That’s, that’s such good information and insight, Paige. Thank you so much. Dr. Krebsbach, are there any risks associated with an induction?
Dr. Lacey Krebsbach:
Sure. In medicine, anytime we use medications, there are potential risks or side effects or adverse events that can happen. The goal of induction is ultimately to get the uterus to contract. And so the process of that can be slow. And for some women it can be fast.
Some women respond very quickly to those medications where the uterus starts to contract and can contract very rapidly. That rapid uterine contraction is a condition called tachysystole. And with that, we can sometimes see that babies don’t necessarily like to have those contractions so close together. Moms don’t necessarily tolerate that very well. And so there are some medications that allow us to have very rapid movement or titration of that medication to turn it off or turn it on where we can resolve those contractions.
In rare cases, if baby doesn’t tolerate that, we can see changes in baby’s heart rate. And that can sometimes lead to the need for more interventions that could lead to the need for monitoring, more internal monitoring that could lead to the need for a cesarean section as well. But ultimately, the goal of an induction is a vaginal delivery.
Courtney Collen:
We talked about the risks or possible risks. What about the benefits? What are the benefits of an induction for a mom looking ahead to her own labor and delivery?
Dr. Lacey Krebsbach:
So many of the benefits, especially in the setting of medical inductions, are that there’s some process going on where it may no longer be safe for baby to be inside, and it might be safer for baby to be delivered. Whether that is a worsening of a maternal health condition such as hypertension or preeclampsia. Whether that is a concern over the placentals, placenta’s behavior, growth issues for baby, or if there’s signs of infection for mom.
Also in the setting of where the water does break early there really is a higher risk of infection developing if we allow women to process because that process can sometimes be hours, but it can also be days. And in that timeframe, any of the normal bacteria that lives on our skin can go up into the uterus and cause infections for both mom and baby.
There are also social benefits for some women. We talked about the elective induction list where you don’t medically need to be induced. But there are instances where women may have had very fast labors in the past or they live a distance away from the hospital or perhaps just socially if their partner is going to be deployed, if they’re going to have other instances where timing their labor and delivery, if they are healthy and favorable with the cervix, is beneficial from that matter too.
Courtney Collen:
My water broke after my 38-week appointment. I remember I was hardly dilated at that time and hoping to wait it out in labor some at home. But I was encouraged to come in by the Sanford triage nurses. An infection was a concern, I should say, in that scenario. But I then opted for an epidural because my body responded really quickly to induction by use of Pitocin. The contractions became so strong.
So my question for you, Dr. Krebsbach or Paige, do you tend to see women requesting an epidural during induced labor more often than those whose labor begins on its own to manage some of that pain?
Dr. Lacey Krebsbach:
I don’t know that we see the request for an epidural more often. I think that the biggest difference in what I discussed with my patients in the office is that in spontaneous labor and natural labor this could be weeks or even days of kind of slow progression where your body is getting used to these contractions they’re farther apart. They’re maybe not as intense.
And so it’s almost like a warming up to the idea of labor versus when you come in to be induced you could go from, you know, zero to labor in a few hours and so the abrupt onset of those contractions, I think it’s more of the abruptness of the contractions where many women feel that inductions are more painful than in the setting of a more slow kind of rolling onset of natural labor.
Paige Neameyer:
Yeah, I would agree with Dr. Krebsbach. I think that if you have your mind set on an epidural, whether or not you go into natural labor on your own or are induced, I think your plans on getting that epidural is about the same. When you do, like Dr. Krebsbach said, come in for that induction, yes, you probably feel a lot more, a lot quicker. But then it’s also done a lot quicker as well. So some people like knowing that as well.
But I think if you’re going to get an epidural, you would get it either regardless. And if your plan was not to get an epidural, people who are induced, if their plan is not to get an epidural, they do that all the time. Just because you’re induced doesn’t mean you have to get an epidural or that you won’t be able to tolerate it. We don’t want your contractions to be every minute like Dr. Krebsbach said earlier with the tachysystole, we have to allow that two to three minute between contractions is actually like perfect. Two to three minutes apart is ideal. It gives the baby and the mom a chance to recover before the next one. And so that’s what our goal is, either way, whether the mom is doing it on their own or being induced, two to three minutes is incredible. Like, that’s amazing.
Courtney Collen:
Yeah. That’s such good insight. Thank you for that. If a woman is trying to say, avoid a cesarean birth, for example, is labor induction something that could reduce the likelihood of that outcome?
Dr. Lacey Krebsbach:
So there was a trial that came out called the Arrive Trial and that was published in 2018 where they looked at low-risk populations with a singleton or a single baby. And they compared groups. One group was being induced at 39 weeks, and the other group was allowed to progress to natural labor.
