Warning: This article contains radical ideas about labor, birth, and women’s right to intelligently choose what’s best for them and their babies! Read at your own risk of empowerment!
The Induction Pressure Cooker and Women’s Autonomy
According to recent data from the latest Listening to Mothers III national survey of 2400 mothers who gave birth in US hospitals from mid-2011 to mid-2012, women are being pressured by their healthcare providers to have inductions. Many women, in their desire to avoid induction, which sometimes also means changing plans from birthing center or home birth to hospital birth, will try to self-induce labor rather than endure a hospital induction. At least 64% of nurse midwives in the US, based on surveys, support the use of natural methods of labor induction.
As a homebirth midwife and also a family doctor licensed to practice obstetrics, I have worked hard to help women avoid unnecessary inductions. Sometimes this has put me at odds with what the medical profession says I “should” be doing – but if things are ever going to change in how obstetrics is practiced, then those of us who can must take a stand for a woman’s right to choose what she feels is best for her and her baby – even though this may be in conflict with conventional obstetric practice.
The sad reality is that conventional medical practices are not always based on the best available medical and scientific evidence, or the best interests of the mother. They are heavily influenced by doctors’ fears of getting sued, data that is skewed by the interests of professional societies, insurance reimbursers, hospital risk assessment teams, and even medical journal articles that have been written by or paid for by medical device and pharmaceutical companies. We have to take a stand for honoring the wisdom of nature rather than succumbing to pressure and fear.
We must also fiercely protect one of the fundamental tenets of medical ethics: respect for autonomy. Autonomous individuals act intentionally, with understanding, and without controlling influences. When it comes to obstetrics, however, some medical authorities have questioned whether pregnant women should retain the right to autonomy, since their decisions affect not only themselves, but also their babies. Thus some women have found themselves with court orders to undergo hospitalizations and obstetrics interventions – including cesarean sections – against their will! It is in the spirit of women’s autonomy in the face of a compromised obstetrics system that I present what I know and have used in my own clinical practice, for getting labor started when the pressure to do so is on for gray area medical reasons.
Medical vs. Elective Induction: An Important Difference
Labor inductions are done too often and many times, for non-medical indications. Unnecessary inductions can lead to a host of additional unnecessary interventions – including cesarean sections – that substantially increase health and safety risks for mom and baby. To be clear, I am opposed to elective induction. Period.
Labor induction should always be based on a medical indication, and the rate should not exceed about 10% of all births. Yet in the US the national average is at least 23% – double what it was 2 decades ago.
Reasonable indications for induction include maternal high blood pressure associated with preeclampsia or eclampsia (this is different than slightly elevated blood pressure in late pregnancy), medical conditions that can put you or baby at risk in labor (uncontrolled diabetes, HIV, heart disease, kidney disease, a blood clotting disorder, or possibly cholestasis of pregnancy), and intrauterine growth restriction. Medical indications require medical inductions – that is, they should be done using conventionally accepted methods under medical supervision – for your and baby’s safety.
Labor should not be induced “electively,” meaning done for convenience-sake, or for cultural, psychological, or “social” reasons rather than medical ones. Elective induction prior to 39 weeks increases the risk of preterm delivery, which potentially increases baby’s risks of lifelong health and developmental problems. Elective induction also increases your risk of cesarean section if you are a first-time mom. All methods of induction carry the risks of complications.
Living far away from the hospital, having a history of fast labors, or having more than five prior vaginal deliveries are not medical indications for induction.
The Induction Gray Zone
So if I am opposed to induction, why am I doing a how-to blog? Because countless healthy, intelligent, and responsible women have approached me over the years, seeking natural alternatives to the medical induction they are being threatened with for “gray area” medical reasons. And when faced with the only option being hospital induction, knowledge of age-old traditional methods of induction becomes power.
Gray zone reasons that women are typically presented with include her being told that:
Her baby is too big so she is going to be medically induced before it gets any bigger.
She is too overdue so she is going to medically induced.
Birthing center or homebirth policy requires her care to be transferred to the OB for a hospital birth if she hasn’t had the baby by a certain window after the due date.
Why are these gray areas?
