Indicated induction is one of the more frustrating scenarios women who wish to labor naturally find themselves in. While there is debate about what exactly constitutes an indicated induction, when truly medically necessary, it can be difficult for both women and their providers to figure out how an induction can be done in a manner conducive to a natural labor or whether an unmedicated should even be attempted.

There are certainly certain situations in which it is particularly difficult to support a natural labor. For example, in an induction performed for severe preeclampsia, it is not advisable for a woman who is extremely ill to ambulate, as she will require medications that must be closely monitored and upright positions are likely to worsen her hypertension. Furthermore, in this situation, an epidural may actually lower blood pressure and improve her chances of at least having a vaginal delivery. Given the life-threatening nature of preeclampsia, maintaining the mother’s stability certainly should supersede all other concerns; however, this can and should still be done with the goal of changing as little as possible of the original intention for the patient in respect to room atmosphere and post-delivery care. Another example of a situation where supporting a natural birth plan is difficult is an induction performed for poor fetal status, such as growth restriction or oligohydramnios. These babies often have difficulty tolerating the induction process and frequently require specific positioning of the mother for stabilization of the fetal heart rate tracing, maternal oxygen and fluid supplementation, and continuous monitoring. In addition, they are at higher risk of acute distress and bradycardia requiring emergency delivery, so many providers recommend diet restriction in this circumstance.

However, most inductions are done for conditions that carry significantly less risk of complications during the labor process and the main risk to be considered is the induction itself. Some examples of these types of inductions are those performed for postdates, gestational diabetes, pre-labor release of membranes, mild gestational hypertension, maternal age, or maternal obesity. In these situations, the induction, if handled appropriately, can be completely compatible with an unmedicated delivery. Baby Conner’s birth is an example of just such a birth.

Usually, for nonurgent inductions, the potential need of an induction can be anticipated several days in advance. When the need for an induction is anticipated, attempts can be made beforehand to either bring about labor nonpharmacologically or to improve upon the cervical Bishop’s score prior to the induction, which makes the induction easier and more likely to succeed.¹ Membrane sweeping is the best studied means of bringing about labor nonpharmacologically. Studies have shown that membrane routine sweeping beginning at term reduces the likelihood of pregnancies extending to 41 and 42 weeks, which may have particular application for patients with advanced maternal age, obesity, or diabetes, in whom research suggests that postdates pregnancies are more problematic. Membrane sweeping has also been demonstrated to be effective in achieving spontaneous labor within 48 hours and reduces the need for formal induction in one out of eight women or decreases the rate of induction by 16%. The main risks associated with membrane sweeping are maternal discomfort, nonclinically significant vaginal bleeding, and pre-labor release of membranes. No differences in the rate of cesarean delivery or maternal or neonatal morbidity have been observed with membrane sweeping, making it a reasonably safe option to offer patients hoping to avoid a formal induction.²

Other nonpharmacological means of bringing about labor have not been thoroughly studied, but offer some promise and suggest the need for more research into alternative, nonpharmacologic means of induction. Three older observational studies examined the use of acupuncture as a means of induction. In these studies, induction was successful in 67% to 83% of patients and achieved a mean induction to delivery interval of 13 hours; however, there was no significant difference in cesarean rates when compared to controls.³ More recent randomized control trials have not shown significant efficacy of acupuncture as an induction tool, though the most recent Cochrane Review suggests acupuncture may improve the cervical Bishop score prior to an induction.⁴ Furthermore, no ill effects are associated with acupuncture so, at this time, it falls into the “may help, won’t hurt” category of nonpharmacologic options that women faced with an induction may wish to pursue.

Nipple stimulation is another tool frequently recommended to bring about labor. It is known that nipple stimulation results in the release of endogenous oxytocin and generates uterine contractions. A review evaluating six randomized studies, four comparing nipple stimulation to no treatment and two comparing nipple stimulation to pitocin, found that nipple stimulation resulted in a significant decrease in the number of women not in labor within 72 hours, reduced postpartum hemorrhage rates, and was comparable to oxytocin in its efficacy in bringing about labor and achieving a vaginal delivery.⁵ However, one trial performed exclusively in high-risk women, including women with postdates pregnancies, hypertension, and intrauterine growth restriction, showed an increase in the rate of perinatal death with nipple stimulation.⁶ While this study was not large in scale and provided only limited antenatal testing via a simple non-stress test prior to randomization, it does suggest caution should be used when recommending nipple stimulation in an unmonitored, outpatient setting in high-risk patients. However, in low-risk patients, it may reduce the need for pharmacological induction.

