This blog post is the first of two parts written with the intention to educate expectant parents about induction, its impact, and the increasing rise of its use in our local hospitals. Part One covers The What and How of Induction – what does it actually mean to be medically induced, and how is that done? 

The frequency of induction varies by location and institution. The rate of induction in Canada has increased steadily from 12.9% in 1991–1992 to 19.7% in 1999–2000. The rate reached a high of 23.7% in 2001–2002, decreased slightly to 21.8% in 2004–2005, and has since remained steady. The 2010 BC Perinatal Health Registry reveals an increased rate, with post-term pregnancies (> 41+0 weeks) representing 34%, the largest group, of the total inductions in BC.

Data from the Registry during 2014/15 reported these overall rates from local hospitals: BC Women’s Hospital: 22.1%, St. Paul’s Hospital 26.2%, Burnaby Hospital 20.4% and Lion’s Gate Hospital 19.3%. Current rates may be higher since the 2015 report. Richmond General Hospital during that time was dedicated to lowering their induction rate and it was at 17.7%. This also reflected a lower cesarean rate at 15.7% compared to higher Cesarean rates at the other hospitals. More on the connection between induction and cesarean in blog post Part Two.  What are the current rates as we enter 2022? 

PART ONE
THE WHAT: Induction of labour is the artificial initiation of contractions before spontaneous onset of labour to deliver the fetus within 24-48 hours. The goal of induction is to get the uterus to begin to contract, making the body go into labour, in order to vaginally birth the baby. When undertaken for appropriate reasons, and by appropriate methods, induction is useful and benefits both mothers and newborns. There are numerous reasons that induction of labour is recommended, and as we explore in Part Two, we will see that not all, are in fact, evidence based, and/or some research findings are contradictory.

THE HOW:
First, it’s necessary that the cervix be ‘favourable’, meaning that it is softening, thinning, shortening and somewhat opening so that induction will be successful, resulting in a vaginal birth. For the purposes of induction, the ‘Bishop Score’ is used to assess if the cervix is favourable to determine the likelihood of success and to select the appropriate method of induction. Bishop Score Calculator for Induction | babyMed.com

It’s crucial that the cervix be favourable, because if not, often further methods might not work and induction fails. Not due to the woman’s body being unable to give birth, but that the induction methods didn’t work, and/or complications arose during the induction process requiring further interventions, including surgery.
There are two main medication options used to help the cervix be ready for the next step in the induction procedure. Using medications with hormone-like substances called prostaglandins, both work to act on softening ‘ripening’ the cervix, much like how male semen works. Each has their pros and cons. Both have similar effects.

CERVIDIL: Cervidil (Dinoprostone): Uses, Dosage, Side Effects, Interactions, Warning

PROSTAGLANDIN GEL: Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term | Cochrane

The use of cervidil or prostaglandin gel can cause contractions to occur, but might not always bring about labour. Cervidil, inserted once into the vagina, close to the cervix, is released over a 24 hour period, unlike prostaglandin gel. The gel is inserted into the vagina where it can take its effect on the cervix. The gel can be given 3 times, 6 hours apart. More than one application may be required. Women can experience intense contractions, perhaps lose sleep for a night and then move into chemical induction. Sometimes these medications are successful on their own to tip the body into labour, without the need for further induction medications.

A third option for getting the cervix favourable is the foley bulb catheter. It’s a mechanical means to change the state of the cervix in preparation for chemical induction. What Is a Foley Bulb Induction?

As well, a procedure called ‘sweeping the membranes’ may be suggested/done. What is a stretch and sweep? This is part of an induction process. It may be offered by a care provider as early as 39 weeks gestation. This procedure has been described as a rough cervical check.

