Induction of labor is common in the United States – approximately 40% of women have their labor induced.

Induction of labor happens for medical reasons and for elective or social reasons. About 75% of inductions are for medical reasons, but this trend is changing quickly with newer evidence on elective inductions. Whether an induction of labor is for medical, social or elective reasons, there are important pieces of education and counseling to review before an induction is offered or started.

Unfortunately, because induction is commonplace on labor wards, counseling conversations about a woman’s induction of labor are often brief and incomplete in the clinic. This leaves a vast amount of information to cover on admission to the hospital or, worse, information that is not covered at all.

This post offers an A to Z on everything you need to know about induction:

The history behind induction of labor
The reasons for induction of labor
A review of the non-medicinal, mechanical, and medicinal methods used for induction of labor with a review of history, evidence, risks, benefits, and costs particular to each method (links available to the evidence so you can read it for yourself!)
A review of the evidence on the risks and benefits of induction of labor
The questions you need to ask your provider about an induction of labor

Plus…

Additional handouts about induction of labor and podcast recommendations
A free tool and decision aid about induction of labor to guide your shared decision-making
A robust FAQ to answer all of your other questions about induction of labor (most of these taken from my own personal counseling about induction of labor with my own patients)

Yes, it’s a lot. But any pregnant woman or provider that has discussed induction of labor will tell you that an induction of labor discussion is anything but simple and straightforward.

At the end of the day, choosing an induction (whether medical or elective) is a personal decision between you, your family, and your provider. To help you navigate the multi-faceted conversation around induction of labor, I created a free tool.

Download your tool here or at the bottom of the post.

Let’s dive in!

(Disclaimer: This post may not reflect the most up to date evidence because evidence is published quickly and trends in obstetrics may change based on new evidence or guidelines. I’ll do my best to keep this post updated with the latest information.)

The Background

yellow bokeh lights — Photo by Pixabay on Pexels.com

What is an induction of labor?

An induction of labor is the process of starting your labor with artificial interventions instead of waiting for labor to start on its own or for your bag of water to break.

What’s the history for induction of labor…how did we get here?

Induction of labor has been around a long time, but the reasons to recommend an induction of labor have changed over the decades as new evidence ebbs and flows. In 430 BC, Hippocrates wrote about stimulating the breasts to induce contractions and using methods for mechanical opening of the cervix. In the 11th century, amniotomy was recorded as an intervention in Persia. Through subsequent centuries, instruments were used to open the cervix, strong enemas were given to start contractions and herbal and folk medicines were administered to start labor (Sanchez-Ramos & Kaunitz, 2009). In 1756, a group of physicians in London met and noted that breaking the bag of water helped to start labor in women (Sanchez-Ramos & Kaunitz, 2009).

In the 18th and 19th century, inductions were offered to women when their pelvis was thought to be too small for birth (pelvic deformity was thought to be from rickets) (Drife, 2021). This was called disproportion – although not seen much today, the modern term is cephalopelvic disproportion (Drife, 2021). In 1810, a physician in the United States used amniotomy – the breaking of the bag of water – to induce labor (Sanchez-Ramos & Kaunitz, 2009). The 1900s brought about the discovery of the pituitary gland and a pituitary extract called oxytocin was developed to induce labor (Sanchez-Ramos & Kaunitz, 2009). The extract was used intramuscularly or subcutaneously; primarily used in large doses, cases of uterine rupture were noted…and the extract fell out of favor with physicians (Sanchez-Ramos & Kaunitz, 2009). In the 1940s, a physician suggested that the extract should be given in the intravenous form (Sanchez-Ramos & Kaunitz, 2009). Then in 1953, the formula of oxytocin was discovered and in 1955, the start of oxytocin for labor induction became mainstream (Sanchez-Ramos & Kaunitz, 2009). In the 1950s, pelvic disproportion remained the main reason for induction of labor; at that time, a prolonged pregnancy was associated with higher perinatal mortality (Drife, 2021).

In 1955, Dr. Edward Bishop wrote an article called “Elective Induction of Labor.” Dr. Bishop realized that some pregnant women went into labor and had faster labors and births than other women. He studied among 1,000 elective inductions between 1951 to 1954 at Pennsylvania Hospital in Philadelphia, Pennsylvania. Dr. Bishop did not include inductions done for emergencies or for fetal distress. The hospital’s primary methods for induction were to start pitocin then to break the bag of waters – called an amniotomy. During his study, Dr. Bishop looked at dilation, effacement, and station. He also included the estimated size of the fetus and if the woman had other prior births. Dr. Bishop thought that scheduling was the main benefit of induction of labor – a woman could plan her birth timing and the physician could plan to be present at that same time. His findings noted that women with a favorable cervix (defined as 3 centimeters dilated, 60% effaced and the fetal head in the pelvis between the pelvic bones) who were given pitocin followed by an amniotomy, birthed within 3.2 hours and 80% of his population birthed within 4 hours. Those who did not have favorable Bishop scores birthed within 4.7 hours; the remaining 11% of women had a labor that was greater than 8 hours (Abboud, 2017).

Dr. Bishop concluded 4 main points:

If a cervix is favorable, administering pitocin followed by breaking the bag of water is an effective form of induction of labor
Regarding the starting Bishop score, Dr. Bishop recommended that a woman’s cervix be dilated to at least 3 centimeters, 60% effaced and the fetal head should be centered between the pelvic bones.
This procedure works best in women that have had births before.
Lastly, induction of labor is acceptable when women meet these criteria (Abboud, 2017).

Dr. Bishop’s article “Elective Induction of Labor” was published in 1955 in Obstetrics & Gynecology. Shortly afterwards in 1964, Dr. Bishop published another article titled “Pelvic Scoring for Elective Induction” in the same journal with a scoring system to help physicians determine if induction of labor is appropriate for a woman; this scoring system was nicknamed the Bishop score and is still used by this term today (Abboud, 2017).

In the 1970s, prostaglandins were developed in a variety of forms and doses and this method joined oxytocin as an option for labor induction (Sanchez-Ramos & Kaunitz, 2009). At the same time, obstetric ultrasound was improving and showed that fetal growth slows at term. But, induction rates started to rise with the advent of oxytocin and prostaglandin methods to use for induction (Drife, 2021).

In the 1990s and 2000s, induction of labor continued to increase, and methods were mainly unchanged. Induction of labor after 37 weeks was considered okay until newer evidence showed that induction of labor between 37 to 38 weeks is not beneficial for the fetus compared to waiting until 39 weeks of pregnancy. Pitocin, amniotomy, prostaglandins and cervical balloons remained the mainstay of methods for induction of labor.

Fast forward to 2018. The New England Journal of Medicine published a randomized controlled trial by Grobman et al. called “Labor Induction versus Expectant Management in Low-Risk Nulliparous Women” (2018) – also known as the ARRIVE trial. (Read the trial for free here.) Before the ARRIVE trial, most research for induction of labor used data from medical records or administrative data. Instead, the ARRIVE trial was a well-designed, randomized controlled trial that randomly assigned women into two groups between 38w0d and 38w6d: induction of labor between 39w04-39w4d or expectant management (waiting for spontaneous labor). The trial found that the induction group had a slightly lower rate of C-section (18.6% vs 22.2%) and a lower risk of hypertensive disorders (9.1% vs 14.1%).

After the ARRIVE trial was published, ACOG (American College of Obstetricians & Gynecologists) published this statement:

“Based on the findings demonstrated in this trial, it is reasonable for obstetricians and health-care facilities to offer elective induction of labor to low-risk nulliparous women at 39 weeks gestation. However, consideration for enactment of this elective induction of labor intervention should not only consider the trial findings, but that this recommendation may be conditional upon the values and preferences of the pregnant woman, the resources available (including personnel), and the setting in which the intervention will be implemented. A collaborative discussion with shared-decision making should take place with the pregnant woman. Additionally, as induction of labor involves coordination between the health care provider and the infrastructure in which induction and delivery will occur, it is critical that personnel and facilities coordinate policies related to the offering of elective induction of labor” (American College of Obstetricians & Gynecology [ACOG], 2018, p.1).

It’s important to note a few other things about the trial:

Enrollment in the trial was offered to 22,533 women across 41 hospitals; only 27% (6,106) women consented to the trial. (This means that 73% of women declined participation in the trial.)
63% of the participants had a Bishop score of less than 5 at the start of their induction. The researchers used a modified Bishop score that only included fetal station, cervical dilation, and cervical length/effacement.
The induction methods were recommended as follows: if the cervix was favorable, oxytocin was recommended to start the induction; if the cervix was unfavorable, cervical ripening was recommended and left up to the provider/institution.
The obstetric provider at the time of admission was a physician for 94% of the women and a midwife for 6% of the women.
The primary outcome was to assess if severe neonatal complications were less with induction of labor compared to expectant management. The complications included: perinatal death, respiratory support, APGAR score <3 at 5 minute, hypoxic-ischemic encephalopathy, seizures, infection, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage or hypotension requiring vasopressor support. The authors did not find a statistically significant difference between the groups for severe neonatal complications.
The secondary outcome evaluated if cesarean delivery was more or less likely with induction of labor; the study found that cesarean birth was less likely in the induction group (ACOG, 2018).

After the ARRIVE trial was published in 2018, the rate of elective induction started to increase across the entire United States.

What is the difference between an induction of labor done for medical reasons and an induction of labor done for social or elective reasons?

Inductions are defined by two terms to distinguish the reason for the induction:

Medical
Elective, social or risk-reducing (elective is the most common term but these terms are used interchangeably depending on the language the provider prefers to use)

Medical inductions have a diagnosis that is the driving reason behind the induction of labor.

Elective inductions are inductions without a medical indication. The term risk-reducing has been proposed because an induction may offer a benefit to the woman or her baby (reduced risk of C-section or a lower risk of hypertensive disorder); but ultimately, an elective induction is an otherwise healthy pregnant woman with a normal pregnancy.

Social induction is used to describe social factors that motivate the need for an induction. An example is a military spouse that is deploying soon; a woman that has 4 other children and a limited window for a family member to come help care for the other children around the birth; a history of a rapid labor and birth (usually defined as a labor that is less than 4 hours); or a significant distance from the hospital (generally 50 miles or more); there could also be a combination of factors for a social induction.

Why is an induction of labor recommended for medical reasons?

ACOG publishes a list of recommendations for the timing of birth when there are conditions complicating pregnancy called “Medically Indicated Late-Preterm and Early-Term Deliveries” (ACOG, 2021).

Medical inductions are recommended for:

Placental/uterine conditions
Fetal conditions
Maternal conditions
Obstetric conditions

ACOG offers a timing recommendation and a specific gestational age for some inductions (ex. gestational hypertension inductions are at 37 weeks, 0 days for most women unless the gestational hypertension is diagnosed after 37 weeks – in those cases, induction is usually recommended that same day of diagnosis).

Most providers adhere to these guidelines for medical induction but there are exceptions based on the patient or the practice.

How many women ask for an induction of labor?

Induction rates have been slowly rising since the 1950s in the United States.

In 1990, 9.6% of women had an induction of labor; in 1993, this number rose to 16% of births (Declercq et al., 2020; Sanchez-Ramos & Kaunitz, 2009).

In 2010, 23.8% of pregnancies were induced (Osterman & Martin, 2014).

In 2018, 27.1% of pregnancies were induced (Kruit et al., 2021).

In 2023, about one third of first time mothers (about 37.8%) and nearly half of non-first time mothers (called multiparas) are having an elective induction or an induction of labor without a record indication (Declercq et al., 2020).

(*It’s important to note that it is hard to determine the exact numbers for how many inductions are for medical reasons versus those for social/elective reasons; there are a number of reasons for this: poor data collection across state/federal levels and institutions – all done within different charting systems; poor coding for admission diagnosis or lack of clear documentation in the chart by the provider about why an induction is being offered/done; and poor counseling in the clinic notes about induction counseling or scheduling.)

Are other developed countries experiencing the same increased rate for induction?

Yes.

In Australia, induction of labor for first time mothers increased from 26% in 2010 to 46% in 2020 (almost double in 10 years!) (https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.14626).

In Finland, induction of labor increased from 17.8% to 30.3% from 2008 to 2019; of note, Finland has had an unchanged rate for C-sections (16-17%) despite this increase in inductions (Kruit et al., 2021).

In the United Kingdom, 33% of pregnancies were induced between 2019-2020 (Coates, 2021).

Regarding global guidelines, the 2022 guidelines from the World Health Organization (WHO) do not recommend routine induction of labor for uncomplicated pregnancies before 41 weeks because spontaneous labor minimizes interventions during labor, limits the overuse of interventions during labor or birth and may be associated with a more positive birth experience than women who undergo induction of labor. The guidelines note that the ARRIVE trial points to benefits for women and children, but the trial’s methods and hospital support may not be available except for high resource countries. The WHO does endorse induction of labor after 41 weeks in those pregnancies with good dating (World Health Organization, 2022).

Why are induction rates increasing so rapidly?

There are several reasons for the sudden increase in induction of labor.

First, women are waiting until later years to start their families and there are a greater number of first-time mothers that are age 35 years or older. Additionally, women are starting pregnancy in an unhealthier state than in prior decades – obesity and chronic disease (hypertension, diabetes, thyroid disease, autoimmune disease, etc.) rates are higher among women.

Second, technology is much better than it used to be. Dating pregnancies is much more accurate than prior decades dispelling prior uncertainty about the gestational age of the pregnancy.

Third, induction of labor methods and the evidence to support their safety and uses is larger and more robust – this allows for more options to complete induction of labor (both outpatient and inpatient) and options to induce labors that may not be able to use all methods (ex. In women with a prior C-sections, prostaglandins are not recommended).

Lastly, the evidence about safety and outcomes of induction is a higher quality of evidence than prior decades. This collection of higher quality evidence continues to grow and point towards newer associations (lower risk of C-section and hypertensive disease) than prior evidence noted.

What do women think about induction of labor?

There are few studies that examine a woman’s thoughts about induction of labor. Declercq at el. (2020) noted that among the small sample of studies, many women note that they are unsatisfied with their experience of induction because of the lack of information they received about the induction process, frustrations with delays in starting or stopping the induction, a sense of a loss of control during the induction, and a sense of “being placed on someone else’s timetable” (p.2). Other concerns that women voiced were a lack of shared decision-making and being pressured into an induction of labor (Declercq et al., 2020).

In 2017, Declercq at el. (2020) surveyed 2,539 women that had an induction of labor for their birth. 16% of women surveyed voiced they felt pressure from their provider to have an induction of labor. White women were more likely than Latina women to feel pressured (21% versus 13%, respectively). Women older than 35 years of age (21%), women with a college education (21%), women that were obese prior to starting pregnancy (23%) and women who reached 41 weeks of pregnancy (26%) felt pressure to have an induction. Even among women that were induced prior to 39 weeks for medical reasons, 24% of these women felt pressured to have their induction. Women that viewed birth as a normal process and were better educated reported higher levels of pressure to have an induction of labor (Declercq et al., 2020). In this same sample, 19% of women who had an induction required a C-section compared to the 10% that did not proceed with an induction that ultimately required a C-section. C-sections in this sample were more common in medical inductions versus elective induction (Declercq et al., 2020).

Coates et al. (2021) looked at the attitudes of women and their birth providers during induction of labor counseling. For first time mothers, there are higher rates of dissatisfaction with induction of labor when induction is not discussed in childbirth classes or prenatal care (Coates, 2021). The authors noted that a lack of participation in the decision-making has been shown to negatively affect the woman’s experience of induction of labor; women want to be involved and have support during the decision process (Coates, 2021).

Women were also surprised at how long an induction of labor takes – on average, women in the study thought an induction takes about 12 hours; 40% of women stated that if they could change one thing about the induction, it would be the speed of the induction itself (Coates, 2021).

Gallager et al. (2020) interviewed 100 women to better understand women’s preference for induction of labor. 99% of women were supportive of induction of labor if indicated for their baby. 96% were supportive of maternal indications for induction before the due date. But 54% were not interested in induction of labor in the absence of fetal or maternal indications prior to the due date. This group of women were much more concerned that induction of labor in the absence of an indication for induction could cause more harm to the baby (Gallager et al, 2020).

To ensure you know the right questions to ask to get the right plan for you, be sure to have the Too Good to Be True Pregnancy guides in your back pocket to guide those last weeks of your pregnancy! There’s even a guide for 41-42 weeks of pregnancy packed with the evidence you need for late term pregnancies.

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What is my cervix and what are the measurements assessed during a cervical exam and what do these mean for induction of labor?

Before you can understand how inductions happen, you need to understand what your cervix is and what your cervix does during labor (or during an induction).

Your cervix is located in the back of your vagina and is attached to your uterus (the large organ made of muscle that grows and supports the baby during pregnancy. During labor, your cervix will start to soften and open. As this happens, the baby will move down through the pelvis. Eventually the cervix opens and softens to the size of the baby’s head and this allows the baby to move out of the uterus/cervix, into the vagina and out of your body.

Before an induction, a cervical assessment is usually done by your provider to assess your Bishop score (although, an exam may be declined by some women). Your Bishop score is made up of 5 factors that determine how ripe and ready your cervix is for labor, or, how unripe and not ready your cervix is for labor.

