Caitlin Whyte (Host): Welcome to Woodlawn Health Doc Talk. I'm your host, Caitlin Whyte, and today we have on Dr. Christopher Ricketts, a primary and obstetric provider at Woodlawn Health joining us. We'll get into the topic of inductions, exploring everything you need to know when you're expecting a new baby. Doctor, thank you so much for being on the show.To start us off, can you tell us just what is an induction?

Christopher Ricketts , MD: Hi Caitlin. I'd be happy to do that. So in brief, an induction is really to be compared with natural or spontaneous labor. In other words, instead of allowing for labor to occur on its own, an induction is the process by which we try to induce, or jumpstart labor artificially. So, I'd like to mention at the outset, of course, that during our time together that the goal of any labor and delivery is a healthy mom and a healthy baby.

You know, regardless of whether or not an induction is involved. What I'd also like to do is to contrast an induction with what is called augmentation which is a term some women may have heard. The usual scenario is a woman who is in labor, but for a variety of possible explanations, her labor is not progressing in a typical or timely fashion, and as a result, her labor will need helped along by outside means, such as rupturing her membranes or giving medicine to strengthen the force of her contractions. And many of the same medicines or techniques are utilized in an induction as in augmentation, but they are in fact distinct circumstances.

And so for a lot of women being induced, it's also common for women to need their labor augmented. And so there can be a lot of overlap between augmentation and induction.

Host: And why might an induction be recommended or not recommended?

Christopher Ricketts , MD: Often towards the end of a pregnancy, many women are uncomfortable and are just ready to be done. And you know, that doesn't mean that her doctor will automatically say yes to an induction. What this really speaks into is the difference between a so-called elective induction and a medically indicated induction.

And so I'd like to explain that a little bit. An elective induction is when a woman is induced because of her personal desire to be done being pregnant. The timing of this can vary, but typically this is between 39 and 41 weeks of her pregnancy. For frame of reference, the typical due date is given right at about 40 weeks.

Some patients are aware that years back, in fact, up until about 10 years ago, we would routinely induce women at or around 37 weeks. This timing is because medically there is a firm line between so-called preterm and full-term pregnancies, and that dividing line was 37 weeks. Then what happened was that some really interesting research spearheaded by the March of Dimes Society began to notice that babies born after 39 weeks did remarkably better in terms of health during the first few and through the first year of life compared to babies born between 37 and 39 weeks. And certainly as compared to babies born prior to 37 weeks. These data were then adopted by the medical community, where nowadays we talk about a preterm pregnancy as prior to 37 weeks, early term as 37 to 39 weeks.

And then we really don't discuss a term pregnancy until 39 to 41 weeks. And so as a result, an elective induction is not really a consideration until a woman is at term, which is after 39 weeks. So to add a layer of complexity to this, there are many times when a problem might arise after 39 weeks, such that an induction would be advised due at a health condition such as high blood pressure or fetal distress.

In these circumstances, we would call this a medically indicated induction, and no longer use the term elective induction. So this then gets into the other major category besides elective induction, which is a medically indicated induction or so-called medical induction. For this circumstance, the health of the mother or the health of the baby usually supersedes the consideration of gestational age.

In other words, the imperative is to have the baby delivered regardless of a woman's gestational age. In other words, how far along she is. The reasons for a medical induction are many, but they can include conditions such as high blood pressure in the mom, poor fetal growth of the baby, diabetes, and low amniotic fluid levels around the baby.

What I'd like to interject to many listeners, which might be obvious, but I'll state it anyway, our conversation about inductions relates only to women who are candidates for a vaginal delivery. If a patient has a history of a cesarean section and has a health condition that warrants an early delivery, she will likely need a repeat cesarean, and really our discussion about inductions does not apply to her.

Host: Now walk us through, what does the process of induction look like?

Christopher Ricketts , MD: Oh, that's a great question. Because I think a lot of people wonder that as well. So when the decision to recommend an induction occurs, often the situation is urgent, but it's not emergent. In other words, it's in the best interest for a mother to be delivered of her baby, but rarely is it a dire emergency. As a result, the induction might be scheduled for a few days out from whenever the decision is agreed upon to have her be induced.

But the reality is, is that other patients may have priority for whatever reason. And another common scenario is that with limited space and nursing resources, a woman on the schedule for an induction might actually be bumped to a different time slot or a different day even because of a woman who comes in, in active labor.

That said, I really do want to emphasize that although no one involved in the decision making for a patient is ever going to do something that puts the life or health of a mom or baby at risk. And although the process can be frustrating at times, know that everyone involved only has your and your baby's best interests in mind.

Host: And just how long does induction take?

Christopher Ricketts , MD: That's a question I get a lot. Speaking of being patient, labor takes time and sometimes it's incredibly rapid, but I, I'll openly say that the human body is simply amazing, especially in my opinion, the female human body. On the other hand, sometimes labor takes days. The average length of labor for most women is between eight and 12 hours, Depending on if it's a woman's first delivery or not, and this timeframe relates to active labor. The process of inducing labor or going from nothing to active labor can sometimes take a day or more. Speaking only for myself and not for any other doctors, I'm very selective and intentional regarding my induction, such that when I decide to induce a woman, I'm committed to her not leaving the hospital without her baby.

