Inductions: Why Are They So Damn Hard?
Labor inductions are a topic that so many doulas struggle with.
Why are they so challenging? And is there anything doulas can do to make them more manageable?
First, let’s start with the basics:
What Is an Induction?
A labor induction is when labor is started artificially. Normally, labor starts on its own due to a shift in hormones that start circulating in a pregnant person's body. Those hormones trigger several different physiological actions that cause the uterus to start contracting and eventually lead to the baby’s birth.
But sometimes, labor doesn't seem to want to start on its own. Or sometimes, there are reasons that labor starting soon might be necessary.
The medical process to start labor is quite complex, and I won’t go into those details in this blog. For now, you just need to know that a combination of medications, medical devices, or procedures are used to get the uterus to start contracting, or to cause the cervix to start opening. All of which are designed to kickstart the birth process.
Now, that sounds easy enough (or not). But here's the thing: If the body wasn't going into labor on its own, chances are it’s because it's not ready, and there's a reason why it's not going into labor on its own.
And for that reason, inductions aren't always successful.
Have you ever tried to force an avocado to ripen? I think we've all been there... Gathering up the bowl of chips and a dish of salsa... Mmm, some guacamole would be excellent!
And then you spy the rock-hard avocado on the counter.
If you're like me, you Google ‘How do you get an avocado to ripen fast?’ and learn to put it in the oven. You end up with an awful, warm, funky tasting avocado that is ruined.
If the avocado was close to being ripe and just needed a little nudge, it might have worked.
Kind of like labor... If someone is close to going into labor and just needs a little nudge, inductions tend to work okay.
But otherwise, you might end up with a funky labor that doesn't work very well.
So why does anyone bother inducing labor?
Why Is Labor Induced?
Hopefully, labors are only induced for medical reasons. The pregnant person may develop a medical complication, and it’s safer or healthier for them not to be pregnant anymore. Preeclampsia is the most common example of a medical condition that necessitates forcing labor to start. Gestational diabetes and cholestasis are other conditions.
The baby may also need to be born sooner rather than later for medical reasons. As the pregnancy continues, the placenta may start aging and not functioning fully. If the baby is not growing well, or shows signs of distress, or its amniotic fluid is decreasing, being born a bit early might be safer than staying.
Those are the primary reasons labor should be induced.
However, the most common reason that labor is induced has to do with one's due date. If someone is 40 weeks pregnant — in other words, their due date — and they haven't had their baby yet, many people are encouraged to have their labor induced. Why?
Well, there's some research that says that, as babies go past the 40-week mark, they may get too large to be born easily, they may not tolerate labor as well if the placenta is aging, and in the worst case, the risk of stillbirth increases. (The incidence is really small: 14.9 out of 10,000 births, or .00149%).
Despite that tiny number, people understandably get a bit nervous if their care provider suggests an induction. Even if they didn't want induction, they often go along with it.
But it's not just 40 weeks. Sometimes, people are advised to get induced at 39 weeks, 38 weeks, or sometimes even 37 weeks. There might be a medical condition contributing to that recommendation. But often, it's really more about personal preference.
“You're getting towards the end of your pregnancy; your baby should be fine. Let's induce labor and get this going.”
You may have heard about situations where an induction is done for convenience: the doctor will be out of town so they schedule for the week before they leave. Or the pregnant person wants to be induced because they're really tired of being pregnant. Or a family member is coming to help for a limited period, and the parent doesn’t want the baby to come late and minimize the support window.
All those reasons are valid. As long as everyone can balance the risks and benefits.
What the Research Says About Inductions
Several studies have been done on the potential complications or benefits of induction.
Complications include additional medical procedures that increase rates of infection, parental distress, and fetal distress. Many studies have found inductions lead to a higher risk of cesarean birth, which is a major surgical procedure that carries significant risks.
One of the most recent studies was done in 2019, called the ARRIVE study. This study compared the outcomes of births between two groups of people: one group who had their labors induced at 39 weeks, and another group who waited until labor started on its own. The researchers looked at rates of cesarean birth, stillbirth, and medical complications between the two groups.
They found no difference in rates of stillbirth. However, there was a slight decrease in the rate of cesareans in the induction group. (The study did not exclude parents who developed medical conditions that led to cesarean births from the control group; excluding them may have lessened the rate of cesarean in the control group lower than the rate in the induction group.)