A good way to think about the Bishop score is to compare your cervix to an avocado. A firm, unripe avocado (or cervix) is going to have a Bishop score that is low (0-5) and is going to take more interventions to ripen during an induction. A squishy, ready-for-guacamole avocado (or cervix) is easier to induce into labor – oftentimes, with fewer interventions.

Below is a picture of the scoring table for a Bishop score. You add up points based on your cervical exam. For example, if your cervix was 2 centimeters (1 point), 50% effaced (1 point), -3 station (0 points), posterior (0 points) and medium (1 point), your Bishop score would be 4.

Source: ACOG (2009)

To better understand each component of the cervix, here’s a deep dive into each part of the cervical exam and the Bishop score:

Dilation – This measurement is how open your cervix is. It is measured in centimeters. If your cervix is closed, your provider will call your cervix “closed” or “0 cm” in your chart. In the office, it is most common to be 1 to 4 centimeters. Usually, if you are 5-6 centimeters dilated, you are close to labor and will not need an induction.
Effacement (thickness) – This measurement is how thick your cervix is. During pregnancy, your cervix is 3 to 5 centimeters thick; if you measure that length on your finger, you will note that the cervix is quite thick. During labor, your cervix thins out to about 2 millimeters as it stretches and thins over the baby’s head. When you are not in labor and your cervix is as long as possible, your provider will call that “long” or “0% effaced.” When your cervix is halfway thinned or about 2 centimeters thick, this is called “50%.” And when your cervix is about 1 centimeter thick or thinner, this is referred to as “75%, 80%, or 90%.” It’s unusual for your cervix to be 100% thinned out in the clinic and you are not in labor.
Consistency – This measurement is how soft or firm your cervix is. The terms firm, medium and soft are used to describe what your cervix feels like when the provider touches it with their fingers. When your cervix is firm, it will feel like your forehead or a rubber ball’s consistency. When your cervix is medium, it will feel like the tip of your nose (less firm than your forehead, a little squishier and bouncier). Lastly, when your cervix is soft, it will feel squishy and stretchy – just like the skin over your chin. A firm cervix will need lots of ripening, whereas a soft cervix usually needs very little ripening.
Station – This measurement is the location of the lowest point of the baby’s head in relation to the ischial spines in your pelvis. The scale goes from -5 to +5 (yes, that is a negative five). Most babies don’t drop low into the pelvis until about 36 weeks – this is called engagement and their station after engagement is at -3 or -2 station. As labor and contractions start, the baby will move to -1 or 0 station. And at +1 to +3 station, pushing is started!
Position – This measurement defines which direction your cervix is pointing in your vagina: posterior, mid-position or anterior. Almost all cervixes are positioned posteriorly or pointing towards the back of the vagina. As labor happens, the cervix will move from the posterior position to the mid-position and then to the anterior position.

(Dilation, effacement, and consistency tell your provider the most about how ripe or unripe your cervix is.)

After calculating your Bishop score, your provider can guess how long an induction of labor may take for you.

To recap, start by asking this question with your provider: What is my full cervical exam and my bishop score? (Do not settle for “Your cervix is 1 centimeter.” If that’s all you’re told – ask for the position, the effacement, the consistency…these measurements will help you fully understand how ripe or unripe your cervix is!) Instead of “Your cervix is 1 centimeter,” it should sound like this: “Your cervix is 1 centimeter dilated, about 3 centimeters long and it’s posteriorly positioned – or in the back of your vagina. It’s more firm than soft to palpation. And you Bishop score is 2.”)

What interventions are used for labor induction?

There are non-medical (think sex to acupuncture), mechanical (cervical dilators or amniotomy) and medicinal (medicine) forms of induction of labor (oxytocin, Cytotec, Prepidil, Cervidil, dilapan-S).

Typically, the beginning of an induction starts with cervical ripening methods that will open or soften the cervix. Once the cervix is opened, then methods such as breaking the bag of water (or amniotomy) or pitocin are used. Each woman will require different methods for her cervix and labor. Sometimes only one method or intervention is needed and sometimes all methods are used during an induction of labor.

How many women try to induce labor with non-medicinal methods?

A 2011 survey in the United States was given to a group of postpartum women that birthed at a Midwestern hospital; 201 women responded; researchers noted:

49.3% of women did not try to induce labor with any interventions.
The remaining 50.7% reported trying a non-prescribed method to induce labor with the following interventions:
- 43.3% attempted walking
- 22.9% attempted intercourse/sex
- 10.9% attempted spicy foods
- 7.5% attempted nipple stimulation
Very few women reported using laxatives, intense exercise, masturbation, acupuncture or any herbal/homeopathic preparations to try and start their labor (Chaudhry at al., 2011)

In Australia, 52-73% of women reported using complementary medicines during their pregnancy and 37-48% reported they consulted with a naturopath or a herbalist during pregnancy (Bowman et al., 2021).

The Tables

Each table details the methods and their history, risks, benefits, evidence, and costs. Many women try a combination of non-medical methods whether they have an induction or not.

(A few notes on the tables: The evidence is listed from highest level to lowest level of evidence (this means that the studies on top are the best evidence that are available on the topic compared to studies that are lower on the list), then by the most recent year published. Each table is presented with the study’s question and the findings because when you read and interpret research, it’s important to understand what the researchers were trying to measure – not just what they found. The tables offer hyperlinks to review the evidence yourself. As a provider, I’ve never seen induction methods presented this way, but thinking about the methods in this table format allows for easy understanding and comparison based on the method you are examining.)

Non-medical methods (i.e. methods that do not include medicine or mechanical interventions)

Acupunture

Source

ACUPUNCTURE
What is this method?	Acupuncture is the insertion of fine needles into specific points in the body; acupressure is the use of thumbs or fingers to apply pressure to specific points of the body.
History	Used in Asia and Europe as an acceptable method of induction; not common in the United States.
Evidence	2017 \| Cochrane Systematic Review Study question: Is acupuncture or acupressure safe and effective in the third trimester for cervical ripening or induction of labor? Findings: No clear benefit from acupuncture or acupressure in reducing cesarean rate; acupuncture may help ripen the cervix; quality of evidence was low to moderate. – 22 trials included; 3,456 women . – Researchers compared electro-acupuncture to manual acupuncture, sweeping of membranes or sham controls; no difference in C-section rates between groups; electro-acupuncture may help to ripen the cervix and shorten labor, reduce the risk of C-section but was associated with a higher risk of operative birth when compared to manual acupuncture (Smith at al., 2017). 2008 \| Randomized Controlled Trial Study question: What is the clinical effectiveness of acupuncture to induce labor? Findings: Two sessions of acupuncture given 2 days before a scheduled induction of labor did not reduce the need for induction of labor in women with a postdates pregnancy. – 364 women included. – 181 acupuncture group and 183 in control group; women in the acupuncture group received 2 treatments over a 2 day period prior to their scheduled induction of labor; acupuncture did not reduce the need for induction, induction methods or reduce length of labor (Smith et al., 2008). 2005 \| Review Article Study question: What randomized controlled trials exist that used complementary or alternative medicines for obstetrics or health promotion? Findings: Some evidence exists for certain alternative interventions, while other interventions require additional research before they are put into practice. – 54 randomized controlled trials included across 17 countries – One trial noted that acupuncture given on the due date resulted in labor 2 days earlier than in group where acupuncture was not used; no difference in Bishop’s score or length of labor was noted – Another trial utilized transcutaneous nerve stimulation 8 days after due date; increases in contractions were noted in the experimental group in the fourth hour of stimulation compared to the control group (the goal of the study was to see if the intervention could stimulate uterine contractions only) (Anderson & Johnson, 2005).
Benefits	– May help the cervix to ripen. – Compared to usual care, acupuncture or acupressure does not increase risk for C-section. – Has been used for low back pain, fetal malposition, nausea/vomiting, tension headaches, depression, heartburn, insomnia, sciatica, rib flare and symphysis pubis dysfunction (Park et al., 2014).
Risks	2014 \| Systematic Review – 105 studies (42 RCTs, 6 case-control trials, 54 case series/reports, and 3 surveys) found that needling pain, bleeding, swelling/bruise, dizziness, discomfort or drowsiness were the most common adverse effects from acupuncture – Adverse events from acupuncture are reported as mild and transient or as 0.01 per 10,000 sessions in pregnant individuals – Very serious adverse event are rare (Park et al., 2014).
Cost	Out of pocket; average cost $300; not covered by most insurance.

Breast or Nipple Stimulation

woman in white long sleeve shirt holding breast like toys — Photo by cottonbro studio on Pexels.com

BREAST OR NIPPLE STIMULATION
What is this method?	Either manual stimulation or mechanical stimulation with breast pump/hand expression device; either one or both breasts can be stimulated at the same time but bilateral stimulation may cause more fetal heart rate decelerations (ACOG, 2009); mechanism is unknown but stimulation can cause uterine contractions and cervical change (Kavanaugh et al., 2005).
History	Reported in Europe in the 18th and 19th to help with protracted labors (Kavanaugh et al., 2005)
Evidence	2005 \| Cochrane Systematic Review Study question: Is Breast stimulation in the third trimester effective for ripening the cervix or induction of labor in comparison to placebo/no intervention or other methods of for induction of labor? Findings: Breast stimulation appears to be beneficial; women that performed breast stimulation were less likely to be in labor 72 hours after starting breast stimulation; breast stimulation also appeared to reduce postpartum hemorrhage rates. May not be appropriate for high-risk pregnancies. – No difference in C-section between groups (9% vs 10%). – No instances of uterine hyperstimulation in any of 5 studies. – Two studies noted reduction in rate of meconium staining (25.6% vs 30%). – A reduction in postpartum hemorrhage risk was noted in two trials (0.7% vs 6%). – Studies noted that women who used method had higher likelihood of labor 72 hours after stimulation intervention – whether they were a primiparous or multiparous woman – but may not be as successful in women with an unfavorable cervix (Kavanaugh et al., 2005). 2015 \| Randomized Controlled Trial \| Turkey Study question: What is the effect of uterine stimulation with oxytocin, nipple stimulation or no stimulation on the birth process? Findings: Nipple and uterine stimulation (oxytocin) both reduced frequency of elective labor induction without an increased rate of cesarean section compared to groups without nipple or uterine stimulation. – 390 women included. – Nipple stimulation shortened the first stage, second stage and third stage of labor compared to no nipple stimulation (3.8 hours, 16 minutes, and 5 minutes versus 6.8 hours, 27 minutes and 6 minutes, respectively) (Gulbahtiyar & Guler, 2015). 2018 \| Quasi-Experimental \| Japan Study question: Are there measurable changes in the oxytocin levels of saliva during breast stimulation that help promote spontaneous labor and is the use of breast stimulation a practical and acceptable intervention to induce labor? Findings: The highest levels of oxytocin in the pregnant woman’s saliva were present at day 3 of breast stimulation; pregnant women found the breast stimulation protocol acceptable and easy to implement. – 16 women collected salivary samples around 38 weeks gestation for three days in a row during and after breast stimulation to test the level of oxytocin in the saliva. – Breast stimulation consisted of 15 minutes on one breast, then switching to the other, and repeating until 1 hour elapsed. – The highest levels were noted at 3 days of testing (Takahata et al., 2018).
Benefits	– Option to manually stimulate breasts with hands or use a breast pump. – Use at home, in triage or during labor/induction. – No increased risk for cesarean section (ACOG, 2009). – May shorten stages of labor and reduce risk for postpartum hemorrhage (ACOG, 2009). – May reduce incidence of meconium staining (ACOG, 2009). – No uterine tachysystole noted in studies (ACOG, 2009).
Risks	– May not be appropriate for high-risk pregnancies. Only studied in low-risk pregnancies (ACOG, 2009).
Cost	Only cost is time of stimulation or breast pump cost (if used).

Dates (dried fruit)

candied dried dates — Photo by Valeria Boltneva on Pexels.com

DATES (dried fruit: Phoenix dactylifera)
What is this method?	Eating pitted dates from 35 weeks of pregnancy to your due date may help to ripen the cervix and shorten your labor. Dates contain a number of minerals and vitamins but also fatty acids (a precursor to prostaglandins).
History	Unable to find sources reporting date use historically for labor induction.
Evidence	2020 \| Systematic Review – Study question: What studies have evaluated the effects of date palm fruit on labor outcomes compared to routine care? – Findings: Eating date fruit can reduce the active stage of labor and improve the Bishop score. – 8 studies included. – 3 trials with 380 women examined if dates reduced active labor duration; data synthesis showed that active labor was shortened by 109 minutes in groups where dates were consumed. – 2 studies with 211 women reported about duration of the first stage of labor; data showed that the first stage of labor is shortened approximately 76 minutes when dates are consumed at the end of pregnancy. – 4 trials with 481 women did not show a statistical significance in the second stage of labor. – 2 trials with 320 women reported on improvement in Bishop score and found that dates dilated the cervix an average of 2.45 centimeters more than groups that did not consume dates (Bagherzadeh et al., 2020). 2017 \| Randomized Clinical Trial \| Iran – Study question: Does date consumption at the end of pregnancy effect the duration of the delivery process in first time birthing women (nulliparas)? – Findings: Eating dates 6-7 dates three days a week from 37 weeks gestation to time of labor or induction reduces the length of labor in all stages (first, second, and third) and the need for oxytocin for labor augmentation. – 182 women included in trial; 91 women in the control group and 91 women in the dates group (women in this group were given 7 packs containing 6-7 dates and asked to consume a pack of dates 3 days a week from 37 to 39 weeks of gestation). – Women in the dates group had more cervical dilation at time of admission: 4.05 centimeters versus 2.5 centimeters. – For spontaneous labor and induction of labor, women in the dates group had shorter first, second and third stages of labor than the control group: For spontaneous labor: First stage 304 vs 330 minutes; second stage 33.4 vs 40 minutes; and third stage 5.1 vs 6.2 minutes. For induced labor: First stage 769 vs 855 minutes; second stage 38 vs 45.4 minutes; and third stage 5.6 vs 7.7 minutes. – Oxytocin was needed to augment labor in 48.70% of the control group versus only 5.5% of the dates group. – There were no differences noted in maternal age, body mass index, or weight of newborn baby. There were also no differences in maternal reports of exercise, intercourse, and use of pain medications during pregnancy or labor. – Authors note that is was not a blinded study and that the exact amount of dates consumed by the pregnant women or the complete control over the pregnant women outside the clinic were not measured (Kordi et al., 2017). 2011 \| Prospective Study \| Jordan – Study question: What is the effect of date consumption on labor and delivery outcomes? – Findings: Date consumption in the 4 weeks prior to an estimated due date reduces the need for induction and augmentation; dates may contribute to a more favorable delivery outcome. – 2 groups of women included; the first group included 69 women that consumed 6 dates a day for 4 weeks prior to their due date and the second group included 45 women who ate no dates in the last 4 weeks of their pregnancy (gestational age, maternal age and parity were all similar between the groups). – Women who consumed dates had a higher cervical dilation on admission: 3.52 vs 2.02 cm. – 96% of women who consumed dates went into spontaneous labor vs 79% of women who did not consume dates. – Only 28% of women that consumed dates required oxytocin during labor versus 47% of women who did not consume dates. – The first stage of labor was shorter in women that consumed dates: 510 vs 906 minutes (Al-Kuran et al., 2011).
Benefits	– Shortens all stages of labor and induction of labor. – Increases likelihood of spontaneous labor. – Reduces need for induction of labor. – Less likely to need Pitocin (oxytocin) augmentation in labor. – Dates contain fatty acids. Fatty acids are needed to assist the body’s high calorie consumption from the smooth muscle during labor. Fatty acids are a better source than glucose to assist the energy the uterine muscles need (Kordi et al., 2017). – Easy to transport to the hospital to eat as a snack during labor. – Option to cut dates into muffins, smoothies, or yogurt if date is not preferred by itself. – Option to puree into a smoothie or honey form if preferred as a liquid.
Risks	No risk noted in evidence. (Jamie’s note: If gestational diabetes present, may need to consume with caution as dates can elevate glucose levels.)
Cost	$10-20 per bag at your local grocery store
Additional information	Dates consumed for longer periods in late gestation appear to be more effective (i.e. starting dates at 35-36 weeks gestation and consuming multiple times a week appears more effective than starting dates at 39 weeks).