Estimates of fetal weight can be grossly inaccurate. Many women are induced before they are really ready for labor, sometimes even ending up with a cesarean, only to have a perfectly reasonably sized baby that wasn’t too big at all. Besides, what IS too big? Many women – even first time moms – can birth “big” babies without induction and without a problem. Size isn’t everything!
Though we are enamored with them, due dates, even based upon ultrasound, are notoriously inaccurate leading to induction at what is calculated to be at term or post due, only for baby to be right on time, or premature. One radical idea is just to ignore your due date entirely! (Though you’ll have to convince your midwife or doc to do the same!)
By all conventional medical standards, the length of a normal human pregnancy extends all the way to the end of the 42nd week of pregnancy. However, statistically, there is considered to be a slightly increased risk of stillbirth after 40 weeks of pregnancy. According to Up to Date, “Perinatal mortality increases as pregnancy extends beyond 39 to 40 weeks of gestation… The perinatal mortality rate at ≥42 weeks of gestation is twice the rate at term, increasing four-fold at 43 weeks, and five- to seven-fold at 44 weeks. However, the absolute risk of fetal or neonatal death is low.“
Nonetheless, this small risk represents a major legal concern for doctors who deliver babies. An obstetrician can expect to be sued 3 times in her career, is legally liable until a child turns 18 years old for any problems that can be attributed to a birth she attended, and the stakes of a lawsuit, in addition to the stress, can be financially and professionally devastating. Induction has become the answer addressing risks to baby. According to some researchers, however, the statistics maybe be overinflated and skewed in favor of induction. And I repeat, according to Up to Date, “the absolute risk of fetal or neonatal death is low.”
Au Natural: What Really Works for Stimulating Labor? Is Any of it Safe?
It is generally optimal to let labor commence on its own. When it does, the conditions are usually best for a natural labor and birth. The baby’s head is in the right position, hormones are kicking in left and right, and the uterus has built up a nice repository of oxytocin receptors primed and ready to embrace your body’s natural oxytocin which will naturally stimulate contractions.
Unfortunately, we don’t all live in a perfect world where nature is respected and honored – thus sometimes we have to make a choice between trying to get labor going naturally and getting it done in the hospital. Occasionally, too, nature does need a nudge. Fortunately we have resources at our fingertips to help things along.
There are a number of options for getting labor started. Few of these have strong evidence behind them and not all of them have been proven to be safe for baby. Nonetheless, many women find these to be a preferable alternative to the risks of medical induction methods and being in the hospital.
Over the years in my own practice, I have found membrane stripping, nipple stimulation, the use of some herbs, and castor oil to be the most effective, particularly in combination. Of these, only membrane stripping and nipple stimulation are considered to be safe.
Here is a review of the most common approaches to getting things going:
Membrane stripping
This does not mean breaking the waters. It is a technique your doctor or midwife can do which involves sweeping her index finger around the inside of your cervix and “lifting” the membranes up off the inner cervix. It is easily performed in the office and has been shown to be both safe and effective in stimulating labor within 48 hours. It is estimated that one in eight women will successfully go into labor with no increased risk of infection as a result of the procedure. It may need to be repeated at an additional office visit on a subsequent day. According to Cochrane Collaboration review, sweeping of the membranes was associated with reduced duration of pregnancy and reduced frequency of pregnancy continuing beyond 41 weeks. Discomfort during vaginal examination, mild cervical bleeding, and irregular contractions are the main “side effects.” Last time I did it was when my daughter-in-law was in her 41st week. She went into labor within the day…
Nipple stimulation
Pulling on the nipples very firmly in a motion intended to simulate a baby’s suckling stimulates uterine contractions and has been used to induce labor (a breast pump is not usually recommended). It usually works within about 72 hours in women with favorable cervices on Bishop scoring (something non-invasive your midwife can calculate with a cervical exam). Breast stimulation causes the uterus to contract, likely through increased levels of the hormone oxytocin, which stimulates contractions. It is typically recommended to be done manually for about 30 minutes at a time on one or both nipples, repeated twice daily. There is little data on safety but it does not appear to be associated with any complications. Safety has not been evaluated in high-risk pregnancies. A plus is that nipple stimulation is associated with reduced postpartum hemorrhage. It’s kind of difficult to do it firmly enough to yourself so having your partner or a close pal do it is more effective. It may be a little uncomfortable but don’t let that worry you about breastfeeding, which can also be uncomfortable at first, but gets easy.