‘Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour’. Membrane sweeping for induction of labour

If/once the cervix is favourable, induction proceeds straight to the use of Pitocin (synthetic version of the pregnancy hormone oxytocin), administered via an IV. This medication causes the uterus to contract. Pitocin is given in a hospital setting along with continuous fetal monitoring.
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Pitocin causes very strong and frequent contractions, earlier on than physiologic labour, and often leads to requests for pain medications, particularly epidurals, which can add further risks. More on this in Part Two. Along with Pitocin, often the care provider will artificially rupture the membranes (A.R.O.M.), in theory to help speed up the process. A.R.O.M. is an irreversible procedure.  Breaking Your Water to Induce or Augment Labor

Bear in mind that induction of labour is very different than normal physiologic labour. To understand how normal physiologic birth works in terms of the hormones involved and their role in initiating spontaneous onset of labour, read here: Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care

The time for the entire induction process may vary, but can take up to 2-3 days, including cervical ripening. Sometimes women go home while waiting for labour to begin, returning to the hospital for a second application, or to begin the next step in the induction process - the use of Pitocin. That part can still take a number of hours, depending on how the dilation phase goes, followed by pushing and birth of the baby. If pain medications are used, ie. an epidural, that will add time to the process. Pushing time may be longer too. If progress is slow, or if the cervix is failing to open with an effective, strong contraction pattern, at some point the care provider will discuss cesarean. Sometimes despite all efforts, the body and baby just aren’t ready. This is termed ‘failed induction’.

Part Two (THE EVIDENCE FOR THE WHY, RISKS & BENEFITS) will follow in a week. It will examine when induction is medically indicated, and when it’s recommended, yet evidence is contradictory/questionable. It will look at how one makes an informed decision. Weighing out the pros and cons to give informed consent or refusal. Please keep an eye out for it.

What is it really about a doula that helps couples so much? We read stats of the reduction in use of pain meds, lowered rates of cesarean births, and less use of interventions when doulas are present. Stats are numbers that quantify. What makes those numbers possible is something that can't be quantified - one trusted, trained caring professional who provides continuous one on one support, who is beside the woman, unwavering and steadfast in tending to her comfort, her emotional and physical well being, whose care is not medical in nature. So, it's not, for example, about labour progress, cervical dilation, blood pressure measurements, but how is the woman feeling? Does she feel cared for? Does she feel safe?
What I bring are essential elements of care that the rest of the team aren't. And it's this exactly that we know makes such an enormous positive impact on how labouring women do and why there's less use of pain medications, with reductions in interventions and cesarean rates. It isn't a number though and it's something that can be hard to wholly describe. 
It IS my presence - ever mindful of how the woman is doing from moment to moment, encouraging and reassuring, calming and grounding. Bringing my years of knowledge/experience to this woman, here and now, understanding what her specific needs are. Ensuring that her partner is doing well also! Partners are freed up when I am present so they can be there fully, without worry or feeling useless. This in turn adds to the woman's sense of well being, so she relaxes and focuses on birthing. 
There is something wonderful that happens when women are tended to in this manner, that makes all the difference for their experience. The more secure they feel, the better labour goes. Yet when labour and birth take a different path, where other choices need to be made, my care still proves invaluable. I'm focused on emotional and mental well being, not tracings on the monitor.  
Care providers have their role. Their attention is focused on the health of mom and baby, through the lens of clinical care. We of course do need that, and the complementary care of the doula's non-medical support. 
My care has so many facets. It shows up in the littlest of details, in the simplest of actions, such as wiping a sweaty brow with a cool cloth. One may ask how do we get from that to 60% reduction in women requesting epidurals?  You'd need to ask the women.

"I wanted support during labour, which you can't always count on from your partner or the nurses, all the time. It's her experience... which partners don't have of being at births and of having had a baby. We'll always be grateful for your attention to us at our daughter's birth."  Shauna

I wrote this blog post for our Doulas of Vancouver site. Thought I would share it here! 

​Her First Calf
From - (1973) by Wendell Berry

Her fate seizes her and brings her down.
She is heavy with it. It wrings her.
The great weight is heaved out of her.
It eases.