Enemas

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ENEMAS
What is this method?	An enema is a container of saltwater solution that is placed via a small tube into the woman’s rectum; the solution causes the body to absorb more water into the rectum and stool (if present) and stimulate a bowel movement within about 5-10 minutes. Enemas can be purchased over the counter and administered at home; enemas are also available in the hospital setting.
History	Used at the beginning of every labor and induction in past decades because advocates thought enemas helped reduce infection rates, vaginal lacerations rates and episiotomies; largely abandoned in the 1980-1990s in the United States; still used widely around the world.
Evidence	2013 \| Cochrane Systematic Review Study question: What effect do enemas have on mothers and babies when administered in the first stage of labor? Findings: Enemas don’t have a benefit; enemas do not prevent infections in mothers or infants; enemas do not prevent perineal tears; enemas do not shorten labor duration. – 4 randomized controlled trials with 1917 women noted that enemas in labor did not reduce postpartum infection rates in mothers or neonatal umbilical infection rates in infants; enemas did not reduce perineal tearing or affect the length of labor. Authors note that routine use of enemas in labor should be discouraged (Reveiz et al., 2013). 2022 Qualitative Study \| Jordan Study question: What are women’s knowledge, attitudes, perceptions, pain and satisfaction with rectal enema use in labor? Findings: Most women in the study knew about rectal enemas, thought they were an important intervention in labor, and expressed a positive attitude about their administration. – 300 women included; most women perceived enemas as important during labor with low levels of pain or complications; most women reported high satisfaction rates with a rectal enema intervention during their labor; the majority of women would choose to have an enema in labor because they thought it contributed to more cleanliness during their labor (Mahfouz et al., 2022).
Benefits	Can be done at home or in hospital; helpful in setting of hard stools or constipation.
Risks	May cause some abdominal cramping, rectal cramping, loose bowel movements and flushing.
Cost	$3-4 per enema

Herbal or Homeopathic Preparations

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HERBAL or HOMEOPATHIC PREPARATIONS
What is this method?	Homeopathic refers to the process of making a solutions or products made from herbs, teas or other products; often times, these products are combined into a tincture (a concentrated liquid) and used during pregnancy, labor or birth (Gregg, 2006). Also referred to as CAM or complementary and alternative medicine.
History	Used for centuries across the world during pregnancy, labor and postpartum, but limited use in United States is due to limited trials and suspected teratogenic effects (Boltman-Binkowski, 2016).
Evidence	There is limited evidence of homeopathics; most data and guidance are passed down through mentors or an apprenticeship, or through observation or experience. (Of note, there was a 2016 systematic review, but the 8 articles in the review only examined castor oil and ginger.) Diane Gregg, a home birth midwife, offered these guidelines in a 2006 Midwifery Today article: – Cotton, pennyroyal, blue cohosh and black cohosh as tinctures can work well to stimulate or strengthen a labor and to induce a postdates women into labor. – Evening primrose oil is successful at increasing labor; at 40 weeks, women were given 1 dose of evening primrose oil three times a day; women went into labor within 1-7 days with this intervention. – Tinctures in pregnancy are generally dosed at 30x, while during labor and postpartum, tinctures are dosed at 200x. – Chamomilla, Belladonna, Magnesia phosphorica and Gelsemium are all helpful in late labor (Gregg, 2006). Midwifery Today published another article in 2022 called Wisdom of the Midwives: Induction: – Midwives recommended using the following herbs to induce labor: blue and black cohosh, golden seal, partridge berry, skullcap, passionflower, St. John’s wort and pulsatilla in addition to the other herbs listed above. – To ripen the cervix, use black cohosh extract; place 10-12 drops under woman’s tongue for action to start. – For evening primrose oil: must be taken for a few days to induce labor; can also use borage seed oil for same action. (These oils contain gamma-linolenic acid which is a precursor to prostaglandins.)
Benefits	No harm noted to mother or baby.
Risks	Dosing, timing and rate of effectiveness are not usually published (Gregg, 2006).
Cost	Varies.
Additional information	Recommend books for more education on homeopathics: – Homeopathic Medicines for Pregnancy and Childbirth by Richard Moskewitz, MD (1992) – The Homeopathic Childbirth Manual by Betty Idarius (1996)

Physical Activity/Exercise

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PHYSICAL ACTIVITY/EXERCISE
What is this method?	Long walks, curb walking, strength training, squats/lunges, swimming – any form of exercise used to try and induce contractions or labor.
History	Writings from the 18^th century note that physical activity during pregnancy was associated with an easier labor and a smaller baby; in the 19^th and early 20^th centuries, women that were very active had lower birth weight babies compared to women that were prescribed maternal rest and had higher birth weight babies (Downs et al., 2012). In the 20^th century, prenatal exercise – defined as at least 2-6 miles of daily walking – was encouraged to promote easier/shorter labors and births, better tolerance of labor pain and to improve muscle tone; additionally, the program helped to facilitate postpartum weight loss (Downs et al., 2012).
Evidence	2022 \| Randomized Controlled Trial Study question: Does controlled maternal physical exercise during the term part of pregnancy help induce spontaneous labor? Findings: Yes; walking at term for 30 minutes, 3 times a week, at a 2.5 mile/hour pace is safe, encourages spontaneous labor and reduces need for operative birth. – 60 women were placed into two groups at 38 weeks gestation: a walking group which aimed to perform 30 minutes of walking 3 times a week at 4 kilometers/hour (about 2.5 miles/hour) or a group that maintained their usual work and household tasks. – The exercise group had a lower rate of induction (17.5% vs 33.3%) and fewer operative deliveries (20.6% vs 38.1%). – No differences were found in gestational age that spontaneous labor started, duration of active phase of labor, c-section rate, APGAR scorers or birth rate. (Of note, sample size was small for trial.) (Pereira et al., 2022) 2021 \| Randomized Controlled Clinic Trial \| Iran Study question: What are the effects of walking in late pregnancy on the outcomes during labor and delivery? Findings: Walking at term increases you Bishop score, the spontaneous onset of labor and may decrease the need for induction of labor, cesarean, operative birth without any effects on the baby’s APGAR scores. – Participants in the exercise arm of the study completed a 40 minute walking program 4 times a week, starting at 34 weeks. The walking program consisted of: a 5 minute warm up, 30 minutes of moderate intensity walking, and a 5 minute cool down. – Spontaneous labor occurred in 91.8% of the walking group and only 58.8% of the control group. – At time of admission for labor, the walking group had an average Bishop score of 6.14 (+/-2.82) compared to an average Bishop score of 3.49 (+/- 2.29) in the group that did not walking. – The walking group demonstrated shorter times for first, second and third stage of labor durations: First stage: 422 vs 612 minutes Second stage: 33 vs 45 minutes Third stage: 7 vs 12 minutes – Vaginal birth rates were much higher in the walking group: 83.7% vs 43.1% (Shojaei et al., 2021).
Benefits	Higher likelihood of spontaneous labor without needing an induction of labor; shorter first, second and third stages of labor.
Risks	None noted in literature.
Cost	No cost, just time (unless using a gym membership).

Purgatives

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PURGATIVES (Most commonly: Castor Oil)
What is this method?	Products or herbal preparations to stimulate labor. Castor oil is the most common preparation; castor oil is made from the bean of a castor plant (Kelly et al., 2013). Purgatives are thought to work by increasing the secretion of prostaglandins which stimulates the uterus and the intestines.
History	Castor oil has been used since ancient Egypt to induce labor; used by midwives more regularly than physicians to induce labor.
Evidence	2013 \| Cochrane Systematic Review Study question: What is the effect of castor oil or enemas for third trimester cervical ripening or induction or labor? Findings: Trials were of poor quality; no increased risk of cesarean section was noted with castor oil use; no differences in operative birth, APGAR scores or meconium stained amniotic fluid were noted. Authors note that interpretation of this data should be used with caution due to the poor quality of trials. – Among the 3 trials included, there were 233 women. There was no difference in c-section rate in the castor oil groups versus the no treatment group; there was no difference between the groups with meconium staining, instrumental delivery or in APGAR scores. – The authors in one trial that had 100 participants noted that ALL women who ingested castor oil felt nauseous (Kelly et al., 2013). 2012 \| Randomized Controlled Trial \| Israel Study question: What is the efficacy and safety of castor oil for induction of labor in postdates pregnancies? Findings: Castor oil is a safe and effective substance to induce labor in postdates pregnancies. – A prospective, randomized, double blind and placebo-controlled study was conducted. – 37 women participated in the treatment group and 43 in the control group; researchers found that the odds of entering labor 12 hours after taking castor oil were 3 times higher than those in the control group. Castor oil continued to work up to 48 hours to induce labor in control group. – Author findings: Castor oil is safe, effective and a reliable modality to induce labor (Gilad et al., 2011) 2006 \| Randomized Controlled Trial \| Saudi Arabia Study question: What is the effect of castor oil on initiation of labor in term pregnant women? Findings: There is a higher likelihood of birth within 24 hours after castor oil use; more studies are needed to evaluate safety and efficacy. – 47 women were included in the trial (24 women in the castor oil group and 23 women in the control group); study participants were 40-42 weeks pregnant with singleton gestation, cephalic presentation and had a Bishop score of <4; baseline fetal measurements were all reassuring/normal prior to start of study. Approximately 2/3 of each group were primiparas. – 60cc of castor oil was given orally to the experimental group and the group was assessed 24 hours later. – In the castor oil group, 54.2% (13 women) went into labor within 24 hours compared to 4.3% of the control group (1 woman). – The average Bishop score in the castor oil group increased from 2.5 +/- 1.29 to 6.69 +/- 3.20. – The researchers also noted that meconium staining was three times more common in the control group – not the castor oil group – but this finding was not statistically significant. – No differences were noted in mode of delivery, vomiting rate, or hyperstimulation of the uterus (Azhari et al., 2006). 2000 \| Prospective Study \| Brooklyn, New York Study question: What is the relationship between castor oil and the onset of labor? Findings: Women between 40-42 weeks who use castor oil are more likely to go into labor within 24 hours than women who do not use castor oil. – Participants were 103 pregnant women with intact membranes between 40-42 weeks; women were not contracting and Bishop score was <4. 54 women were in the castor oil group and 48 were not assigned treatment. – A single 60cc dose of castor oil was given to the experimental group. – 57.7% (30 of 52 women) went into labor within 24 hours after consuming castor oil compared to only 4.2% (2 of 48 women) in the control group. – 83.3% of women in the castor oil group birthed vaginally (Garry et al., 2000). 2006 \| Article: Birth Herbs and Homeopathics: Stats and Stories – Reports use of castor oil to induce labor in home birth practice was successful in about 4 in 10 women (Gregg, 2006).
Benefits	Effective at ripening cervix and inducing labor.
Risks	One trial has shown increased risk of meconium-stained amniotic fluid (Mitri et al., 1987); this has not been reproduced in newer studies.
Cost	$8/bottle over-the-counter

Red Raspberry Leaf Tea

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RED RASPBERRY LEAF TEA
What is this method?	Raspberry leaf (rubus idaeus) is a herb that is thought to strengthen the smooth muscle of the uterus; this helps the uterus to contract and may prevent postpartum hemorrhage.
History	Used for centuries; most common herb used by women during pregnancy.
Evidence	Overall, evidence is weak and inconclusive. 2021 \| Systematic Integrative Review \| 13 studies from 1941-2016 Study aim: To review the research literature for raspberry leaf tea during pregnancy. Findings: Most women use raspberry leaf tea to promote labor and birth, but evidence is weak and more research is needed to support its use and effectiveness. – Raspberry leaf has been shown to affect the uterine smooth muscle in animals and humans. – Toxicity has only been noted in high doses given to animals in intravenous or intraperitoneal (injected into the abdomen area). – Human studies have not shown any harm or benefits except for one study that should raspberry leaf during labor may augment labor and shorten the second stage. – Trials included multiple forms of red raspberry given to animals and humans: extracts, crushed leaves with saline, tea, tablets, tinctures or mixed routes and preparations. – A 2016 case report by Cheang et al. noted that in a woman with gestational diabetes requiring insulin, that 2 cups of red raspberry leaf tea caused hypoglycemic events not attributed to anything else in her dietary recall. – 3 retrospective cohort studies were weak because of small samples, bias, and other confounders. – A 2001 double blind, placebo controlled randomized controlled trial examined 192 women; women in the experimental group were given 2.4 grams of raspberry leaf tablets daily starting at 32 weeks of pregnancy; compared to the placebo group, there were no statistically significant differences; however, women taking the raspberry leaf tablets had a shorter second stage by 10 minutes (Bowman et al., 2021). 2005 \| Review Article \| 17 countries, 54 randomized controlled trials included Study aim: To review randomized controlled trials that have used complementary or alternative medicine for obstetrics or health promotion. Findings: Some alternative medications have evidence and some require more research before use is recommended in practice. – Regarding red raspberry leaf tablets, one trial demonstrated that women who took red raspberry leaf tablets starting at 32 weeks did not have any difference in length of pregnancy, length of stages or labor or type of birth (Anderson & Johnson, 2005).
Benefits	Current evidence does not show any benefits to humans (Bowman et al., 2021).
Risks	Herb may inhibit activity of CYP (cytochrome); may interact with other herbs or drugs; use with caution if other drugs or herbs used at the same time (Bowman et al., 2021).
Cost	$12/bottle over-the-counter

Sex, Sexual Activity, Orgasm, or Masturbation

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SEX, SEXUAL ACTIVITY, ORGASM, or MASTURBATION
What is this method?	Engaging in regular intercourse after 37 weeks has long been an effort to induce labor. While the effects of sex are not well studied or understood, theories suggest that sex induces labor by: oxytocin release from orgasm causes contractions or that semen contains the highest level of prostaglandins for a bodily fluid (which help ripen the cervical tissue).
History	Long used as a method to start labor.
Evidence	2019 \| Systematic Review/Meta-Analyses of Randomized Controlled Trials Study question: What is the effectiveness of sexual intercourse on spontaneous labor in term singleton pregnancies? Findings: Sexual intercourse at term did not significantly increase onset of spontaneous labor. – 3 trials with 1,483 women with singleton pregnancies at term (37 weeks or more) engaged in sexual intercourse and compared to women who did not engage in intercourse in an effort to start spontaneous labor; there was no difference between the groups and both groups demonstrated similar starts to spontaneous labor (Carbone et al., 2019). 2006 \| Questionnaire Study question: How often are term pregnant women having sex and does regular sex affect onset of labor or mode of birth? Findings: Sex at term was associated with earlier onset of labor and a lower likelihood of labor induction at 41 weeks. – 200 women kept diary about when they had sex from 36 weeks to 41 weeks of pregnancy; sex after 37 weeks was associated with a 72% reduction in the pregnancy going to 41 weeks’ gestation! The researchers noted that sex at term (37 weeks or more) was associated with earlier onset of labor and a reduced rate of labor induction at 41 weeks (Tan et al., 2006)
Benefits	Encourages spontaneous labor at term and reduces need for a post-dates induction of labor.
Risks	May cause some mild contractions.
Cost	Time.

Sweeping or Stripping Membranes

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SWEEPING OR STRIPPING MEMBRANES
What is this method?	Sweeping or stripping of membranes is an intervention performed during a cervical exam. Your cervix must be open to complete the procedure. The provider moves a finger through the cervix to reach the bag of waters; once at the bag of waters, the provider uses the pressure of their finger to separate the bag of water from the cervix and lower uterine segment. Sometimes this is done in a single circle and sometimes the provider performs a few circles of the membranes. This action causes irritation to the cervical tissues which can in turn soften the cervix, start labor contractions or cause the amniotic sac to rupture. Generally recommended after 39 weeks gestation.
History	Intervention first credited to James Hamilton of England in 1810 (Swann, 1958).
Evidence	2020 \| Cochrane Database Systematic Review Study question: Is sweeping membranes safe and effect for induction of labor for women at or near term gestation (>36 weeks)? Findings: A membrane sweep is likely effective for inducing spontaneous labor, but the evidence was low quality in this review. A membrane sweep probably reduces the need for an induction of labor. It is unclear if there is an optimal number of membrane sweeps that should be performed to induce labor or when the timing of sweeps should be performed. – 40 studies included; 6940 women. – After a membrane sweep, women are 20% more likely to go into labor and are 27% less likely to need an induction of labor. – There is no difference or little difference between vaginal birth or c-sections rates if membrane sweep is performed. – No serious morbidities for mother or infants were noted from a membrane sweep (Finucane et al., 2020).
Benefits	– A membrane sweep can reduce the need for induction of labor, or for oxytocin or prostaglandins during induction or labor. It is a simple procedure that can be performed in office, in labor and delivery triage or at the start of an induction of labor. – Lui et al. (2018) found that a membrane sweep at the start of an induction was associated with a 32% increase in a spontaneous vaginal birth within 48 hours; the same was not found in multiparas at the start of their induction of labor (Carlson et al., 2021). – Not associated with increased risk for c-section or assisted vaginal birth, maternal or neonatal death or other morbidities (Carlson et al., 2021).
Risks	– During the procedure: cramping, discomfort. – After the procedure: cramping, infection, premature rupture of membranes, vaginal bleeding or cervical discharge after sweep, contractions without labor (prodromal labor). *Some providers have voiced concern about membrane sweeps in women colonized with group beta streptococcus (GBS); membrane sweeps in GBS positive women have not been shown to have adverse maternal or neonatal outcomes (Carlson et al., 2021). ACOG’s practice bulletin on induction of labor states that there is insufficient evidence to guide membrane sweeping in GBS positive patients (ACOG, 2009).
Cost	None.

*Not mentioned above, but don’t forget about the importance of rest and sleep to help your body go into labor or prepare for an induction of labor. Although spicy foods are common intervention to induce labor, there’s not any study or data to support the practice other than opinion or experience. Additionally, I couldn’t find anything to support chiropractic care to induce labor (although the hypothesis makes sense: if chiropractic adjustments help your body alignment to help the baby to engage, then this puts the body and the baby in optimal position when labor starts. If you are looking for more information about chiropractic care in pregnancy, read this 2007 article: Pregnancy and Chiropractic: A Narrative Review of the Literature.