Herbs
Herbs, especially blue cohosh and cotton root bark are popular amongst midwives, including certified nurse midwives, to stimulate labor. They are typically used in the form of alcohol extracts, taken in doses of several milliliters at a time, repeated up to 4 times/day, or more often under skilled guidance. While these herbs can be highly effective, and I have used them extensively in my practice over nearly 30 years, the use of blue cohosh has been implicated in serious complications in the newborn including heart attack and stroke at birth in three published case reports. Midwives also report increased risk of meconium in the baby and need for resuscitation, though this may be due to the factors that led to the use of the herbs, including the baby being overdue.
While the existing adverse reports are unlikely due to the herb, the pharmacology of blue cohosh does not allow this association to be ignored. Thus the use of herbs to induce labor should preferably be done under the guidance of a midwife or other reliable health professional skilled in the use botanical medicines in pregnancy. My extensive academic research on blue cohosh and herbs for labor induction is presented in the American Herbal Pharmacopoeia Blue Cohosh Monograph.
Red raspberry leaf is a safe exception. It may be taken in a strong tea, prepared using ¼ oz. (about 4 grams) of the dried herb to 1 pint of water, steeped for 20 minutes, and several cupfuls taken daily until labor commences. It is not associated with causing preterm labor and has been associated with decreased complications at birth for the mother and baby.
Evening Primrose Oil (EPO)
EPO has been used extensively by midwives to help “ripen” the cervix when taken in doses of about 1500 mg orally and the oil of several opened gel caps also applied directly to the cervix for up to a week prior to when you hope to go into labor. Overall studies are very limited. In one report, women taking oral evening primrose oil had, on average, a labor lasting 3 hours longer than women who did not ingest evening primrose oil. Nothing should be inserted into the vagina if your waters have broken.
Castor oil
There is little formal data on the effectiveness of castor oil to induce labor, but many women who try it report it to be very effective. Unfortunately, it causes terrible diarrhea that may lead to anal burning and irritation during labor. If you use it and get loose stools, make sure to replace your fluids and electrolytes. I have actually used the warmed oil topically on the belly as a massage oil and it may have been helpful in stimulating some labors – but I’ve never used it without also using nipple stimulation and some herbs.
Acupuncture
Acupuncture has been used to help ripen the cervix and induce labor. A Cochrane Collaboration review of 14 trials reporting data on over 2220 women randomized to receive acupuncture compared with sham acupuncture or usual care. Most trials were from Western countries; two were from Asia. The data wasn’t too impressive but there were was a great deal of inconsistency in the points that were used, the sizes of the studies, and other parameters that make it hard to fully interpret the data. It is a harmless method if clean needles and proper techniques are used.
Acupressure
Acupressure is the application of pressure usually using the fingertips, in place of needles, on acupuncture points. The accompanying
diagram illustrates the points typically used. Firm pressure is applied for several minutes, repeated several times daily. There is no evidence that these points used alone actually get labor going. In my experience it takes more than this to put a mom into labor!
Sex
Human sperm contains a high amount of prostaglandin, a hormone-like substance that ripens the cervix and helps labor to start and it has been suggested that sexual intercourse may be an effective means. There isn’t enough evidence to show whether it really is effective or how it compares with other methods, but if your water isn’t broken and you want to give it a try – no harm, no foul. Most midwives recommend three times per day to maximize the chance that it will work!
Spicy Foods
There is absolutely no evidence that spicy foods can trigger labor and since they can cause heartburn in late pregnancy, they might not be the best option…
The Next Dimension
There’s a lot more to labor and birth than meets the eye or that always has an obvious physical or medical solution. Our emotions and beliefs have a tremendous impact on our experience. We can’t necessarily account for the mystery, but we can do something about our emotions, especially fear, about labor and birth. Animals in nature don’t go into labor when they are frightened. In fact, labor will stop if a mammal is threatened by a predator. Adrenaline inhibits oxytocin which helps to stimulate and sustain contractions. Sometimes we go overdue because our bodies or babies are just not ready for birth yet and need a little more time in the oven. Sometimes fears might be holding us back. If you are overdue and being pressured by someone to go into labor, aside from asking them to back off a bit, it’s a good time to dig deep for any skeletons in the closet. I’ve “met” all kinds of skeletons in my practice: the grandmother who died in childbirth, the mother and three sisters who never went into labor and all needed cesareans, the mother or best friend who has been giving you a hard time for planning a home birth. Get centered and clear out everyone else’s baggage and your family history baggage and see if this helps.