She moves into what she has become,
sure in her fate now
as a fish free in the current.
She turns to the calf who has broken
out of the womb’s water and its veil.

He breathes. She licks his wet hair.
He gathers his legs under him
and rises. He stands, and his legs
wobble. After the months
of his pursuit of her, now
they meet face to face.

From the beginnings of the world
His arrival and her welcome
have been prepared. They have always
known each other.

​A Meeting

She steps into the dark swamp
where the long wait ends.

The secret slippery package
drops to the weeds.

She leans her long neck and tongues it
between breaths slack with exhaustion

and after a while it rises and becomes a creature
like her, but much smaller.

So now there are two. And they walk together
like a dream under the trees.

In early June, at the edge of a field
thick with pink and yellow flowers

I meet them.
I can only stare.

She is the most beautiful woman
I have ever seen.

Her child leaps among the flowers,
the blue of the sky falls over me

like silk, the flowers burn, and I want
to live my life all over again, to begin again,

to be utterly
wild.

I Wear My Stretchmarks Like Tattoos

to show

I am a woman

whose belly has billowed

a mainsail on a pirate ship

on its way to treasure

a queen-size-bed topsheet

on a new clothesline in March

they make

silver parentheses

around my freckled navel

tiny river tributaries

from the cold spring of my joy

pattern rising to the touch

The Beginning 
​by Kent L. Bijou

She looks at me with half closed eyes,
As if to pierce my soul.
The sounds she makes are strong and firm
For one just moments old
With skin still soft from life's ordeal
She muscles up a whine
Small fingers reach, yet never touch
But sure they will in time
For life's begun, and all is new
So many things to learn
She's not the first one nor the last
We've each once had our turn.

An Ode To Ethan 
​by Joyce Baron Kerr

Today it happened,
it's finally done,
the birth of my boy,
the little man, my son.

After a long tiring wait, 
a sweet sound came,
the point when our lives, 
would never be the same.

It was the sound of the cries,
signaling the start of new life.
I can't describe how proud I am, 
of my brave and beautiful wife.

I'll admit that I too,
cried tears of joy.
When for the very first time,
I at last saw my boy.

As I stood there in awe,
and gazed down at his face,
in an instant the world,
became a much better place.

My heart was bursting, 
with an intense sense of pride,
as I pictured my life, 
with my son at my side.

I know it's early days,
and we've only just met,
but I promise I'll be,
the best father a boy can get.

I'll love you forever,
my son and my wife,
keep you safe, and protect you, 
for all of my life

This is written by one of my clients who wished to share her experience around decision making for place of birth and ultimately choosing and having a home birth. Thanks for sharing. To learn more about birthing at home, please visit my website: www.vancouverhomebirthdoula.com


"I was 40 when I gave birth. The "system" seems to be designed to scare pregnant ladies over 35. Because of my age, I didn't even think a home birth was possible until my midwife told me it was.  I had been subject to a lot of anxiety during my pregnancy. Hospitals are not happy places for me, and the idea of giving birth at home seemed so much easier logistically, physically, culinarily (that's not a word), mentally and emotionally.
So that's what I aspired for and that's what I did. Although I still had a bag packed and had to be mentally prepared for a change of plans, it happened at home as I had envisioned. I'm so happy for this decision and this outcome. Transition to postpartum care was so smooth. 
My midwives and Debra supported me throughout and I had full confidence in the medical care I was receiving. We are fortunate in that our midwives are well connected to the hospital system, so I knew that if we needed to go, the midwife would arrange this well enough in advance that it wouldn't be an emergency.
It is a personal choice, based on one's comfort level and idea of safe space, but we can make that choice ourselves (unless the Universe decides otherwise), regardless of the "system" or random opinions and commentaries that pregnant women tend to be subjected to.
My mother told me her friends were surprised that we did this at home, so I guess it's not as common as it used to be back in their native India. My mother didn't seem too shocked, as most of her siblings were also born at home. We are blessed to have options, and home birth is an important one."