Mechanical methods (i.e. methods that do not include medicine; these methods use devices or tools to promote labor)

Amniotomy

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AMNIOTOMY (aka “Breaking the Bag of Water” or “Rupturing Membranes”)
What is this method?	A 10-inch long thin plastic device with a small hook on the end is used to open a small hole into the bag of water during a cervical exam. The amniotomy device looks most like a knitting needle, but there are also small gloves with a tiny point on one finger of the glove that are used as well. Amniotomy works by releasing prostaglandins in the surrounding tissues which increases contractions and labor progression in a labor or induction (Carlson et al., 2021).
History	First introduced by Iranian physicians in the 11th century. In the 1800s, historians noted that the use of a catheter and a wire to perform a high amniotomy was recommended to prevent infection. In the 1930s, a group of providers noted that “dry labor” helped to accelerate the labor process. In 1938, the American Journal of Obstetricians & Gynecologists noted that amniotomy is an acceptable intervention if the head is at or below the spines, the mother is 40 weeks in gestation or more, and the cervix is soft and less than 1 centimeter in length (Hall, 2001).
Evidence	2020 \| Systematic Review and Meta-Analysis Study question: Does routine early amniotomy increase the risk for cesarean section? Findings: Early amniotomy does not increase risk for cesarean section and reduces the time to birth. – 4 trials with 1273 women were included; women had either a foley catheter or prostaglandins for their cervical ripening and were assigned to either: early amniotomy or late amniotomy; the control group were the women who has spontaneous rupture of membranes. – Women in the early amniotomy group had a similar rate of cesarean section (31.1% vs 30.9%) and had a shorter time from amniotomy to time of birth (about 5 hours). – In the early amniotomy group, there was a slightly lower risk of vaginal delivery (67.5% vs 69.1%) (De Vivo et al., 2020). 2013 \| Cochrane Database Systematic Review Study question: What is the effectiveness and safety of amniotomy (by itself) to shorten labors that start on their own (spontaneous labor)? Findings: Amniotomy should not be used routinely to shorten spontaneous or prolonged labors during standard labor and delivery care. Authors also note that this evidence should be made available to women as a point of discussion for women and their care teams. – 15 studies included; 5583 women participating – No clear difference in the length of the first stage of labor, cesarean risk, maternal satisfaction with birth experience or APGAR cores if amniotomy performed or membranes left alone during spontaneous labor. – No clear difference between cesarean rate, maternal satisfaction with birth or APGAR scores in women with spontaneous labors that have become prolonged if amniotomy performed or membranes left alone during spontaneous labor. – In the studies examined, the reviewed studies were not consistent in the timing of amniotomy (Smyth et al., 2013). 2022 \| Randomized Controlled Trial \| Newark, Delaware Study question: Does rupture of membranes within 1 hour of foley catheter expulsion shortens the duration of spontaneous labor in patients undergoing COMBINED misoprostol and foley catheter interventions for term labor induction? Findings: Early amniotomy within 1 hour of cervical balloon expulsion is associated with shorter time to birth in nulliparas and multiparas without an increased risk for infection, cesarean risk or prolapsed umbilical cord. – 160 participants were divided into 2 groups (79 had early rupture of membranes and 81 had expectant management) . – Induction interventions were as follows: foley catheters were placed and induced with 30cc sterile water and at the time of foley placement, a 25 microgram dose of Cytotec was also placed in the posterior vagina; Cytotec doses were repeated every 3 hours, up to 5 doses; if Cytotec could not be repeated, Pitocin was started at 2 milliunits per minute and increased per hospital policy). – Participants in the early rupture group had a shorter time to delivery (11.1 hours versus 19.8 hours); for nulliparas (first time pregnant women), early amniotomy resulted in an average time of 13.2 hours versus 20.8 hours in the expectant group; for multiparas (women with a prior birth), early amniotomy resulted in an average time of 6.35 hours versus 15.5 hours in the expectant group. – No differences were noted in rates of intra-amniotic infection; a cord prolapse occurred once in each group; and there was no statistically significant difference in cesarean births between the two groups (Gomez Slagle et al., 2022). 2018 \| Randomized Controlled Trial \| India Study question: What is the effective of an early amniotomy on induction or labor versus an amniotomy done later in the induction? Findings: Starting an induction of labor with an amniotomy was associated with a faster time to birth but a higher rate in cesarean section. – 150 women with a Bishop score of 6 or greater were randomized to two groups: starting an induction of labor with early amniotomy and then oxytocin infusion, or, starting the induction with 4-8 hours of oxytocin (followed by a “delayed” amniotomy). – Early amniotomy reduced the time to birth (7.35 hours versus 11.66 hours) but was associated a higher rate of C-section (10.7% versus 2.7%). – Early amniotomy increases the chance of birth within 12 hours (86.7% achieved birth within 12 hours compared to 60% in the delayed amniotomy group) – Of note, 3 of the C-sections were due to meconium in the early amniotomy group (Jamie’s note: a cesarean section for meconium is not usually an indication for expedited birth unless there are fetal heart rate concerns as well )(Bala et al., 2017). 2023 \| Prospective Cohort Study Study question: Is amniotomy successful at inducing labor when the cervix is not effaced? Does early amniotomy increase the risk of cesarean section? Findings: Amniotomy at <50% cervical effacement was associated with a lower chance of dilation to 10 centimeters and a vaginal birth compared to amniotomy at >50% cervical effacement. – 1,256 women were included in study; all singleton, term, nulliparous patients undergoing induction and amniotomy. – Study looked at the success of amniotomy in labor induction when a cervix is not effaced; patients were put into two groups: cervix was >50% or <50% effaced. – The primary outcome of the study was to measure which participants completed the first stage of labor (made it to 10 centimeters dilation). – 365 (29%) of women had an amniotomy while the cervix was <50% effaced; this group was 13% less likely to complete the first stage of labor and 13% less likely to have a vaginal birth than those who had an amniotomy with >50% cervical effacement. – Researchers also looked at women that had a cervical ripening balloon and then had an amniotomy with cervical effacement of <50%; in this group, the women were 16% less likely to complete the first stage of labor (Rimsza et al., 2023). 2019 \| Retrospective Cohort Study Study question: Is there a difference in pregnancy outcomes after early amniotomy in women with class 3 obesity (body mass index > 40.0) undergoing an induction of labor? Findings: Early amniotomy in nulliparous (first time birthing women) with class 3 obesity may have 3 times the risk to have a cesarean section; early amniotomy in multiparous (women that have birthed a baby before) with class 3 obesity may have 2 times the risk to have a cesarean section. – 285 women included in study – 107 women (37.5%) underwent an early amniotomy (defined as artificial rupture of membranes before 4 centimeters) – 178 women (62.5%) underwent a late amniotomy (defined as artificial rupture of membranes after 4 centimeters) – Early amniotomy was associated with a 2.05 increased risk of cesarean birth. – There were no differences in length of labor or maternal/neonatal morbidity between the groups. – When divided by nullipara or multipara, nulliparas that had an early amniotomy had a 3.1 times greater risk of cesarean birth (Pasko et al., 2019). 2019 \| Retrospective Cohort Study \| Australia/New Zealand Study question: Does early amniotomy increase the risk for cesarean section? Findings: Early amniotomy was associated with an increased risk for cesarean section in obese women; neonatal morbidity was not increased with early amniotomy. – 15,525 women were included in study – Groups were divided by early amniotomy (rupturing membranes less than 4 centimeters dilated) or not early amniotomy. – 10,421 women (67% of cohort) had an early amniotomy – The early amniotomy group was found to have a higher rate of cesarean section than the not early group, but the labor induction was 2.5 hours shorter with the early amniotomy – Of note, as body mass increased in the early amniotomy group, so did the risk of cesarean section (Battarbee et al., 2019)
Benefits	– If low risk, breaking the bag of water does not require continuous fetal monitoring unless there is meconium-stained amniotic fluid. – Not painful procedure because there are not nerve endings in the fetal membranes; procedure feels similar to a cervical exam. – Offers an option to augment labor without or before use of other medications.
Risks	– Umbilical cord prolapse, chorioamnionitis, umbilical cord compression and rupture of a vasa previa (ACOG, 2009). – ACOG’s induction of labor bulletin states that there is insufficient data on the best time to perform amniotomy in patients receiving antibiotic prophylaxis for group beta streptococcus (ACOG, 2009). – Routine amniotomy is not recommended for HIV positive patients because it increases the risk of vertical transmission of the virus to the baby (ACOG, 2009).
Cost	$2.75 per hook.

Cervical Balloon Catheters

Pictured above: A single balloon catheter and a double balloon catheter (Source).

CERVICAL BALLOON CATHETERS
What is this method?	Catheters are placed into the cervix with a deflated balloon via digital methods (the provider uses their fingers to advance the balloon catheter through the cervix) or via a speculum exam (the provider visualizes the cervix at the end of the speculum and uses an instrument called a rings forceps or kelly forceps to advance the catheter through the cervix). Once the catheter is threaded through the cervix, the balloon is inflated between the bag of water and the cervix. The pressure from the balloon causes softening and stretching of the cervix at the same time. Most balloons used in clinics or labor units are either foley catheters (the same balloon used for bladder catheters; used off-label for cervical ripening, i.e. not FDA approved for this use) or COOK double-balloons (FDA approved in 2013 for cervical ripening). Cook balloons can be inflated to 80cc in each balloon; foley catheter balloons are used inconsistently across providers and are inflated from 30-80cc depending on the provider or protocol.
History	Origins may date back to the 1860s; widely used for many decades since 1960 – initially foley catheter balloons were used; double balloon catheters were invented in the 1990s.
Evidence	2023 \| Cochrane Database Systematic Review Study question: What is the effectiveness and safety of mechanical methods > 24 weeks gestation for labor induction when compared to vaginal prostaglandin E2 (PGE2), low-dose misoprostol, amniotomy and oxytocin? Findings: Balloons have an overall better safety profile; balloons are likely as effective as vaginal PGE2 but balloons may be slightly less effective than oral misoprostol (de Vaan et al., 2023). Balloon vs vaginal PGE2: – Among 6619 women, there was little or no difference noted between vaginal birth not achieved in 24 hours or cesarean section (moderate level evidence) – Balloons catheters were associated with a 65% reduction in hyperstimulation with fetal heart rate changes (moderate evidence), a 52% reduction in neonatal morbidity or death (moderate evidence) and a 18% reduction in admission to NICU (neonatal intensive care unit) (low evidence) when compared to PGE2 (de Vaan et al., 2023). Balloon vs low-dose vaginal misoprostol: – Studies are not clear on whether a balloon or vaginal misoprostol achieves a birth within 24 hours (low quality evidence). – A balloon probably reduces the risk of hyperstimulation with fetal heart rate changes by 61% compared to vaginal misoprostol (moderate quality evidence). – Balloons may increase the risk for a cesarean section by 28% compared to vaginal misoprostol but the 12 studies for this statistic were of low quality. – Studies could not determine if there was any difference in neonatal/maternal mortality/morbidity, APGAR scores or NICU admission because the evidence was low quality (de Vaan et al., 2023). Balloon vs low-dose oral misoprostol: – Balloons may be less effective at achieving birth within 24 hours compared to oral misoprostol. – Balloons may slightly increase the risk of cesarean section compared to oral misoprostol. – Studies could not determine if there is a difference between hyperstimulation with fetal heart rate changes, neonatal/maternal mortality/morbidity, APGAR scores or NICU admission because the evidence was low quality (de Vaan et al., 2023). 2018 \| Systematic Review Study question: Does a cervical balloon with more inflated volume result in a shorter time from induction to birth? Findings: Yes, when single-balloon catheters are infused with 60-80cc of fluid versus 30cc of fluid, the time from induction to birth is reduced by about 2 hours. – 1432 women with singleton pregnancies included across 7 randomized controlled trials. – Women with larger volumes in their cervical ripening balloons had shorter time, an average of 1.97 hours less, from induction to birth without any difference in cesarean rates (16% vs 18%). – For nulliparous women, a larger balloon volume was associated with a 1.82 hour decrease in induction to birth time. – For multiparas, a larger balloon volume was associated with a 2.67 hour decrease in induction to birth time (Schoen et al., 2018). 2016 \| Systematic Review Study question: Does a foley catheter alone or misoprostol in different doses alone or a combination of foley catheter with misoprostol have a better safety profile? Findings: Foley catheters seem to have a better safety profile than ANY form or ANY dose of misoprostol for induction of labor. – 5,015 women across 22 randomized controlled trials included comparing foley catheter with or without misoprostol to misoprostol alone – Foley catheters result in 46% less hyperstimulation and 28% fewer cesarean sections than misoprostol. – Foley catheters WITH misoprostol compared to misoprostol alone resulted 29% (RR, 0.71, 95% CI, 0.52-0.97) less hyperstimulation than misoprostol alone. – Cesarean births were relatively the same across methods/combinations (34% vs 34%). – Of note: Meta-analysis of the studies to assess safety profile comparing the foley catheter to misoprostol could not be accomplished because of lack of power in the data (Ten Eikelder et al., 2016). 2015 \| Systematic Review Study question: Do foley catheters used for cervical ripening increase infection risk? Findings: Foley catheters used for cervical ripening are not associated with an increased risk of infection. – 5,563 women included across 26 randomized controlled trials – Researchers compared women given only prostaglandins for induction to women with only a foley catheter for induction; rates of chorioamnionitis were the same for both groups: 7.2% vs 7.2%; endometritis rates were similar: 3.8% vs 3.5%; neonatal infection risk was similar: 3.2% to 3.6%. – Note: Trials with double balloon catheters and outpatient cervical ripening were not included in this study (McMaster et al., 2015). 2017 \| Prospective Randomized Controlled Trial \| St. Louis, Missouri Study question: Does tension on a transcervical balloon for cervical ripening result in a faster time to birth? Findings: Tension resulted in a faster time to balloon expulsion but not a faster time to birth. – 140 women included; Bishop scores were 6 or less when cervical ripening started; 67 women in tension group and 73 women in the no tension group. – Procedure: Balloon catheters were placed then taped to tension. After placement, low dose Pitocin was started and increased to a maximum rate of 6 milliunits/minute) while balloon was in place. Every 30 minutes, tension was reapplied. – Time to birth was similar in both groups (16.2 hours in tension group and 16.9 hours in no tension group); time to expulsion was higher in the tension group (2.6 hours) versus the no tension group (4.6 hours). – Vaginal birth rates within 24 hours were about the same (79% in the tension group and 71% in the no tension group) and cesarean rates were also about the same (25% in the tension group and 37% in the no tension group) (Fruhman et al., 2017). (Jamie’s note: Cesarean rates vary widely across the United States and should be interpreted carefully; to understand how your provider or practice compares to research, you need to ask what the primary cesarean rate is at your place of birth.)
Benefits	– Does not require continuous electronic fetal monitoring after initial placement unless fetal monitoring is otherwise indicated. – Foley catheters do not increase risk of infection. – Available as outpatient option: Providers can place balloons in the office or on labor and delivery allowing women to complete outpatient ripening at home for the first 12 hours of induction if low-risk/provider supported. One randomized controlled trial noted a 9.6 hours reduction in hospital stay with outpatient foley catheters are used for cervical ripening. (ACOG, 2009) – Beneficial for women where hyperstimulation is a concern or where prostaglandins are not recommended (TOLAC and fetal growth restriction). – Easily removed by nurse or provider. – Simple mechanical method (no medication involved). – Low cost; no refrigeration required. – Balloons infused with 60-80cc likely shorten time from induction or birth by about 2 hours. – Balloons decrease the risk for a cesarean section (ACOG, 2009). (Jamie’s note: It’s okay if the balloons come out at home during outpatient ripening – that’s the whole point!)
Risks	In 2018, an adverse event report was filed with the FDA; a Cook balloon was used for cervical ripening and burst; the patient continue to have a normal labor after the event with no other maternal or neonatal issues noted (of note, the amount infused into the balloon was not included in the report.)
Cost	Foley catheters average $2-3 each; COOK double balloon catheters are $32 each

Dilapan-S

Source

Dilapan-S
What is this method?	Synthetic hydrogel rods that are placed in the cervix, absorb water from tissues, and expand to 2-3 times their size causes the cervix to open and soften.
History	FDA approved in 2015 for induction of labor; read the FDA approval here (Department of Health & Human Services & Food and Drug Administration, 2015). Available in 40 countries.
Evidence	2022 \| Randomized Controlled Trial \| England Study question: What is the efficacy, maternal/neonatal safety, and maternal satisfaction of Dilapan-S compared to dinoprostone? Findings: Induction of labor with Dilapan-S is associated with similar cesarean rates and maternal/neonatal outcomes as compared to dinoprostone. – 674 women were randomized to either Dilapan-S (n=337) and dinoprostone (n=337). Of note, planned sample size was 860 women but the trial met restrictions secondary to the COVID-19 pandemic. – Up to 5 Dilapan-S rods were placed for cervical ripening; dinoprostone pessaries were left in place from 24-32 hours depending on hospital protocol. – Researchers reported that more dinoprostone inserts fell out and had to be reinserted than Dilapan-S rods; dinoprostone was removed in 63 women because of tachysystole, uterine hyperstimulation with non-reassuring fetal heart rates or abnormal heart rate changes compared to only 19 women that required removal of their Dilapan-S rods. – Primary outcome was if a vaginal birth was not achieved and a cesarean section was required: 37.4% of the Dilapan-S and 34.3% of the dinoprostone groups required cesarean sections. – Only 51.2% of women required pain management in the Dilapan-S group compared to the dinoprostone group (66.3% required pain management) (Gupta et al., 2022). 2019 \| Randomized Controlled Trial Study question: Is Dilapan-S inferior to the foley balloon for preinduction cervical ripening at term? Findings: Dilapan-S was not inferior to foley balloon for cervical induction and may be preferred by patients over a foley balloon for sleep, ability to relax and ability to perform other activities during the cervical ripening. – 419 women, > 37 weeks with unfavorable cervix (<3 centimeters dilated or < 60% effaced) were randomized to either foley balloon (n=209) or Dilapan-S (n=210). Foley balloons were inflated to 60cc. Both groups received their intervention for 12 hours. – Vaginal delivery was slightly more common in Dilapan-S group vs foley balloons (81.3% vs 76.1%); statistical difference was not enough to show that Dilapan-S is better/superior to foley balloons. – No difference noted in any maternal or fetal adverse outcomes (Saad et al., 2019). *Research to watch… 2023 \| Randomized trial to compare outpatient induction between PGE2 to dilapan-S – This study aims to examine if Dilapan-S rods (both 12 and 24 hour rods) are comparable to PGE2 (Propress 10mg dinoprostone vaginal pessary) for outpatient induction of labor for nulliparous women at 39 weeks of pregnancy.
Benefits	– Can be used outpatient for induction of labor. – Can remain in cervix for 12-24 hours. – Option to place in the clinic or on labor and delivery unit. – Does not require continuous fetal monitoring, tension to leg, or protrusion from introitus (vaginal opening). – May have higher patient satisfaction than foley balloons. – FDA approved for induction of labor.
Risks	– Device entrapment or breaking. – Expulsion out of cervix or vagina. – Discomfort or bleeding. – Rupture of membranes. – Cervical laceration (Dilapan-S, 2023).
Cost	$80/rod; average use is 3-5 rods ($240-400)
Additional information	Learn more at manufacturer’s website: Dilapan-S Cervical Dilator.