Having a heart to heart with baby is another “next dimension” idea. One of my dear friends was quite overdue with her first baby. She was planning a homebirth but the screws had been on about a hospital induction. A nurse on L&D at that hospital herself, she really preferred to have her baby at home, but of course was willing to do what she needed for her baby’s best interest. One evening she wrote a flowing letter to her baby, telling her that she’d do whatever was needed for her safe and healthy birth, and that she felt being born at home was really such a wonderful option. She waxed poetic – and lo and behold went into labor within hours of finishing that letter!
Sometimes there’s just an element of mystery in the world of birth that I can’t explain. For example, my patient who went 2.5 weeks overdue but just “knew” her baby would be born either on her own or her mother’s birthday, which were one day apart. She kept begging me to wait a few more days. Baby looked good so I waited. Sure enough, after a very quick labor for a first-time mom, that baby was born on her grandma’s birthday!
Anne’s Story
Anne, a 28-year old petite woman, was over 41 weeks pregnant with her first baby and was planning a home birth. She’d had some mild irregular cramps for the previous 2 weeks, which were especially bothersome at night, but no signs of labor. Her cervix was undilated and about 30% effaced when she was checked by her family practice doctor, who was her back-up physician for her birth. Her doctor recommended she insert misoprotol to induce labor. She was supportive of Anne laboring and birthing at home if the misoprotol kick-started her labor but if not, wanted her to come to the hospital for induction at the end of the week. Anne was not keen on the use of misoprotol due to risks of it causing overly strong uterine contractions that – rarely – can lead to uterine rupture.
Anne contacted me upon her family doctor’s advice. Of note, I do not support the home-use of misoprotol for labor induction. I feel it is best used in the hospital under medical supervision. We discussed natural options and Anne decided upon nipple stimulation and the use of herbs. Her husband was to do nipple stimulation for 30 minutes on one breast in the morning, and repeat for 30 minutes on the other breast in the afternoon, twice each day. Anne began taking a combination of herbs that included equal parts of blue cohosh root, cotton root bark, and black cohosh root, with the instruction of taking 1/4 measured tsp. every 4 hours, stopping overnight, and for up to 2 days maximum.
By the middle of Day 1 Anne began having mild uterine contractions. By 1 pm on Day 2 her labor kicked in full-on, with contractions 5 minutes apart, so the herbs were discontinued. The baby’s heart was monitored regularly with a fetoscope and was normal throughout labor. Her beautiful daughter was born at home, late in the afternoon, on Day 2 of the herbs, with no complications for mom or baby.
Tough Choices
Ultimately, you have the right to make your own best decisions. It can be super tough to know what to do when your midwife is under pressure to get your labor going, or your doctor is telling you one thing and your momma-protective-bear-intuitive-self is telling you another. Keep in mind that the decision to induce is rarely an emergency. You have time to think it through. Feel it out. You have time to ask questions. If you do need an induction, you’ll know you made an educated choice.
You can talk with your physician about alternatives to hospital induction. A Cochrane Collaboration review of 28 studies found that home induction of labor with certain medications can be feasible and safe in some circumstances; this might be an option your doctor would consider rather than keep you in the hospital during the early part of the induction, which can sometimes take several days.
Nipple stimulation, red raspberry leaf tea, and membrane stripping are great, safe, and often effective options that can be combined and also repeated. Give yourself a few days of lead time to give things a chance to work.
Also, make sure to clear out any unfinished emotional business and allow room for some mystery and magic. You might just be amazed at what can happen!
Want to join me, Christiane Northrup, Sarah Buckley, Ina May Gaskin and others as we discuss the risks of labor induction? Here is a link to a free video excerpt on elective induction, generously shared by Happy Healthy Child. Please watch here — you’ll be inspired!
To your best possible birth!
Love,
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