There has been a lot of research on inductions. For the most part, it shows that there's an increase in medical intervention and a rise in the Cesarean rate. There may also be significant dissatisfaction for people who've had inductions because they didn't know what to expect. And that's what I want to talk about next.
Preparing Clients for Induction
When I was practicing as a doula, clients would come to me either with questions about induction or because their care provider had suggested an induction. There are many things a doula must consider when an induction is recommended.
The first thing to find out is if the client knows what an induction is. I don’t expect they’ve looked at the studies. But do they even know what's involved in having their labor induced?
Do they know the potential risks? Has their care provider explained any of the possible complications to them?
I would compare their information with what I knew my clients wanted for their birth. What kind of birth were they hoping for? What were their biggest desires and most significant fears?
For every individual client, their ideas about induction would be unique.
Then, I hoped there was an actual medical condition for advising an induction. Not that I wanted there to be a medical complication; I just didn’t want there to be an unnecessary induction.
When a medical condition is present, it’s easier to talk about the benefits of induction that outweigh the risks. If there aren’t any benefits, the risks are all just risks — nothing to balance them out.
Clients need both so they can give fully informed consent and know what will happen to them and their baby before they start the process.
But What About Me, the Doula?
That’s what I wanted for my clients. But what was this going to be like for me?
Inductions are really challenging for doulas. Inductions are usually very long, at least 24 hours. Often, the first 24 hours are spent just getting things started. Various medications or devices are applied to the cervix to prepare it for labor. Followed by another 24 hours to get contractions going, regular, and effective.
People could be in the hospital for two days before having their baby. That is different from what they were expecting. I asked my clients, ‘What do you think an induction is like?’ And they’d respond, “Well, the hospital told us to show up at 7am. We expect we’ll have a baby by 7pm... It's going to be awesome!”
It was usually me breaking the news to them. There was so much they didn't know and so much that they hadn't been told. It was quite awkward to be the one to inform them they could be in the hospital for days. And that it's an emotional and mental marathon as much as a physical one.
I also had to break the news that their birth would look a lot different from what they planned. There would be more restrictions on what they'd be able to do because of the medication and the medical equipment in use. And I would be limited in what I could do to support them.
The reality is that if labor is two days long, I can't be there for two days. I would let them know I wouldn't be there for the beginning part, or I may have to have a backup doula come in to give me a break. The emotional relationship my clients and I had developed was now being tested.
Show Time! Getting Ready for an Induction
Over the years, I developed ways to help make the conversation with clients less awkward, and make inductions more successful for all of us.
Prevention. No, doulas cannot prevent inductions. But we can prevent inductions from being such an unknown.
In prenatal visits, ask clients if they’ve heard about inductions. Has their care provider ever mentioned in induction? What information would be helpful for them? Most clients will have no questions, no interest, and no idea that this could happen to them. So don’t force the information on them. But do plant a seed by saying, 'Hey, there's this thing called induction that could happen to you. Do you want to know about it?' Planting the seed is the most important part.
Information. It’s much more likely you’ll provide information when it is suddenly necessary. I’d often get a call: “Hey, I saw my midwife today, and they're recommending an induction.”
Now, there are a series of questions to ask: Why is the induction recommended? How do you feel about it? Find out where they are. They might be thrilled, “Hallelujah, this is great news!” And then I’d know, Okay, we're going to plan for the best induction possible.
But often, they’d say, “I wasn't expecting this. I'm scared. I've heard these terrible things.” And then you can respond with, "Okay, let's talk."
My conversations like this were pretty long. I'd find everything they knew about induction and determine if it was remotely realistic. I would ask them if they wanted me to share what I knew about inductions. This is an important part of being a doula: whenever we're offering information — especially potentially a lot of information, especially around something that might feel emotionally charged — we want to ask for their consent.
Ask, "Would you like me to share what I know? Are there specific things you want to know?" and then let them steer the conversation.
I feel a few things are essential for clients to know about inductions: They take a long time. And your birth may look different than what you expected.
Even if they don't want a lot of information, I would let them know these two things in terms of my role, and what they can expect from me. So even if they didn't want to know anything about an induction, even if they say, "My doctor told me to show up in the hospital at 7am, so I'm just going to be there,” I would say, "Okay, here's what my role is going to look like for your induction...” And by explaining my role, I could tell them a little bit about the induction process and what to expect.