Medicinal methods

Dinoprostone (Cervidil or Prepidil)

Source

DINOPROSTONE (Cervidil or Prepidil)
What is this method?	CERVIDIL – Cervidil is a medication called a prostaglandin (PGE2). – Cervidil is packaged as an insert, or pessary, that is placed in the posterior fornix (the back of the vagina) by a provider or nurse for cervical ripening during induction of labor. – It measures approximately 1×3 cm (centimeters) and is a hydrogel chip that releases medication at 0.3mg over 12 hours. – After the insert is placed in the vagina, the insert is left in place for 12 hours; after 12 hours, the insert is removed and thrown away. PREPIDIL – Prepidil is a medication called a prostaglandin (PGE2) and is manufactured by Pfizer. – Prepidil is a gel packaged in a syringe that is placed in the cervix by the provider; dose is repeated evert 6-12 hours for up to 3 doses.
History	CERVIDIL – Created in 1977; FDA approved in 1993 for induction of labor. – Popular because it can be placed by RN or provider. Requires continuous monitoring because of continued release of PGE2. PREPIDIL – FDA approved in 1992.
Evidence	2014 \| Cochrane Database Systematic Review Study question: What are the effects of vaginal prostaglandins (E2 and F2a) during third trimester cervical ripening or induction of labor compared to no treatment or placebo? Findings: PGE2 increase change of vaginal birth within 24 hours; uterine hyperstimulation with fetal heart rate changes were common but did not affect cesarean rates; cervical change is likely with PGE2 and no increase in operative birth rates were noted; all forms of PGE2 appear effective (tablets, gels or pessaries). – 11,487 women across 70 randomized controlled trials included. – Vaginal PGE2 probably increases the chance of a vaginal birth within 24 hours. – Uterine hyperstimulation with fetal heart rate changes is common: 4.8% versus 1.0%. – Vaginal PGE2 probably reduces the risk for a cesarean birth by about 10%. – Broad effects on maternal and neonatal outcomes remain uncertain (Thomas et al., 2014). 2011 \| Systematic Review and Meta-Analysis Study question: What is the safety and effectiveness of dinoprostone vaginal insert compared to repeated dinoprostone and misoprostol administration in pregnant women at term? Findings: Effective method for nulliparous women; increased risk of hyperstimulation noted; reduced risk for cesarean births in nulliparas; across all groups, reduced risk for needing additional oxytocin augmentation. – 911 women across 18 randomized controlled trials included. – Dinoprostone is an effective induction method in nulliparous women with an unripe cervix and performed better than repeated doses of vaginal Cytotec. – Authors noted a 2-fold increased risk for uterine hyperstimulation in nulliparas. – A reduced cesarean risk of 24% was noted in nulliparas. – Lastly, authors noted a 36% reduction in need for pitocin after the dinprostone was used (Facchinetti et al., 2011). 2017 \| Prospective Randomized Controlled Trial \| Istanbul Study question: Does early amniotomy after dinoprostone insert reduce the duration of labor and increase the rate of birth within 24 hours? Findings: Yes; early amniotomy after cervical ripening with a dinoprostone insert is a safe, efficient way to speed up time to birth without increasing cesarean rates during induction of labor. – 200 term pregnant women participated in trial and divided into two groups after receiving dinoprostone insert: early amniotomy or left to spontaneously rupture membranes on their own. – Women that underwent early amniotomy had a median time interval of 13.72 hours from induction to birth compared to the spontaneous rupture of membranes median time of 22.73 hours. – Vaginal birth was higher in the early amniotomy group (89%) versus the spontaneous rupture group (45%) (Bostanci et al., 2017). 1997 \| Prospective Randomized Study Study question: What is the efficacy and safety of PGE2 formulations – Prepidil and Cervidil – for cervical ripening and induction of labor? Findings: Both PGE2 are effective but the vaginal pessary (Cervidil) achieves cervical ripening over a shorter time, requires less oxytocin and likely less in cost. – The vaginal pessary (Cervidil) group resulted in a shorter time to vaginal birth (20.6 hours versus 26.4 hoours), shorter time to cervical ripening (11.1 versus 15.2 hours) and shorter time to achieve active labor (18.3 versus 25.5 hours) and less time in the hospital (3.7 versus 4.4 days) than the intracervical gel (Prepidil) (Chyu & Strassner, 1997). 1995 \| Randomized Controlled Trial Study question: What is the safety and efficacy of vaginal misoprostol compared to dinoprostone gel (PGE2) for cervical ripening during induction of labor? Findings: Vaginal misoprostol was more effective for cervical ripening but associated with more meconium and uterine tachysystole at the dose of 50 microgram vaginally every 3 hours than the dinoprostone gel. – 135 patient enrolled; 68 in the misoprostol group and 67 in the dinoprostone group. – The time from start of induction to birth was shorter in the misoprostol group (482 minutes vs 903 minutes). – Oxytocin augmentation occurred more often in the dinoprostone group. – There was no significant difference in mode of birth (14.7% of misoprostol patients and 19.4% of dinoprostone patients had cesarean births), abnormal fetal heart rate tracings, APGAR scores, neonatal resuscitations or admission to neonatal intensive care unit. – Meconium passage was noted in 27.9% of the misoprostol group versus 10.5% of the dinoprostone group (Wing et al., 1995).
Benefits	Cervidil – Easily removed in instances of fetal distress or uterine hyperstimulation. – Can be placed by nurse or provider depending on hospital policy. – May reduce cesarean rate in first time birthing women. – May reduce need for Pitocin later in induction of labor.
Risks/downsides	Cervidil/Prepidil – Must be refrigerated. – Expensive compared to other methods. – Not recommended for outpatient use (must stay in hospital for use). – Requires continuous fetal monitoring. – Cervidil FDA insert from clinical trials reported a 2% risk of fetal distress; 4.7% risk of uterine hyperstimulation without fetal distress; 3.8% risk of fetal distress (Ferring Pharmaceuticals & Gassman, 2020).
Cost	– Cervidil: $297.47-$456.99/per insert – Prepidil: $356.17-$569.37/packet
Additional information	– Prepidil FDA insert: Read here.

Misoprostol (Cytotec)

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MISOPROSTOL (Cytotec)
What is this method?	– Misoprostol is a medication called Prostaglandin (PGE1); misoprostol is a pill that is taken by mouth (either as a pill or a part of a pill or mixed in an oral solution), placed in cheek (buccal)/under tongue (sublingual), or placed in the vagina to soften/thin cervix and start contractions; pill doses vary from 25-100 micrograms based on route and facility. – Dose is repeated every 4 hours until regular contractions are established. Oral solution route is not common in the United States.
History	– Misoprostol was created in the 1970s as a mediation for gastric ulcers/peptic ulcer disease. – FDA approved a new label in 2002 to use misoprostol for cervical ripening and for induction of labor but the label does not review efficacy, doses, safety or dose frequency.
Evidence	BUCCAL OR SUBLINGUAL MISOPROSTOL VS ORAL MISOPROSTOL 2004 \| Cochrane Database Systematic Review Study question: What is the effectiveness and safety of misoprostol administered via buccal or sublingual in the third trimester for cervical ripening? Findings: Sublingual misoprostol appears to be at least as effective as when the same dose is administered orally. – 3 studies with 502 participants compared 200 micrograms of misoprostol given the buccal/sublingual route to 50 micrograms misoprostol given vaginally and 50 micrograms of misoprostol given the buccal/sublingual route to 50 or 100 micrograms misoprostol given orally (by mouth). Authors found that the misoprostol given via the buccal route was associated with a 30% reduction in cesarean rate when compared to misoprostol given the vaginal route. – Researchers noted that the same dose of misoprostol was used sublingually as orally, there was a 37% increased chance of a vaginal birth within 24 hours, a 26% reduction in need for oxytocin use, and a 47% reduction in cesarean section, but these were not statistically significant (Muzonzini & Hofmeyr, 2004). ORAL MISOPROSTOL VS VAGINAL MISOPROSTOL 2023 \| Cluster Randomized Controlled Trial Study question: Which is more effective at achieving a vaginal delivery: standard dose of vaginal misoprostol or oral misoprostol? Findings: No difference in timing to vaginal delivery BUT vaginal misoprotol was associated with a lower likelihood of needing any oxytocin (68.8% vs 78.4%). -1,322 women randomized to vaginal misoprostol – 1,224 women randomized to oral misoprostol – Tachysystole occurred less often with vaginal compared to oral groups (3.5% vs 5.9%). – Time to delivery did not differ between groups. – Oxytocin was required less frequently before delivery in vaginal misoprostol group (68.8% vs 78.4%) (Adhikari et al., 2023). 2014 \| Cochrane Database Systematic Review Study question: What is the use of oral misoprostol for labour induction? Findings: Oral misoprostol is an effective induction agent to achieve a vaginal birth; oral misoprostol is as effective as vaginal misoprostol and results in fewer cesarean sections than vaginal dinoprostone (Cervicil) or oxytocin. – 76 trials with 14,412 women included. – In 9 trials with 1,109 women comparing oral misoprostol to a placebo, women given oral misoprostol were 58% less likely to need oxytocin and had a 28% lower cesarean rate. – In 12 trials with 3,859 women comparing oral misoprostol to vaginal dinoprostone, women given oral misoprostol were 12% less likely to need a cesarean section; some studies showed that induction of labor may be slower with oral misoprostol versus dinoprostone. – In 9 trials with 1,282 women comparing oral misoprostol to oxytocin, women given oral misoprostol had a 23% lower rate of cesarean section but a 1.6 fold increased risk of meconium fluid when compared to oxytocin. – 37 trials with 6,417 women comparing oral and vaginal misoprostol and found no difference between the primary maternal or neonatal outcomes. Researchers did not that in the oral misoprostol group, babies were 40% less likely to have a low APGAR score and a 43% decrease in postpartum hemorrhage compared to vaginal misoprostol (Alfirevic et al., 2014). SUBLINGUAL MISOPROSTOL VS VAGINAL MISOPROSTOL 2008 \| Systematic Review Study question: What is the safety and efficacy of sublingual administration of misoprostol compared to vaginal misoprostol in the third trimester of pregnancy for an induction of labor? Findings: No significant difference was found between sublingual and vaginal routes in regard to number of vaginal births achieved in 24 hours or cesarean birth. An increased risk of uterine hyperstimulation (1.7 time greater risk) was noted in the sublingual group compared to the vaginal group (Souza et al., 2008). VAGINAL MISOPROSTOL VS PITOCIN, CERVIDIL, OR PREPIDIL 2010 \| Systematic Review Cochrane Database Study question: What is the effect of vaginal misoprostol for third trimester cervical ripening or induction of labor? Findings: Vaginal misoprostol results in a higher rate of vaginal birth within 24 hours and less epidural use compared to CerviDil (dinoprostone), Prepidil or Pitocin, but causes more uterine hyperstimulation. Compared to PGE2 (Cervidil or Prepidil), vaginal misoprostol was associated with less use of Pitocin (oxytocin) but more meconium staining. – 121 trials included but only 13 trials were double-blinded (a higher quality of research) – Compared to placebo, use of misoprostol was associated with a 51% reduced risk of not achieving a vaginal birth in 24 hours (Jamie’s note: this means that it was 49% more likely you would have a vaginal birth within the next 24 hours after using misoprostol instead of the placebo) and a 3.5 times higher rate of uterine hyperstimulation without fetal heart rate changes. – Compared with Cervidil (vaginal PGE2), Prepidil (intracervical PGE2) and Pitocin (oxytocin), vaginal misoprostol was associated with less epidural use and higher chance of vaginal birth within 24 hours but more uterine hyperstimulation. – Compared with Cervidil (vaginal PGE2) and Prepidil (intracervical PGE2), vaginal misoprostol was associated with less use of Pitocin (oxytocin) but more meconium staining. – Authors did note that lower doses of vaginal misoprostol were associated with less uterine hyperstimulation and a dose of 25 micrograms of vaginal misoprostol is similar to other methods in effectiveness and risks (Hofmeyr et al., 2010). VAGINAL MISOPROSTOL VS BUCCAL MISOPROSTOL 2020 \| Randomized Controlled Trial – Triple Masked (IMPROVE trial) Study question: What is the safety and efficacy of vaginal and buccal misoprostol for women undergoing induction of labor at term? Findings: Evidence was unable to point to one method as superior to the other – but vaginal misoprostol may lead to a higher rate of vaginal birth, faster vaginal birth, and fewer cesarean births for fetal concerns than buccal misoprostol. – 319 women enrolled \| 152 women in the vaginal misoprostol group and 148 in the buccal misoprostol group. – Initial dosing was started at 25 micrograms of misoprostol for both vaginal and buccal routes and increased to 50 micrograms for subsequent dosing if needed, up to 7 doses. – Time to delivery was less in the vaginal misoprostol group: 20.1 hours vs 28.1 hours. – Cesarean birth for fetal nonreassurance was higher in the buccal misoprostol group: 9.5% vs 3.3%. Overall cesarean rates were 15.8% (vaginal misoprostol) vs 22.3% (buccal misoprostol). – Postpartum hemorrhage rates (5.3% (vaginal vs 4.0% buccal), need for oxytocin (65.% vaginal vs 75% buccal) and need for blood transfusion (0.6% vaginal vs 0.7% buccal) were similar in both groups (Haas et al., 2019). *(Jamie’s note: I was curious what number of misoprostol doses were needed to achieve induction because misoprostol can be repeated up to 6-7 times to achieve cervical ripening; the authors only reported the doses of misoprostol need to get into active labor which doesn’t offer information on how many doses were needed to achieve cervical ripening; for active labor, the authors reported an average of 2.0 doses for vaginal misoprostol and 3.0 doses for buccal misoprostol to induce active labor. The authors also reported that the reason for stopping misoprostol was for onset of active labor (vaginal 4.6% vs buccal 6.8%), sufficient cervical ripening (vaginal 39.5% vs buccal 29.1%), safety concerns (vaginal 30.9% vs buccal 23%), multiple reasons (vaginal 20.4% vs buccal 25.7%) and other (if interested, review the table here). This data set is also somewhat unclear because a significant part of stopping misoprostol (55.9% of vaginal misoprostol group and 64.2% of the buccal misoprostol group) was due to safety concerns, multiple reasons or other; such larges percentages are hard to apply to specific populations.)
Benefits	– Low cost. – All routes effective at ripening cervix and starting contractions. – Superior to Cervidil (dinoprostone) in regards to a shorter induction of labor with less hyperstimulation and lower rates of meconium stained fluid (Carlson et al., 2021). – Does not increase risk for cesarean section. – Does not require refrigeration. – Can be placed by nurse or provider depending on hospital policy.
Risks	– *Not for women with a prior c-section (risk of uterine rupture is approx 10%). – May cause uterine hyperstimulation but evidence is limited on the doses and routes that cause hyperstimulation (in most evidence, Cervidil causes more hyperstimulation than Cytotec). – Cannot remove medicine once given/absorbed. – If vaginal route used, will require a vaginal exam for each dose (alternative routes are oral or buccal/sublingual). – May increase risk of meconium-stained amniotic fluid (ACOG, 2009).
Cost	$0.66 to $2 per 100 microgram pill
Additional information	FDA insert: Read it here.