Now, this is a clinical trial, very controlled setting, but what they found was that women who were induced at 39 weeks actually had a decreased chance of cesarean section and outcomes as far as concerns with maternal hypertension, complications with delivery, neonatal results were equal if not better in the induction group. Now, we can’t extrapolate that to all pregnant women. There’s many high-risk features where being induced at 39 weeks is not appropriate. But you don’t necessarily increase your risk for cesarean section by choosing or needing an induction.
Paige Neameyer:
I think that there’s a lot of factors that are out of our control, out of the patient’s control, out of the care team’s control, how the baby’s going to respond. And that could be either whether you’re induced or not induced.
Sometimes babies just don’t tolerate labor, or something happens where the patient needs to progress to a C-section. And that just happens. I don’t really think that one way or another that I have personally seen whether being induced or not induced puts someone at higher risk for a C-section. But I mean, I understand the question, like it’s a very important question.
Courtney Collen:
Let me jump to this. Things that the internet tells you might help induce labor naturally. Things like dates, pineapple, certain types of tea, maybe some certain oils, having intercourse, stimulation of the nipple. Dr. Krebsbach, is there any truth to any of this, and what would you tell women who might be looking for some answers and they are wanting to induce labor ASAP?
Dr. Lacey Krebsbach:
So one thing I talk with my patients a lot about is if there was anything that was medically proven to work in all pregnant patients, nobody would ever get to their due date or go beyond. So there are certainly things that aren’t harmful but aren’t necessarily medically accurate in getting labor started.
One of the medications that we use when we do cervical ripening is a medication called prostaglandin. And that’s one we use for early labor inductions.
Now, there are a few natural things that will stimulate the release of prostaglandins. Nipple stimulation and intercourse are both possibilities that could potentially kind of kickstart the uterus. Not proven that it, you will go into labor, but again, not necessarily harmful.
Some of the foods and drinks and those questions that I see the pineapple, there’s no evidence of that but again, you know, not necessarily harmful.
The red raspberry leaf teas, there’s just not a lot of great safety data on that. So if you’re drinking that just as in normal consumption, it’s unlikely to be harmful, but there’s also no evidence that it works.
There actually are studies on the dates. However, the date issue is that usually you need to consume three to 10 dates a day for multiple weeks in advance. So usually starting at, you know, 35 to 36 weeks, you’re eating potentially up to 10 dates a day every single day. And in those scenarios, there might be a slight increased chance of delivering before your due date. But again, very controlled studies that it wasn’t sure necessarily significantly statistical significance.
One that I do get questions on a lot is use of castor oil. Castor oil is something that’s been around for a very long time as a very potent laxative. And so one of the things that can happen when you consume castor oil is you can develop a lot of GI cramping even a lot of very frequent and loose stools, which to any pregnant woman, it does not sound appealing.
Courtney Collen:
Sounds awful to a non-pregnant woman.
Dr. Lacey Krebsbach:
<Laugh>. Exactly. Also with that, you can become a little dehydrated and any woman who’s been pregnant knows that if you’re behind in your fluids, you’re dehydrated. For whatever reason, the uterus starts to cramp and contract. So not necessarily scientifically validated or safe, really, for most people.
Courtney Collen:
Well, thank you for clearing the air a little bit on that. When we talk about trying to induce labor naturally at home, is there a timeframe that would be considered unsafe to start doing some of these things if we think that that’s going to work for us? When you say something like 35 weeks, that seems early to me. But talk through like what would be a safer time, if any, to start some of these experimental labor induction methods?
Dr. Lacey Krebsbach:
Sure. Really, we consider a term pregnancy at 37 weeks. However, there is still a lot of development that happens up until 39 weeks. So doing things like nipple stimulation after 37 weeks, it can release your natural oxytocin, which is Pitocin in its natural form, can lead to some uterine contractions, but hasn’t been shown to be effective unless you’re already favorable, meaning that cervix is already starting to soften, starting to dilate a little bit. So doing anything like that preterm wouldn’t necessarily be suggested.
With respect to things like intercourse, again, at term, at 37 weeks and beyond, if you want to attempt that, but in the setting of knowing for sure that your water hasn’t been broken or there aren’t leaking fluids, because that can increase the risk of course for infection as well.
And then there are certainly pregnancies where none of these options should be considered. There are instances where there are placental abnormalities or there are previous surgeries that have happened on the uterus that put you at very high risk for inducing where we wouldn’t recommend even these home mechanisms to try to get labor started.
Courtney Collen:
Paige, if a woman has – on her birth plan – hopes for an unmedicated, natural labor and delivery, is there a way for her to lower her chance of having an induction if that’s not something that she truly desires for her labor and delivery?
Paige Neameyer:
That is such a great question. I guess medically there are always things that come up medically, but if her goal is to have an unmedicated, natural birth, I think that we do an amazing job with this. We do have something called an empower tower that we recently created where it has all different things that help with distraction, relaxation and pain control once you are in the hospital.