Listeners to the podcast may have heard of times when a woman was brought in to be induced and for whatever reason it doesn't take, and she is sent home still pregnant to either wait for natural labor or wait for another induction date to try again. I can understand how this can be really frustrating and a bit demoralizing and personally try to avoid this scenario whenever possible. Now, that said, this is not to be confused with when a patient comes to the hospital thinking she is in labor but is deemed not to be so and is sent home.

Host: Well, now that we know a bit more about the process, what are some of the risks associated with being induced?

Christopher Ricketts , MD: Interestingly, there are actually no unique risks associated with induction that are not present with natural labor. But there are some risks that are increased with an induction compared with natural labor. For example, there is an increased risk of a dysfunctional labor that may require augmentation, which we touched on a little bit ago.

There's also an increased risk of what's called an instrumented delivery, and that's the use of forceps or vacuum to help the delivery of the baby. Other risks for an induction include a higher risk of needing a cesarean section for delivery. But also a higher risk of needing what's called regional anesthesia, more commonly known as having an epidural.

 I'd like to also take a moment, just to comment on epidurals. Sometimes it is frustrating for patients to be told that it's too early for an epidural because they're already having quite a bit of pain with their labor course. But, what people should understand is the reality is, is that giving an epidural too early in labor actually prolongs labor. And at this point in the game, we all like to avoid making it last any longer than we have to.

Host: And can you break down the methods that are used for induction?

Christopher Ricketts , MD: There are actually many approaches at our disposal when it comes to inducing labor, and the method chosen for me is really directly linked to a variety of factors such as what number of pregnancy it is for a woman, what her cervix exam is, and where the baby is positioned in the pelvis.

 There are certainly other considerations, but these are among the factors of how I decide what method to use to induce labor. In broad strokes, sometimes the cervix is what we term unfavorable, which is a term that means that it isn't very stretchy, it isn't really in a good position ready for labor or that it's completely closed.

There's certainly other factors that I take into consideration too, but this at least gives listeners something to go on. If the cervix is unfavorable, then often a patient will be given a medicine in the hospital placed by the nurse. This is placed at the cervix and is used to soften the cervix and essentially prepare the cervix for labor.

Sometimes I find that this is all a woman needs to be put into labor, but more commonly, this sets the stage for the next stage for her induction. For this approach, usually a patient is brought in, overnight and in, in the morning, the next steps are used. So what can these involve? The additional steps include things like breaking the water, also called rupturing the membranes.

What this does is this actually causes a release of chemicals called prostaglandins, and these are central to labor, as well as allows the head of the baby to descend into the pelvis and physically push against the cervix to bring dilation during labor. Another approach that we will sometimes use to help the cervix dilate, regardless if a woman's water is broken or not, is to place a balloon catheter into the cervix.

This is most commonly called a cook catheter or cook balloon. What it does is, it is filled with water, and as it begins to get filled with water, it actually stretches the cervix open and is usually left in place until either it naturally falls out on its own or is removed at about three to four centimeters dilation, at which time, if a woman's water hasn't broken, then this is a time that rupturing the membranes commonly occurs.

If she is contracting, then often we will use a medicine called Pitocin, and this is given through the IV. Interestingly, I will not uncommonly be asked if Pitocin is that drug that makes contractions hurt. And although I openly say yes, it is, I don't intend for women to have unnecessary pain. But the reality is, is that stronger contractions typically are also more painful.

Host: And as a pregnant person, how can I prepare for an upcoming induction?

Christopher Ricketts , MD: So I really think the best preparation is to first understand the why of the induction. You know, ask those questions you need to ask. After this, understand the how of the induction and what steps might be taken if the induction isn't going as planned or isn't successful for a vaginal delivery. You know, patients do need to grasp the reality that even though a vaginal delivery is the goal, the overarching higher goal is always a healthy mom and healthy baby. Even if that means having a C-section. During a pregnancy, we always have two patients at a time to keep in mind and each are top of mind in our decision making process.

Host: How will induction affect my overall birth plan?

Christopher Ricketts , MD: I think my best answer to this is for people to be flexible, to be patient and ask all the questions you need to ask. Often nurses, who do this every day in the obstetrical units, they're fantastic resources to also be able to answer some of the questions. Now by the same token, recognize that there are may be times that we will need to make decisions for you in order to have as healthy an outcome as possible.

I don't make decisions out of my convenience or comfort. If that were the case, I have to tell you I wouldn't be doing obstetrics. No, it is an honor and a privilege that I and my partners take seriously. But whenever possible within the bounds of, you know, proper medical decision making, we'll always try to honor a woman's birth plan.

 I do want to lastly mention that after delivery, we at Woodlawn Health strongly subscribe to the skin to skin model of mother-baby bonding whenever possible, even after C-section. We want babies to go right to mom's chest. If people aren't familiar, the data in terms of positive benefits surrounding immediate skin to skin contact, they're really strong. And without a doubt, this is something that we are deeply committed to.

Host: And to wrap up our conversation, Doctor, can I have an epidural if I am being induced?

Christopher Ricketts , MD: That's a great question. I'm happy to give a clear, explicit answer and that is definitely yes. Within the times where any epidural would be appropriate during natural labor, those same availability occurs for women who are being induced.

Host: That was Dr. Christopher Ricketts. For more information, please visit our website@woodlawnhealth.org. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you.

I am your host, Caitlin Whyte, and this is Woodlawn Health Doc talk. Thanks for listening.