Oxytocin (Pitocin)

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OXYTOCIN (Pitocin)
What is this method?	Oxytocin is an oligopeptide hormone. The hormone is created in the hypothalamus and stored in the posterior pituitary. It is a positive feedback hormone – release of oxytocin leads to more release of oxytocin. Oxytocin causes contractions in the muscle of the uterus by increasing the calcium level of the muscle cells. When oxytocin is released, the uterus contracts; then more oxytocin is released, which causes the uterus to keep contracting until birth is completed (Osilla & Sharma, 2023). The uterus responds to oxytocin within 3-5 minutes and a steady state of the drug is present in the bloodstream after about 40 minutes (ACOG, 2009).
History	FDA approved for labor induction/augmentation with a medical indication for induction of labor and during the third stage of birth (the birth of the placenta) to prevent hemorrhage and control postpartum bleeding, but not approved for elective induction of labor (Food and Drug Administration, 2023). The FDA offers this notice in Oxytocin’s FDA label: “Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction. Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin is not indicated for elective induction of labor” (Food and Drug Administration, 2023, p.1).
Evidence	2009 \| Cochrane Database Systematic Review Study question: What are the effects of oxytocin alone for third trimester cervical ripening and induction of labor compared to other methods of induction? Findings: When compared to intravaginal or intracervical PGE2, prostaglandins increase the chance of a vaginal birth within 24 hours; oxytocin may increase the number of interventions in labor. – 61 trials included with 12,819 women. – When compared with expectant management, women given oxytocin were more likely to have birthed in 24 hours than those managed expectantly (91.6% vs 46.2%). Women who received oxytocin were 1.1 times more likely to choose an epidural. – Oxytocin was more likely to not result in a birth within 24 hours compared to vaginal prostaglandins (70% of the oxytocin group was still pregnant at 24 hours compared to only 21% of the vaginal prostaglandin group). Again, women given oxytocin were 1.09 times more likely to request an epidural compared to the vaginal prostaglandin group. – Compared to intracervical prostaglandins, women given oxytocin were 1.47 times more likely to be pregnant 24 hours after the start of induction (50.4% vs 34.6%) and 1.37 times more likely to have a cesarean section (19.1% vs 13.7%) (Alfirevic et al., 2009). *There is limited evidence comparing oxytocin alone to other methods for induction of labor in research; additionally, in women with premature rupture of membranes, oxytocin is often used instead of vaginal prostaglandins for augmentation of labor because other routes of prostaglandins (oral, buccal or sublingual) are not well studied (Carlson et al., 2021). In a 2018 study by Pimentel el al. that evaluated effectiveness of vaginal misoprostol, a woman’s Bishop score and risk for a cesarean birth were inversely related. Researchers noted specifically that a Bishop score of less 4 was related to a 0.47 increased risk of cesarean section (Carlson et al., 2021).
Benefits	– Offers an option to induce labor in women with a prior cesarean birth desiring a vaginal birth where prostaglandins are not recommended.
Risks	– Main risks are uterine tachysystole, fetal heart rate decelerations and a Category 2 or 3 fetal heart rate tracing (ACOG, 2009; Carlson et al., 2021). – Requires hospitalization for induction use and continuous fetal monitoring. – Hospital policies vary on low dose or high dose regimens. – Water intoxication and uterine rupture secondary to oxytocin infusion are rare but noted in the literature (ACOG, 2009).
Cost	$67.53 per bag of 30 units/500mL (a 10 unit vial costs $28-$34)
Additional information	– FDA insert for oxytocin: Read it here. – The uterus doesn’t respond to oxytocin well before 20 weeks because oxytocin receptors are not as sensitive. Between 20 to 30 weeks of gestation, the receptors become more responsive until about 34 weeks; receptors do not become sensitive again until term gestation (ACOG, 2009).

Combination Methods

Over the decades, providers and researchers combined different methods to see which were more effective when paired together. This table offers the evidence about combination pairings.

Combination Methods
Cervical balloon with vaginal misoprostol	2020 \| Systematic Review Study question: What are the effects of misoprostol combined with a cervical single or double-balloon catheter versus misoprostol alone for labor induction? – Findings: Combined use of misoprostol and a cervical balloon catheter reduces the intervention to birth time and the number of NICU admissions in women induced with an unfavorable cervix. – 15 randomized controlled trials included; combined induction interventions with misoprostol and cervical balloon resulted in 2 hours less from induction to birth, a 61% reduction in uterine hyperstimulation and a 25% reduction in NICU admission. There was no difference in cesarean sections, chorioamnionitis, birthweights or APGAR scores (Ornat et al., 2020). 2021 \| Randomized Controlled Trial Study question: What is the difference in time to delivery between buccal and vaginal administration of misoprostol along with a foley catheter for induction of labor? Findings: Vaginal misoprostol is superior to buccal misoprostol and resulted in twice the likelihood of an earlier birth and no difference in cesarean birth. – 215 women were put into two groups: 108 in the buccal misoprostol group and 107 in the vaginal misoprostol group. – The vaginal misoprostol group achieved a faster time to birth: 19.7 hours versus 24.1 hours. – 65% of the vaginal misoprostol group versus 49% of the buccal misoprostol group achieved a vaginal birth within 24 hours (Gomez et al., 2021). 2016 \| Randomized Controlled Trial Study question: What is the effectiveness of four commonly used methods for induction. Findings: Misoprostol with foley bulb resulted in twice the chance of birth before either misoprostol alone or oxytocin alone. – 997 women were placed in one of 4 groups: misoprostol only (25 micrograms per vagina every 3 hours); cervical foley balloon infused with 60cc of saline; misoprostol AND cervical foley balloon; and oxytocin AND cervical foley balloon. – The fastest median times to birth were: misoprostol–foley (13.1 hours), foley–oxytocin (14.5 hours), misoprostol alone (17.6 hours), and foley alone (17.7 hours) (Levine et al., 2016). 2013 \| Randomized Controlled Trial Study question: Does a foley bulb plus vaginal misoprostol result in a shorter induction to delivery than vaginal misoprostol alone? Findings: A combination method with foley bulb with vaginal misoprostol resulted in a shorter labor than vaginal misoprostol alone; no difference in labor complications were noted. – 123 women undergoing induction of labor were put into two groups: 56 women in the foley bulb with vaginal misoprostol group and 61 women in the vaginal misoprostol group. – Induction to delivery time was shorter in the foley bulb with vaginal misoprostol (average 15.3 hours) versus the vaginal misoprostol group alone (average 18.3 hours). – Induction to complete cervical dilation time was shorter in the foley bulb with vaginal misoprostol (average 13.7hours) versus the vaginal misoprostol group alone (average 17.1 hours) (Carbone et al., 2013).
Cervical balloon with oral misoprostol	2011 \| Prospective Randomized Controlled Trial Study question: What is the effectiveness of combination oral misoprostol and mechanical dilation to improve the efficiency of induction of labor? Findings: Combination oral misoprostol and double balloon catheter improves the efficiency of induction of labor in term pregnancies without premature rupture of membranes. – 122 women with term pregnancies with planned induction of labor included in the study. – Primary outcome was a failure to birth vaginally within 48 hours. – Median time for induction with combination oral misoprostol and double balloon catheter was 15.8 hours versus 32.6 hours in the control group (oral misoprostol only). Researchers did not include women who had premature rupture of membranes during their induction. – Rate of failure in the combination group was 10.8% vs.28.2% in the oral misoprostol group (Kehl et al., 2011).
Cervical balloon with oxytocin	2020 \| Meta-Analysis Study question: Do combination induction methods of foley and prostaglandins or foley and oxytocin decrease the time to vaginal delivery? Findings: When compared to foley alone, the use of oxytocin and foley reduced the time to vaginal birth by 4.2 hours without any difference in any maternal or fetal outcomes than foley alone for induction of labor (Orr et al., 2020).

Those tables covered the possible methods that may be used in an induction of labor with an outline of the history, evidence, risks, benefits and cost.

Let’s shift to the evidence on women that are getting inductions of labor and ask: What are the risks and the benefits to induction of labor?

What does the evidence say about induction of labor?

The most recent evidence is listed in the table first. Dr. Chapa always says medicine changes fast! This table may not reflect the latest evidence on induction of labor.

Year	Article	Findings	Clinical Application
2024	Induction of Labor and Cesarean Birth in Lower-Risk Nulliparous Women at Term: A Retrospective Cohort Study BIRTH: Issues in Prenatal Care (Butler et al., 2024)	Study question: Is induction of labor associated with cesarean birth and perinatal mortality in uncomplicated first time births compared to expectant management outside the confines of randomized controlled trials? Findings: Induction of labor in low risk, nuliparas (first time birth women) was associated with a higher cesarean birth risk at 38, 39, 40, 41 and 42 weeks of gestation when compared to expectant management. – Cohort study done in Victoria, Australia – From 2010 to 2018, 640,191 women included – Induction of labor compared to expectant management was associated with an increased risk for cesarean birth for all gestational ages – Medical inductions were not included in the study – Induction of labor at 38 weeks was 1.23 times more likely to result in a cesarean birth – Induction of labor at 39 weeks was 1.31 times more likely to result in a cesarean birth – Induction of labor at 40 weeks was 1.42 times more likely to result in a cesarean birth – Induction of labor at 41 weeks was 1.43 times more likely to result in a cesarean birth	Induction of labor at 38, 39, 40 and/or 41 weeks may increase risk for cesarean section in low risk nullipara women.
2023	Outcomes of Elective Induction of Labor at 39 Weeks from a Statewide Collaborative Quality Initiative American Journal of Perinatology (Langen et al., 2023)	Study question: What is the impact of adopting a practice of elective induction of labor at 39 weeks among nulliparous, term, singleton, vertex (NTSV) pregnancies in a statewide collaborative? – Cohort study (a lower quality of evidence) – 1,558 women underwent elective induction of labor versus 12,577 women that were expectantly managed. – Women in the elective induction of labor group were more likely to be > 35 years old (12.1% vs 5.3%), report white non-Hispanic as ethnicity (73.9% vs 66.8%) and have private insurance. – Women in the elective induction of labor group were more likely to have a cesarean birth than women that were expectantly managed (30.1% vs 23.6%), however, when cohorts were matched with a propensity score, the cesarean rates did not differ between the 2 groups (30.1% vs 30.7%). – Time from admission to birth was longer for the elective induction group (24 hours vs 16 hours). – Expectant managed women were less likely to have a postpartum hemorrhage (8.3% vs 10.1%) or operative birth (9.3% vs 11.4%). – Women who had an elective induction of labor were less likely to have a hypertensive disorder (5.5% vs 9.2%).	– Induction of labor is likely more time in the hospital than expectant management. – Cesarean rates may not be reduced with an elective induction of labor. – Postpartum hemorrhage and operative birth may be less likely with expectant management. – Hypertensive disorders may be less likely with an elective induction of labor at the end of pregnancy.
2023	Analysis of Obstetric Outcomes by Hospital Location, Volume, and Teaching Status Associated with Non-Medically Indicated Induction of Labor at 39 Weeks JAMA Network Open (Hersh et al., 2023)	Study question: Do obstetric outcomes of nulliparous women with low-risk pregnancies managed with non–medically indicated induction of labor at 39 weeks’ gestation compared with expectant management differ among hospitals by location, obstetric volume, and teaching status? – Cohort study (a lower quality of evidence) – 455,044 births analyzed – Odds of cesarean birth were lower across all locations, volume and teaching status except for low-volume hospitals – in low volume hospital, there was no significant difference in cesarean birth odds. – Postpartum hemorrhage and chorioamnionitis rates were lower in elective inductions across all settings.	– Non-medically indicated induction of labor may be associated with lower rates of cesarean birth across a multitude of hospital settings.
2023	Comparison of Maternal Labor-Related Complications and Neonatal Outcomes Following Elective Induction of Labor at 39 Weeks of Gestation vs Expectant Management: A Systematic Review and Meta-analysis JAMA Network Open (Hong et al., 2023)	Study question: What maternal labor-related and neonatal outcomes are experienced following elective induction of labor at 39 weeks of gestation compared with expectant management? – Systematic review and meta-analysis – 1,625,899 million participants in study – Maternal outcomes included: emergency cesarean section, perineal injury, postpartum hemorrhage, and operative vaginal birth. – Neonatal outcomes included: admission to NICU, low 5-minute APGAR score, macrosomia and shoulder dystocia. – Induction of labor was associated with a 37% reduction in likelihood of 3^rd or 4^th degree perineal tear, a 13% reduction in operative birth, a 34% reduction in macrosomia (a baby weighing more than 4000 grams at birth), and a 38% reduction in likelihood of a low 5-minute APGAR score. – In multiparous women only, a 39% reduction in emergency cesarean section was noted. – In nulliparous women only, shoulder dystocia was 1.2 times more likely.	– Perineal tearing, operative birth, macrosomic babies and low 5-minute APGAR scores are all likely lower with elective induction of labor. – In first time birthing women, shoulder dystocia was more common. – In second time birthing women, a moderate reduction in emergency cesarean section was noted.
2022	Elective Induction of Labour at 39 Weeks Compared with Expectant Management in Nulliparous Persons Delivering in a Community Hospital Journal of Obstetrics and Gynaecology Canada (Burrows et al., 2022)	Study question: What is the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies? – Retrospective study of pregnant women that birthed at Brockville General Hospital between 2018 and 2021 – 174 patients included – 56 patient underwent elective induction of labor (32.2%) and 118 (67.8%) were expectantly managed. – Those patients in the elective induction group had a 61% reduced risk of cesarean birth compared to the expectant management group; the elective induction of labor group also demonstrated better maternal and neonatal composite scores.	Elective induction may be associated with a lower risk of cesarean section.
2020	Elective Labor Induction at 39 Weeks Compared with Expectant Management: Factors Associated with Adverse Outcomes in Low-Risk Nulliparous Women Obstetrics & Gynecology (El-Sayed et al., 2020)	Study question: What characteristic adverse outcomes are associated with low-risk nulliparous women randomized to elective labor induction or expectant management? – 5,007 women included. – Adverse outcomes included: perinatal death or severe neonatal complications, 3^rd or 4^th degree lacerations and postpartum hemorrhage. – Elective induction of labor was associated with a 30% lower rate of adverse outcomes; however, as body mass increased, a 4% increased risk in adverse outcomes was associated with each increase in body mass index point. – Increased body mass index was associated with a 4% reduction in 3^rd or 4^th degree tears; lower rates of 3^rd and 4^th degree tears were also noted in black women versus white women (1.2% vs 3.9%). – Hispanic women had a higher risk of postpartum hemorrhage compared to white women (6.3% vs 4.0%).	Elective induction may be associated with certain groups of adverse outcomes in women or babies. Body mass index may play an important role in risk reduction or increased risk for induction of labor.
2020	Induction of Labour at or Beyond 37 Weeks’ Gestation Cochrane Database of Systematic Reviews (Middleton et al., 2020)	Study question: What is the effect of a policy of labour induction at or beyond 37 weeks’ gestation compared to a policy of awaiting spontaneous labour indefinitely? – 34 RCTs with approx 21,500 mainly low-risk women in 16 countries; researchers looked at inducing labor at 41 weeks versus waiting until labor occurred after 41 weeks gestational age – Inducing labor at 41 weeks versus waiting for spontaneous labor was associated with fewer perinatal deaths: 4 infant deaths occurred out of 18,795 infants in the 41 week induction group versus 25 infant deaths in the expectant management group. – Women in the induction of labor group were less likely to have a C-section; there was little or no difference in the rate of operative birth between the groups. – Fewer babies were admitted to the NICU in the induction group and APGAR scores were slightly better in the induction group. – Induction seems to have made little difference in perineal trauma; breastfeeding rates; or postpartum hemorrhage. Difference between groups and length of hospital stay was unclear in the studies.	Induction at 41 weeks versus waiting for labor is associated with a lower rate of infant death, C-section, NICU admission and a better APGAR score.
2019	Elective Induction of Labor at 39 Weeks Compared with Expectant Management: A Meta-analysis of Cohort Studies American Journal of Obstetrics & Gynecology (Grobman & Caughey, 2019)	Study objective: To perform a systematic review of observational studies that elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analysis to estimate the association of elective induction with cesarean delivery. – 6 cohort studies included; 66,019 women undergoing elective labor induction and 584,390 undergoing expectant management. – Elective induction of labor was associated with a lower frequency of cesarean section (26.4% vs 29.1%) and lower risks for neonatal outcomes (lower rates of respiratory morbidity, meconium aspiration syndrome, and NICU admission)	Elective induction of labor may be associated with a lower rate of cesarean section and may be associated with less respiratory issues or NICU admission for infants.
2019	Induction of Labour at 41 Weeks Versus Expectant Management Until 42 Weeks (INDEX): Multicentre, Randomised Non-Inferiority Trial British Medical Journal (Keulen et al., 2019)	Study question: What is the difference between induction of labor at 41 weeks versus expectant management until 42 weeks in low risk women? – 1810 women included across 123 midwifery practices and 45 hospitals in the Netherlands. – Primary outcome composite included: APGAR < 7.05, APGAR score <7 at 5 minutes, meconium aspiration syndrome, plexus brachialis injury, intracranial hemorrhage, and admission to a NICU. – The induction of labor group had a lower composite score than the expectant management group: 1.7% (15/900) vs 3.1% (28/901).	Induction of labor at 41 weeks versus expectant management to 42 weeks may be associated with fewer infant outcomes.
2018	Induction of Labour for improving Birth Outcomes for Women at or Beyond Term Cochrane Database of Systematic Reviews (Middleton et al., 2018)	Study question: What are the effects of a policy of labour induction at or beyond term compared to waiting for spontaneous labor on pregnancy outcomes for the mother and infant? – 30 RCTs* with 12,479 women; trials took place in Norway, China, Thailand, the USA, Austria, Turkey, Canada, UK, India, Tunisia, Finland, Spain, Sweden and the Netherlands. – Compared with expectant management, induction of labor was associated with 67% lower risk of perinatal death (RR 0.33); there were 2 perinatal deaths in the induction group and 16 perinatal deaths in the expectant management group. – There were fewer stillbirths in the induction of labor group versus the expectant management group (1 vs. 10, respectively). – C-section risk was 8% less likely in the induction group versus the expectant management group. – Operative birth was slightly higher in the induction of labor group. Rates of admission to NICU were 12% lower and APGAR scores were slightly better in the induction of labor group. There was no difference in postpartum hemorrhage, perineal trauma or length of stay in the hospital.	Induction of labor was associated with a lower risk of perinatal death (the baby passing away) or stillbirth, a slightly lower risk of C-section for women with an induction of labor and a slightly higher rate of operative delivery (use of forceps or vacuum). The authors note that 426 women would need to be induced to prevent 1 infant death (this is referred to as NNT**).
2018	Labor Induction versus Expectant Management in Low-Risk Nulliparous Women The New England Journal of Medicine (Grobman et al., 2018)	Study question: What are the perinatal and maternal consequences of induction of labor about low-risk nulliparous women? – 3,062 women included. – Randomized controlled trial. – The trial randomly assigned women into two groups between 38w0d and 38w6d: induction of labor between 39w04-39w4d or expectant management (waiting for spontaneous labor). – The induction group had a slightly lower rate of C-section (18.6% vs 22.2%) and a lower risk of hypertensive disorders (9.1% vs 14.1%).	Elective induction of labor may reduce the risk of cesarean section and hypertensive disorders of pregnancies versus expectant management.
2018	Elective Induction of Labor at 39 Weeks Among Nulliparous Women: The Impact on maternal and Neonatal Risk PLOS One (Sinkey et al., 2018)	Study question: What is the optimal management of pregnancies at 39 weeks? – Data analysis. – 233,736 women included. – 2 groups: elective induction of labor at 39 weeks or expectant management. – Cesarean rates were higher in the expectant management (35.9% vs 13.9%); even in patients with an unfavorable cervix, cesarean rates were lower in the elective induction of labor group: 8.0% vs 26.1%. – There was no statistical difference in maternal mortality. – There were more stillbirths (0.13% vs 0%), neonatal deaths (0.25% vs 0.12%) and neonatal morbidity (12.1% vs 9.4%) in the expectant management group.	Elective induction may be associated with a lower rate of cesarean birth – even in an unfavorable cervix and lower rates of stillbirth, neonatal death or neonatal morbidity.
2018	Maternal and Perinatal Outcomes After Elective Induction of Labor at 39 Weeks in Uncomplicated Singleton Pregnancy: A Meta-analysis Ultrasound in Obstetrics & Gynecology (Sotiriadis et al., 2018)	Study question: What is the available evidence on elective induction of labor at 39 weeks on the risk of cesarean section and on maternal or perinatal outcomes? – Meta-analysis included 5 studies with 7,261 women. – Induction of labor was associated with a 14% reduction in cesarean risk, 35% reduction in hypertensive disorders of pregnancy, and a 27% reduction in neonatal respiratory support.	Elective induction may be associated with a lower risk of cesarean section, hypertensive disorders of pregnancy and neonatal respiratory support.
2016	Caesarean Section Rates and Adverse Neonatal Outcomes After Induction of Labour Versus Expectant Management in Women with An Unripe Cervix: A Secondary Analysis of the HYPITAT and DIGITAT Trials. British Journal of Obstetrics & Gynecology (Bernardes et al., 2016)	Study question: What are cesarean section rates and adverse outcomes after induction of labor or expectant management in women with an unripe cervix at/near term? – 1,172 women included; 572 had an induction of labor and 600 had expectant management – No significant difference in cesarean rates noted between groups or when women had a Bishop score between 3-6. – Arterial umbilical cord gas values in the infant were better in the induction group, but the authors noted that 32 inductions would need to occur to avoid 1 low cord gas.	Induction of labor does not appear to increase cesarean section risk – even when a Bishop score is low (unripe).