I do think if your goal is unmedicated and your water is still intact and you’re laboring at home, it’s OK to labor at home for as long as you want, as long as you feel safe, your contractions aren’t too close together. If they’re still like five to 10 minutes apart, 10 minutes apart, that’s OK. Once you get closer to that five minutes apart, and like I said, your water’s still intact, that’s when we would want you to come in more. But as far as whether or not being induced if they can prevent being induced … nobody has to sign up for the will call. No one has to get induced unless it’s medically indicated.
Courtney Collen:
Sure, sure.
Paige Neameyer:
But even if you are induced, I do feel like there are so many ways we can help to help that birth plan so that you don’t have to get an epidural. We have amazing large whirlpool jet tubs that we can dim the lights, we can do little candles in there, we can put your playlist on. I think anybody who comes prepared knowing they want to do an unmedicated birth can be successful.
Dr. Lacey Krebsbach:
I think one thing to keep in mind for all patients, especially those patients that perhaps an induction wasn’t something on the radar when they come into the office and perhaps there’s a new finding, like a new onset, high blood pressure or something that urgently the recommendation turns from we’re waiting for labor to now we need to send you to the hospital. That can be a very scary moment for patients. That can be very abrupt, change and shift in the plan that they had made.
I just hope that patients realize that an induction is not, you know, a failure of your body or a failure of your pregnancy by any means. There are so many things that are out of your control when it comes to your health in pregnancy, and complications that can arise at the drop of a hat.
And so, ultimately, and Paige mentioned this before, but ultimately our birth plan for everybody is a healthy mom and a healthy baby. And we want you to achieve that regardless of how it has to be started.
But we don’t take inductions lightly, especially medical inductions. There’s very strict guidelines as to when and the timing of inducing pregnancies for each specific type of complication that could arise. And we adhere to those guidelines very closely here at Sanford with the goal again is we want this to be a good experience for you, but also a safe experience, and we want to give you a safe baby at the end of it.
Courtney Collen:
Thank you so much. That is such a good reminder. And we are so grateful for all that you both do at Sanford Health to care for an expectant mom before and during and after the labor and delivery.
Paige and Dr. Krebsbach, for that mom or and or her spouse or partner, what advice helps maybe calm fears or eases anxieties? Maybe she’s coming in and labor is going a different way than she had hoped, like a blood pressure concern. You know, the way baby is facing in utero. What do you say in the moment and how do you help ease anxieties that they have?
Paige Neameyer:
For me, and I think a lot of our nurses, just letting the patient know, we are there for them. We are going to keep them updated on everything that we’re seeing. If we are concerned about something, we will let them know when it’s time for them to be concerned. But ultimately, we’ve got them, we are going to watch mom, we’re going to watch baby very closely. And we want to hear those fears.
We want to know what the patient’s feeling and what they’re anxious about, so that, I mean, maybe they’re anxious about something and we don’t know about it, and we could easily address it. We want to be there for them.
And I think just having good communication and letting them know, we are here for you. And I think it’s important to know, like, things aren’t always going to work out the way that you have planned, but the way that we can do our best to make sure that mom and baby are healthy and OK, we’re going to do everything we can to make sure that that is the end goal.
Dr. Lacey Krebsbach:
I often will joke with my patients that labor process and sometimes the last couple weeks of pregnancy are a crash course into parenting where you no longer have control over anything that goes on anymore. This baby is the boss and they’re making the decisions most of the time. And yeah, you just kind of have to go along for the ride.
But seriously … we’ve dedicated our lives and our careers to women’s health care for a reason. We want the best for our patients. We want the best for their babies. We’re privileged enough to be present for these moments, these life-changing days and moments, and we would never want anything bad to happen to our moms or our babies.
So even though it’s sometimes a surprise that an induction is coming, it doesn’t necessarily mean that you know, it’s a bad experience. It certainly can be a very positive, healthy experience.
Courtney Collen:
I had one of those very positive, healthy experiences myself, and I am so grateful for the care team at Sanford, for your teams, for that experience before and after labor and delivery. If you’re listening and you’re planning ahead for labor and delivery, have these conversations with your care team to make sure that you’re getting the best care for you and for baby.
Paige Neameyer, Dr. Lacey Krebsbach, thank you so much for your time and for all that you do for women and families all over the region.
Both:
Thank you. Yeah, thanks for having us.
Courtney Collen:
I hope you learned as much as I did from our conversation today. This was another episode of the “Her Kind of Healthy” podcast series, brought to you by Sanford Health. For Sanford Health News, I’m Courtney Collen. Thanks for being here.
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Posted In Family Medicine, Fargo, General, Pregnancy, Women's