For example, I might say, “Okay, they want you to be at the hospital at seven. Now, normally, you'd go to the hospital when you're in labor. And I would join you at that time. But because you're going to the hospital when you're not in labor, I won't be joining you until your contractions are coming regularly, just like when I would have joined you at home. I understand you might feel pretty nervous when you're going in. And there might be a lot of questions and uncertainty. So I can show up for the first hour or two in the morning, to be there for emotional support. I can help you get settled in and be there while the process gets started. If that sounds useful, then I can come in the morning. But I’ll leave after an hour or two until you're having contractions and you need my labor support.”
This is how I set realistic expectations for my clients. I didn't ask for their permission. I didn't ask what they thought about it. I only asked whether they wanted me to be there for those first few hours, and if they did, I let them know then it was only for an hour or two. I would offer to call and check in throughout the day. But I set a very clear expectation that This is how it works. This is how it's going to go. I would do it in a very loving but firm way because I was setting boundaries that would allow me to provide good labor support when they're actually having contractions.
After I explained those things and answered any questions or concerns, I’d ask if there was anything that they particularly wanted me to do. When we finished the call, I would hang up and let it go.
I often felt frustrated that clients didn't want information I thought would be helpful; I was often frustrated because I knew they were stepping into a birth they really hadn't planned on. I might be frustrated if they wanted me to come and stay for a long time and I had to tell them no. A lot of emotions might come up for me. But to protect myself, I had to get off that call and say, “I did the best that I could,” and let it go.
Because there's still so much of the story left to unfold.
Being At an Induction
Here are a couple of tips to create the best induction experience possible.
The birth space. When you arrive at the birth space, check out the ambiance. What's going on in the room? Would they be laboring like this if their labor had started on its own? Or is it not a good, conducive atmosphere for labor?
Labor is reliant on a number of hormones. And those hormones do really well in certain situations. And they don't do well in other situations. There are a lot of medical interventions during an induction, and if people resign themselves to a lot of medical staff coming and going, bright lights, wires and tubes everywhere, they don’t even try to get in the mood for labor.
And — hint hint — the mood for labor is very similar to the mood for lovemaking. A medical environment is not where most people want to make a baby. You can redirect the atmosphere, turn down the lights, put on some music, and get people chilled out to create a more soothing, relaxing, loving environment with less of a medical vibe.
Pace yourself. When an induction is looming, do your best to be rested, well-fed, and get some exercise so that when you’re called to the birth, you’re the best you can be. Also, call your backup doula and let them know you’ve got an induction happening. Make sure they know you’re going to an induction soon, and they may be called in to give you a break.
That break — depending on all the factors that go into a birth — might consist of coming in for a few hours so you can nap after you’ve been there for a long time, or it might be coming to take over for you after you’ve been at the birth for 12 or 18 or 24 hours. All of this depends on what time of day or night you were called to the birth, and what kind of condition you were in going into the labor.
When you know that you have a backup doula who’s ready to give you a break, it can keep you going a little bit longer. And if you're a backup doula for somebody who's doing an induction, knowing that if you get called in, it's going to be for a limited time, can make it much easier to get called in because you know you're not going to be there for days.
It’s also essential to be open to whatever needs to happen at the birth. Your clients may have wanted fewer interventions than they're experiencing, and you may feel bad that you aren’t helping them attain that. But when an induction happens, you must embrace as many things as needed to keep that labor going. We call this active management.
Inductions are the most successful when the labor progresses steadily. And that might mean choosing things that were otherwise on people's “I want to avoid” list. The best way to prevent a cesarean in a labor induction is to keep the labor progressing and moving as smoothly as possible.
And finally — remember — this is the birth of a baby, the birth of a family. Babies come into the world in all different ways. And this is just one of the many ways.
Inductions can be hard, they can be long, and they can be frustrating. They can be awkward, and they can be tiring. But knowing how they happen and how we can set our clients and ourselves up for success, can make inductions much less daunting for the doula.
If you want real in-depth instruction for navigating inductions, check out my online birth doula training or learn advanced skills in my doula business and marketing coaching program.
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