This table summarized the evidence on induction of labor. Now, let’s take what we learned about the methods and the evidence in this table and review some real-world questions about induction of labor. These questions are meant to educate you about induction of labor and give you a guide to discuss induction of labor questions with your provider and team for your birth.

Frequently Asked Questions

What other questions should I ask about induction of labor?

Questions to ask yourself and your family before talking with your provider:

Why or why not would I want an induction of labor?
What induction of labor methods do I need to learn more about?
Are there any induction of labor methods that are not safe for me or my baby? Are there methods I do not want to try or use?
Is it important to me to be able to complete some of my induction of labor at home if it is safe for me and my baby. Is that something you offer or support?

Questions to guide your shared decision-making:

Why is an induction recommended for me?
What benefits does an induction of labor offer me and my baby?
What risks does an induction of labor pose to me and my baby?
What are my alternatives to an induction?

Other recommended questions:

How long can I expect my induction to take? What is the average number of hours for an induction for patients at your hospital?
How are inductions scheduled at the hospital? What if my induction is moved?
Is outpatient cervical ripening an option for me? How does that process work?
What is the C-section rate for inductions at your hospital for first time pregnant women and woman that have had a baby?
Can I eat and drink during my induction? Am I able to shower during my induction?
Will I need IV fluids my entire induction?
Do I need continuous fetal monitoring during my induction? Do you have wireless monitoring so that I am able to get up and walk around freely while monitoring the baby?
Are there birthing balls and peanut balls on your unit? What other interventions do you offer to support physiologic birth?
Am I able to shower, bath or use water for pain relief or hygiene during my induction?
Can I use a breast pump during my induction to help augment my labor?
Can I cancel my induction if I decide I no longer want to be induced or I go into labor beforehand?
Does your hospital honor AWHONN staffing recommendations? Current staffing guidelines recommend that a nurse should only have 1 laboring patient when that patient is on Pitocin (oxytocin).
Does an induction increase or decrease the length the number of days I will be in the hospital?
What if I end up needing a C/S? Does this mean I will always need a C/S?
I am planning on using a doula. When is the best time for them come?

When does spontaneous labor normally happen for women?

10% of babies are born preterm (< 37 weeks gestation).
12% of spontaneous labor happen between 37 to 38 weeks gestation.
Only 4% of babies are born on their due date!
For the remaining pregnant women at term, 80.5% of first time pregnant women will go into labor before 41 weeks, 0 days (Corbett et al., 2022).

How do I decide which method is best for me?

The short answer:

Decide together with your family and your provider. Everyone’s induction and journey look different.

The long answer:

As demonstrated by this post, there is a lot to consider when planning an induction of labor. Start with requesting a cervical exam (if desired) and calculating your Bishop score with your provider. The California Maternal Quality Collaborative recommends cervical ripening until a Bishop score = 6 or more for multiparous women (women who have had a birth before) and cervical ripening until a Bishop score = 8 for nulliparous (first time pregnant women) (Carlson et al., 2021). If your cervix is less than 6 or 8, plan for cervical ripening during your induction of labor.

Next, discuss which non-medicinal agents you have used (if any) or plan to use with your provider. For example, if you plan to use evening primrose oil the week before your planned induction, this will hopefully help to ripen your cervix.

Then, discuss any interventions to reduce the need for your induction of labor (as appropriate); most commonly, this is a membrane sweep or a membrane strip before the scheduled induction.

Lastly, review the options for cervical ripening (cervidil, prepidil, Cytotec, dilapan-S, cervical ripening balloons) that your provider and place of birth offer and which your provider recommends or are preferred by you. Review your provider’s thoughts on oxytocin and amniotomy (breaking the bag of water).

Share your thoughts, opinions, and concerns! Are there any interventions you want to avoid or prefer? This is the time to share,

Do the stages of labor still happen during an induction of labor?

Yes, but there are a few differences.

In a normal, spontaneous labor, the first stage of labor is from 0 to 10 centimeters dilation, however, the first stage of labor is more commonly divided into two stages: the latent and active stages. The latent stage begins when the uterus starts to contract AND the cervix is changing from those contractions. Generally, latent labor is defined as 0 centimeters, or closed, up to 6 centimeters dilation. At 6 centimeters dilated, the body moves into the active stage of labor; regular, strong contractions continue until the cervix is fully dilated to 10 centimeters.

During inductions, the timeline for the latent stage of labor takes much longer – sometimes days instead of hours. A woman may start her induction of labor at 2 centimeters dilated, but it may take 24-36 hours to get her cervix to open to 6 centimeters. The body takes a longer time because the interventions are forcing the cervix to soften and open while causing the uterus to contract at the same time.

Once the cervix is open to 6 centimeters and the uterus is regularly contracting, the woman’s labor progress generally speeds up considerably because the body is helping too!

Spontaneous active labor and induction of labor timelines are usually not comparable; this is one of the most important pieces of counseling about induction of labor.

What’s the difference between induction and augmentation?

Induction of labor is the process of using medications or mechanical methods to start contractions or ripen the cervix (the assumption is that the woman is NOT in labor before any interventions and that the interventions start the process of labor to promote birth).

Augmentation is the process of supplementing a labor process the body has already started. For example, a woman’s bag of water breaks and she is contracting irregularly; she chooses to augment, or make her contractions stronger, with Pitocin or Cytotec. You may also see this in a woman that presents in latent labor at 5 centimeters; after 6 hours, she is still 5 centimeters and a provider offers to augment her labor with an amniotomy; in this case, her body is contracting enough to open the cervix to 5 centimeters, but the augmentation offers a way to support the actions of labor the body is already attempting.

What percentage of women need cervical ripening during their induction of labor?

83-85% of women will need some type of cervical ripening during their induction of labor (McDonagh et al., 2021).

What can I do to make my induction of labor successful?

Educate yourself about induction of labor. Ask lots of questions and voice your concerns.
Do not hesitate to ask your provider what the practice’s cesarean rates are – this information helps you in two ways:
- While reading evidence and looking at other cesarean rates, you have a better understanding how where your provider compares. For example, if evidence cites that cesarean rates in trials for misoprostol were 32%, but your practice has a very low primary cesarean rate of 11%, then your provider is doing a very good job at induction management to prevent unnecessary cesarean sections. On the other hand, if your provider has a cesarean rate of 35%, this is higher than the average; discussions should take place on how best to lower your risk for a cesarean birth during an induction of labor.
If a medical induction of labor is recommended for you, understand the reasons behind the recommendation. Ask your provider to provide the guidelines, evidence, or recommendations for you to read and review (or review them yourself at the end of this post).
Do what you can to help start spontaneous labor in the weeks leading up to your birth; there is good evidence that these measures work to help reduce your need for an induction of labor:
- Use a midwife as a birth provider; evidence supports that women that birth with midwives have lower rates of induction and higher rates of spontaneous labor
- Walk for 30-40 minutes 3-4 times a week starting at 36 weeks until you go into labor
- Have regular intercourse starting at 36-37 weeks (evidence states that 2-3 times a week is adequate)
- Eating 5-6 dates daily starting at 36 weeks has been shown to reduce the need for induction
If you request an elective induction, learn about the methods for induction used at your hospital, your hospital’s policies about eating, drinking, ambulating, fetal monitoring, etc., the hospital’s primary cesarean section statistics and the scheduling process for elective induction of labor. An elective induction is not an emergency – there is plenty of time to review all information in the clinic. (Jamie’s note: Most often I find that different expectations about induction policies, interventions and length of induction are the reason for unhappy pregnant women and/or families during the induction process.)
Decide if you want a cervical exam in the days or weeks prior to your induction, and if so, discuss your Bishop score in detail with your provider and the best interventions to promote cervical ripening during your induction of labor.
Ensure that you and your provider choose interventions to ripen your cervix to the recommended Bishop scores:
- Nulliparas (women giving birth for the first time) should achieve a Bishop score of 8 before Pitocin is started.
- Primiparas or multiparas (women who have given birth before) should achieve a Bishop score of 6 before Pitocin is started (California Maternal Quality Care Collaborative, 2019).

What else do I need to consider about an induction of labor?

There are some things you can control and some things that you cannot control.

You can control what type of provider you choose to attend your birth (medical residents, OB/GYNs, certified nurse-midwives, certified midwives, or family practice providers). You can control whether you have a student care for you – if you don’t want a student, simply decline the student’s participation in your care. Medical residents are a little different; always ask for the attending physician on call if you are concerned about something in your plan of care.

You cannot control hospital and unit policies (the number of visitors, if you can eat or drink, if you need an IV). You cannot control the c-section rates of a hospital, but you can choose to birth at another place or with another provider. Regarding cesarean section rates, consider the rates reported in the research above and compare that to your hospital’s rates. If your hospital has a low cesarean rate (9-10%), then the research presented above may not be comparable to your hospital’s practices (9-10% is a very low cesarean rate and often means that your hospital’s providers are doing a great job compared to the national average for cesarean rates).

I want to schedule an induction of labor but I don’t want to have my cervix checked in the office before my induction of labor.

This is uncommon since most women want to have their cervix assessed in the office. In these instances, it is your choice whether someone can perform a cervical exam or not. If you decline a cervical exam until the time of admission for your induction, then I usually recommend an induction of labor is started at nighttime. It is easier to assume an unripe cervix that needs ripening than assume wrong and discover a cervix that isn’t ripe at 9am in the morning.

What do professional organizations say about induction of labor?

American College of Nurse-Midwives (ACNM)

Last updated in 2016, the college’s position statement endorses that spontaneous labor offers a substantial benefit for mothers and babies, that medical induction should be offered only when backed by evidence that benefits outweigh the risk for mother or baby, and that informed consent should include the normal process of labor and birth, the possible benefits and harms of induction and the optimum methods for induction of labor.

In 2022, the college published a free access Clinical Bulletin Number 18: Induction of Labor. The bulletin highlights that elective induction may offer some benefits to women, but emphasizes that induction of labor medicalizes the birth process. Additionally, induction may incite the cascade of interventions.

Position Statement: Induction of Labor (2016)
Clinical Bulletin Number 18: Induction of Labor (2022)

American College of Obstetricians & Gynecologists (ACOG)

This college has offered a practice bulletin on induction of labor for decades. The most current edition is: Practice Bulletin – Number 107: Induction of Labor (published in 2009 but reaffirmed in 2020). Unfortunately, you must be a member of the college to read the bulletin.

The college states that the goal of induction is to achieve a vaginal birth by stimulating the uterus to contract. Ideally, the bulletin states that induction of labor is a beneficial option when expeditious birth outweighs continuing a pregnancy while awaiting spontaneous labor. Women should be counseled on both the risks and benefits to each particular mother or baby’s situation and risk factors (ACOG, 2009).

After the ARRIVE trial was published in 2018, ACOG published this statement:

The college ends their clinical guidance from the ARRIVE trial with this statement: non-medically indicated early-term births are still not appropriate (early term is defined as 37 weeks 0 days to 38 weeks 6 days of gestation). In other words, induction of labor that is not medically indicated before 39 weeks 0 days is not recommended or endorsed by the college (ACOG, 2018).

Association of Women’s Health, Obstetric, & Neonatal Nurses (AWHONN)

This association does not endorse elective induction of labor before 39 weeks of gestation. Induction after 39 weeks’ gestation should be “carefully weighed against expectant management.” (Association of Women’s Health, Obstetric, and Neonatal Nurses [AWHONN], 2019, p.1).

Read more: Elective Induction of Labor

California Maternal Quality Care Collaborative (CMQCC)

Per the collaborative’s induction of labor algorithm: “Per ACOG guidelines, induction of labor before 41 weeks should only be performed if there is a maternal or fetal medical indication to do so. If 39-41 week without a medical indication for induction of labor, do so only with a favorable cervix” (CMQCC, 2019, p.1).

Read more: Appendix R – Induction of Labor Algorithm

March of Dimes

If pregnancy is healthy, March of Dimes recommends waiting for labor to start on its own. If a non-medical induction of labor is recommended, March of Dimes recommends waiting until 39 weeks for induction and to double check that the pregnancy is dated correctly before induction is started (March of Dimes, 2018).

Read more: Medical Reasons for Inducing Labor

What is the difference between outpatient and inpatient cervical ripening?

Inpatient cervical ripening means that you are admitted to the hospital and you do not leave during your induction of labor to go home (unless you are discharged home for an unripe cervix and rescheduled for another day).

Outpatient cervical ripening means that an intervention is performed to start your induction, but you spend the first 10-12 hours at home before presenting to the hospital for admission. This is an option for some women during induction of labor (low-risk, > 37 week pregnancies). Generally, hospitals and units have their own individual policies to guide outpatient cervical ripening (these are usually written by the medical directors and reflect the comfort level of the physicians, midwives, and nurses with the process).

Most outpatient ripening is done with cervical balloons, but some providers offer outpatient prostaglandins for cervical ripening.

The research comparing outpatient to inpatient ripening is of low quality but reports that outpatient cervical balloons may be associated with a 30% reduction in cesarean birth, a 55% reduction in uterine hyperstimulation and a 63% reduction in admission to the NICU. Maternal satisfaction in the studies was not well reported. On average, the reduction in number of hospital hours by spending some time at home with cervical ripening is 9.6 less hours overall (Alfirevic et al., 2020).

What are the prostaglandins everyone keeps talking about?

Prostaglandins are lipids produced by your body that have biochemical effects on different receptors in your body.

Prostaglandin receptors are located in the smooth muscle of the uterus. There are 4 types of prostaglandin receptors: EP1, EP2, EP3, and EP4 (EP = E prostanoid) (Pierce et al., 2018).

The four different receptors are important to distinguish because the medicinal methods work on different EP receptors (Pierce et al., 2018).

Cervidil (dinoprostone) works on all four EP receptors: EP1 and EP3 increase the contractility of the uterus while EP2 and EP4 help to relax the uterus (Pierce et al., 2018).

Cytotec (misoprostol) is a potent binder to the EP3 receptor and may activate some of the EP2 receptor. Because Cytotec binds in such a potent fashion, this may be a reason for the higher rates of uterine rupture or uterine hyperstimulation noted in some evidence (Pierce et al., 2018).

Source

What about women that have had a C-section and desire a vaginal birth (called a TOLAC or trial of labor after cesarean)?

Induction of labor is an option for many women after a cesarean section. Hospital and practice policies vary widely – some practices and hospitals are very supportive of TOLAC and some do not offer the option at all. Because uterine rupture risk is higher with prostaglandin use, only mechanical methods (cervical balloons, Dilapan-S, amniotomy) and oxytocin are offered as interventions for induction of labor (ACOG, 2019).

It’s also important to note that no randomized controlled trials comparing maternal and neonatal outcomes between women undergoing trial of labor after cesarean versus elective repeat cesarean exist – all evidence is based on observational studies (ACOG, 2019).

That being said, a successful vaginal birth after cesarean offers a number of benefits to women. Women who achieve a vaginal birth avoid a major abdominal surgery and the risks of hemorrhage, blood clots and infection associated with surgery; recovery is also shorter. Avoiding a repeat cesarean section also reduces the risks associated with multiple cesarean sections: hysterectomy, bowel/bladder injury, need for blood transfusion, infection, or an abnormal implantation of the placenta) (ACOG, 2019).

Most evidence reports that 60-80% of women that attempt a TOLAC are successful! There are many factors that go into an induction with a prior cesarean section and individual factors should be reviewed with your provider (ACOG, 2019).

What happens when none of the induction interventions are working and my body isn’t doing anything?

This is called a failed induction. Typically, this is when a woman never gets past 5 centimeters during the entire induction process despite prostaglandins, oxytocin and amniotomy. Details about the definition of failed induction of labor are below.

What is a failed induction of labor?

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine define failed induction as:

No cervical progression in the latent phase of labor
After oxytocin has been administered for 12-18 hours AND the membranes are ruptured (bag of water if broken)

Researchers found that when these guidelines were followed for 4,123 first time pregnant women (nulliparas), only 2% of the women met the criteria for failed induction of labor between 39 to 40 weeks (Carlson et al., 2021).

It’s also important to note that when women meet active labor and require a c-section, it is not called a failed induction, but instead described by the reasons for the c-section: arrest of dilation, arrest of descent, non-reassuring fetal heart rate, etc. (Carlson et al., 2021).

Some hospitals use an algorithm similar to this one published by the California Maternal Quality Care Collaboration (2016):

Which method(s) is the lowest cost for induction of labor?

This question has been studied multiple times. The two lowest cost induction methods individually and for the total cost of an induction of labor are oral misoprostol or foley catheters.

A misoprostol pill costs less than $1.00 (USD) and a foley catheter costs less than $3.00 (USD).

When comparing every costs during an induction (nursing care, IVF fluids, provider care, medicine/products used, etc.), oral misoprostol and foley catheter methods are about the same cost-wise ($4,440 versus $4,158*, respectively). If outpatient cervical ripening is completed, this has a cost savings of about $1,000 per induction of labor and makes foley catheters the lower cost of the two methods (ten Eikelder et al., 2017; *Euros converted to approximate dollars for comparison).

Some last thoughts from a certified nurse-midwife…

But first, if you’re planning an induction of labor, have you also planned for your postpartum period?

Planning for your postpartum period really does help. You should plan as much for your postpartum period as you plan for your birth or the baby’s nursery.

Cristi said: “These guides are insanely helpful. I’ve been deep diving into all the links you provide. And I love having something I can reference for future expectations. Thank you so much!”

After my first birth in 2016, I remember thinking:

“Gosh, my vagina is so sore and I’m 6 weeks postpartum! Sitting is still a little uncomfortable…Is this normal?”
“I feel like my baby is nursing all the time; I barely have time to pee, grab more water and a snack between nursing sessions.”
“I have never been so tired in my whole life.”

Then my second babe arrived and I experienced a whole new level of learning to balance postpartum needs:

“How do I go to Target with 2 small children? Where is the best place to park the car?”
“What do you do if both kids are crying at the same time?”
“How long does a baby nurse at night?” (My first baby slept through the night at 8 months…the second one took until he was 18 months old).

It took me until my third baby to really feel like I knew what I was doing. And then I thought, women need a better guide to help during postpartum healing. Not just a guide for right after a birth, but how to manage that entire first YEAR after birth.

That’s how The Phenomenal Postpartum Guides came to fruition. Your one-of-a-kind guide to your postpartum period. The 11 guides and 5 bonus resource guides offer an overview of each postpartum period, helpful shortcuts to make nursing, mothering and household care tasks easier, and encouragement and support for planned and unplanned rest stops along the way.

Your guides will cover postpartum education to help you prepare for the expected and unexpected, to develop a postpartum plan that serves you, your baby and your family and to help you find joy and peace so you can enjoy your postpartum period and not feel overwhelmed the entire first year after birth. Instead of feeling uninformed or thinking “I wish I knew that…”, you’ll feel confident, calm and ready to embrace the normal period of postpartum that occurs after the birth of a baby.

I put every tip, trick, great podcast episode or piece of wisdom I have picked up or learned as a mother, midwife of friend into this set of guides with the hope that they serve, prepare and educate YOU in all the ways I wasn’t prepared as a new mama.

That’s me! I need these guides ASAP to prep for my postpartum period! ❤️

A few thoughts from a certified nurse-midwife…

light bulb — Photo by Pixabay on Pexels.com

Your Bishop score is a piece of counseling but not the whole pie. it’s one of many factors to consider. Use it as a piece of information to help guide your cervical ripening. And if you need cervical ripening, get cervical ripening. I’ve seen women present for their admission for an induction and state that they don’t want a balloon or misoprostol or prostaglandins…or whatever their preference is. But, if you request an elective induction of labor and you need cervical ripening, these expectations will set you up to have an unsuccessful or failed induction of labor. Successful cervical ripening increases your chance of a successful vaginal birth.

In regards to counseling, the biggest frustration I see from patients to families to nurses to providers…well, everyone… is that there is not enough time spent on counseling and education about induction of labor. Ask questions. Ask follow up questions. Don’t assume anything.

Cervical ripening done overnight is done the right way when rest can happen concurrently with the ripening. In other words, the idea is not for women to come in at 7pm in the evening and stay awake all night during the first part of the induction.

These tips can maximize rest for the woman and her family, while simultaneously ripening the cervix:

In low-risk women, cervical ripening balloons do not usually require continuous fetal monitoring (remember, cervical ripening balloons are used as outpatient ripening and there’s no fetal monitoring at your house); policies differ from hospital to hospital, but most hospital require 20 minutes to 2 hours of monitoring after a balloon is placed to assess for reassuring fetal heart patterns. After reassurance is established, discontinuing monitoring overnight helps women to rest because the nursing staff does not have to disturb the woman while she is trying to rest/sleep by continually adjusting fetal heart rate monitors overnight. The woman is able to get up and use the bathroom, ambulate and eat/drink easily when she is not tethered to the fetal monitor. Offer or ask for a sleep aid if needed (melatonin, Unisom or Benadryl are all safe and effective) and consider changing vital signs to every 8 hours during this time period to allow for minimal disturbances (more frequent vital signs are appropriate for hypertension concerns).
In low-risk women where combination balloons and misoprostol are used, the fetal heart rate monitor can be used for 1-2 hours after misoprostol dosing and then discontinued if the fetal heart rate is reassuring to allow the women and her family to walk around the unit. Do not discount the power of ambulation on a contracting uterus; staying in the bed instead of walking inhibits normal labor processes.
Some hospitals offer wireless fetal heart rate monitoring – these are beneficial for EVERYONE as movement during the entire induction process is good for your body, your baby, your uterus and your labor progress.

Often, women are disappointed at how long the induction of labor takes – especially the part up to active labor (which can take 24-48 hours). Take a deep breath and try to remember that inductions are forcing your body into labor. It takes a long time because your body isn’t helping the process at all. Eventually, your body will start to help too, but this is generally at 6 centimeters dilated!

You are going to have discomfort, cramping and pain – these are realities, not exceptions. Make a plan to manage your pain.

In the early stages of induction, getting out of the bed is one of the best things you can do. Do not get admitted and then stay in bed for the next 24 hours straight. If you have ever seen women in labor without an epidural, they are not resting and laying in bed the entire time; inductions should be viewed the same.

Lastly, sometimes the right choice is to go back home. In real life, this looks like this:

You come in at 39 weeks, 0 days with a low-risk pregnancy for an elective induction of labor. You have an IV placed and labs drawn. Your cervix is closed, firm and posterior. You are not contracting. It’s your first baby, You have 4 doses of Cytotec and nothing changes with your cervix. As long as you and your baby are looking great, the next best step may be to go home and come back in a few days to try the induction again.

It’s really hard to predict who this is going to happen to and it is uncommon; just don’t forget that it may be your best option.

If you made it this far in the post, thank you for reading. I have spent 10 years inducing women for medical, social, elective and risk-reducing reasons and it’s been a decade of frustration about what we’re not offering in the clinic. This post addresses the gaps that I see, but it’s not all inclusive.

I created a tool to use for providers and families to guide counseling about induction of labor.

The tool is free and you can download yours here anytime or on the TOOLS & HANDOUTS page.

Good luck on your journey! Don’t miss the resources below or the links to all the evidence or citations in the reference list below.

Catch up on past blog posts!

1 year ago on the blog…Can I Eat Fish During Pregnancy?

2 years ago on the blog…Two Tips For Practicing Midwives

3 years ago on the blog…How to Prevent Burnout of a “Mid-wife” Crisis in Your Career

4 years ago on the blog…The State of Midwifery (Part 1)

Other Resources

Books
- Homeopathic Medicines for Pregnancy and Childbirth by Richard Moskewitz, MD (1992)
- The Homeopathic Childbirth Manual by Betty Idarius (1996)
Guidelines or position statements
- ACNM
  - Position Statement: Induction of Labor (ACNM, 2016)
  - Clinical Bulletin Number 18: Induction of Labor (ACNM, 2022)
- ACOG
- WHO
  - WHO Recommendations on Induction of Labor, at or Beyond Term (2022)
  - WHO Recommendations on Mechanical Methods for Induction of Labour (2022)
For obstetric nurses
- Commentary: Amniotomy: Necessary Intervention or Bad Habit? (Nursing for Women’s Health)
For providers
- Article: Clinical Insights for Cervical Ripening and Labor Induction Using Prostaglandins (2018)
- This chart is a helpful reference to have on a labor and delivery call room wall or for teaching students.
History of induction
- Balloon Dilators for Labor Induction: A Historical Review
Methods of induction
- Cervidil – Highlights of Prescribing Information (FDA, 2020)
- Mechanical Methods for Induction of Labor (Cochrane, 2023)
Patient education
- Approaches to Limit Intervention During Labor and Birth (ACOG, 2019)
- Induction of Labor (ACNM, 2008)
- Induction of Labor at 39 Weeks (ACOG, 2022)
- Labor Induction (ACOG, 2022)
- Medical Reasons for Inducing Labor (March of Dimes, 2018)
- My Birth Matters (mybirthmatters.org) – English/Spanish
- Pregnancy At Age 35 Years Or Older
- What Every Pregnant Woman Needs to Know About Cesarean Birth (National Partnership for Women and Families, 2016)
- VIDEO recommendations:
  - Medical Reasons for Inducing Labor (March of Dimes)
  - My Birth Matters playlist (CMQCC; English/Spanish)
Podcast recommendations
- Evidence on Red Raspberry Leaf Tea for Natural Labor Induction (Evidence-Based Birth, Episode 153)
- Pros and Cons of the Foley and Dilapan-S® for Cervical Ripening During an Induction (Evidence-Based Birth, Episode 153)
Research/evidence to read
- ARRIVE Trial (New England Journal of Medicine, 2018)
- Complementary and Alternative Medicine in Obstetrics (International Journal of Gynecology and Obstetrics, 2005)
- Outpatient Induction of Labour – Are Balloon Catheters an Appropriate Method? (Geburtshilfe Frauenheilkd, 2021)
- Review of Evidence-Based Methods for Successful Labor Induction (Journal of Midwifery and Women’s Health, 2021)

References

Abboud, C. (2017). “Elective induction of labor” (1955), by Edward Bishop. Embryo Project Encyclopedia. ISSN: m1940-5030. https://hdl.handle.net/10776/11420

Alfirevic, Z., Kelly, A.J., & Dowswell, T. (2009). Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD003246.pub2

Alfirevic, Z., Aflaifel, N., & Weeks, A. (2014). Oral misoprostol for induction of labor. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD001338.pub3

Alfirevic, Z., Gyte, G.M.L., Pileggi, V.N., Plachcinski, R., Osoti, A.O., & Finucane, E.M. (2020). Home versus inpatient induction of labour for improving birth outcomes. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD007372.pub4

Al-Kuran, O., Al-Mehaisen, L., Bawadi, H., Beitawi, S., Amarin, Z. (2011). The effect of late pregnancy consumption of date fruit on labour and delivery. Journal of Obstetrics and Gynaecology, 31. https://doi.org/10.3109/01443615.2010.522267

American College of Obstetricians & Gynecology. (2018). Clinical guidance for integration of the findings of the ARRIVE trial: Labor induction versus expectant management in low-risk nulliparous women. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2018/08/clinical-guidance-for-integration-of-the-findings-of-the-arrive-trial

Anderson, F.W.J. & C.T. Johnson. (2005). Complementary and alternative medicine in obstetrics. International Journal of Gynecology and Obstetrics, 91, 116-124. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/135608/ijgo116.pdf?sequence=1

Association of Women’s Health, Neonatal, & Obstetric Nurses. (2019). Elective induction of labor. https://www.jognn.org/article/S0884-2175(19)30005-X/pdf#:~:text=The%20Association%20of%20Women’s%20Health,carefully%20weighed%20against%20expectant%20management.

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Bagherzadeh, K.A., Elmi, A., Mirghafourvand, M., & Navid, R.B. (2020). Effects of date fruit (Phoenix dactylifera L.) on labor and delivery outcomes: A systematic review and meta-analysis. BMC Pregnancy and Childbirth, 20(210). https://doi.org/10.1186/s12884-020-02915-x

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The Background

What is an induction of labor?

What’s the history for induction of labor…how did we get here?

What is the difference between an induction of labor done for medical reasons and an induction of labor done for social or elective reasons?

Why is an induction of labor recommended for medical reasons?

How many women ask for an induction of labor?

Are other developed countries experiencing the same increased rate for induction?

Why are induction rates increasing so rapidly?

What do women think about induction of labor?

What is my cervix and what are the measurements assessed during a cervical exam and what do these mean for induction of labor?

What interventions are used for labor induction?

How many women try to induce labor with non-medicinal methods?

The Tables

Non-medical methods (i.e. methods that do not include medicine or mechanical interventions)

Acupunture

Breast or Nipple Stimulation

Dates (dried fruit)

Enemas

Herbal or Homeopathic Preparations

Physical Activity/Exercise

Purgatives

Red Raspberry Leaf Tea

Sex, Sexual Activity, Orgasm, or Masturbation

Sweeping or Stripping Membranes

Mechanical methods (i.e. methods that do not include medicine; these methods use devices or tools to promote labor)

Amniotomy

Cervical Balloon Catheters

Dilapan-S

Medicinal methods

Dinoprostone (Cervidil or Prepidil)

Misoprostol (Cytotec)

Oxytocin (Pitocin)

Combination Methods

What does the evidence say about induction of labor?

Frequently Asked Questions

What other questions should I ask about induction of labor?

When does spontaneous labor normally happen for women?

How do I decide which method is best for me?

Do the stages of labor still happen during an induction of labor?

What’s the difference between induction and augmentation?

What percentage of women need cervical ripening during their induction of labor?

What can I do to make my induction of labor successful?

What else do I need to consider about an induction of labor?

I want to schedule an induction of labor but I don’t want to have my cervix checked in the office before my induction of labor.

What do professional organizations say about induction of labor?

What is the difference between outpatient and inpatient cervical ripening?

What are the prostaglandins everyone keeps talking about?

What about women that have had a C-section and desire a vaginal birth (called a TOLAC or trial of labor after cesarean)?

What happens when none of the induction interventions are working and my body isn’t doing anything?

What is a failed induction of labor?

Which method(s) is the lowest cost for induction of labor?

Some last thoughts from a certified nurse-midwife…

That’s me! I need these guides ASAP to prep for my postpartum period! ❤️

A few thoughts from a certified nurse-midwife…

Other Resources

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