Over-the-counter agents, such as castor oil or homeopathic medications, and sexual intercourse are also frequently recommended in the natural childbirth community as a means to bring about labor without a formal induction. However, the limited research to date on these methods has failed to show any clear benefit to this common advice. Homeopathy has only been studied in one trial that failed to show any benefit over routine care.⁷ Likewise, only one randomized study has examined sexual intercourse as a possible induction technique and did not demonstrate any benefit, though in a later observational study, couples who reported coitus at term were found to have an earlier onset of labor and reduced need for induction at 41 weeks.^8,9 Castor oil, which has demonstrated efficacy at producing uterine contractions, has also been studied only to a small degree. It was shown to be effective at producing labor in one randomized trial of 42 women; however, a larger study failed to demonstrate this benefit, though no harm was associated with its use.^10–12 Current reviews of the literature also did not find a benefit of castor oil or any other over-the-counter medications or sexual intercourse.¹³

Consequently, given the limited efficacy of nonpharmacologic options, most women who require a medically indicated induction will require an in-hospital, medical induction, with all the potential impacts on their labor plan that were previously discussed (see Chapter 5). Providers and patients must then choose the pharmacologic induction that offers the best chance of a vaginal delivery and is most conducive to nonpharmacologic methods of pain relief. The most common form of induction agents are pitocin, prostaglandin E2 dinoprostone (Cervidil), and misoprostol (Cytotec) administered orally or vaginally. Multiple trials have demonstrated a higher rate of epidural use among women induced with pitocin, compared to both women who labor spontaneously and those who are induced with prostaglandins.¹⁴ Most women report that pitocin contractions are stronger, more frequent, and more difficult to manage with nonpharmacologic pain relief methods than spontaneous contractions. Hence, most would consider pitocin administration to be relatively noncompatible with a natural birth plan.

However, induced delivery can be achieved without pitocin. When misoprostol, administered both vaginal and orally, was compared to both oxytocin and other prostaglandin agents of induction in a large number of trials, misoprostol was associated with less epidural use, fewer failures to achieve vaginal delivery within 24 hours, and lower rates of cesarean. When misoprostol was compared to dinoprostone, misoprostol was also less likely to require pitocin augmentation. Misoprostol was associated with higher rates of uterine hyperstimulation than either oxytocin or dinoprostone, but this did not cause increased fetal distress or worse neonatal outcomes. Misoprostol was also associated with higher rates of meconium fluid, but this also was not associated with poor neonatal outcomes, suggesting that this increase may be due to an effect of misoprostol on the neonatal gastrointestinal system, rather than an indication of distress, as it is typically thought to be.¹⁵ Studies have also compared the vaginal and oral routes of misoprostol administration and found oral administration is as effective as vaginal administration, is associated with a better neonatal condition at birth, and has less postpartum bleeding.¹⁶ Unfortunately, despite the large quantity of evidence of its comparable safety and efficacy to other agents, misoprostol is still not FDA approved for labor induction and some providers are reluctant to use the medication “off-label.” Off-label use of medications in general is common and legal, provided it is supported by quality evidence, but off-label use carries a higher medical–legal risk, especially in obstetrics. It is also unlikely that misoprostol will ever be FDA approved for induction because it is an inexpensive medication that is already being widely used for this purpose, thus there is no incentive, in terms of increased revenue, for the manufacturer to go through the lengthy and expensive process to acquire FDA approval. Hence, many patients wishing to labor naturally may not have access to this medication which is more likely to help them achieve an unmedicated vaginal delivery than other medications.

Yet, beyond the induction agent used, there are other important ways an unmedicated delivery can be supported in induction setting. Provided the mother and baby are stable, the key to enabling an unmedicated delivery is maintaining ambulation and freedom of movement during the induction. This is frequently challenging, given the need to continuously monitor most patients undergoing an induction, but can be achieved by utilizing the mobile monitoring techniques and solutions explored in Chapter 10. Placing a hep-lock IV, as opposed to continuous IV fluids, and permitting oral intake, at least for hydration, also encourages freedom of movement. However, inductions are frequently long and, in most inductions, the mother and baby are stable enough to permit eating, as well as drinking. Restricting diet contributes to both physical and emotional fatigue in all laboring women, but is particularly difficult for those trying to work through their labor without medical pain relief. If signs of distress or complications develop, diet may need to be restricted in anticipation of a cesarean delivery, but this should be approached on an individualized basis rather than a blanket policy.

Maintaining access to hydrotherapy is also incredibly valuable for women undergoing induction. Often the shower or tub can be just enough of a comfort to help a mother who would otherwise have given up on her plan. However, continuous monitoring during hydrotherapy is particularly difficult and is the component of care that most frequently restricts shower and tub access in the induction setting. In order to offer induced women easier access to hydrotherapy, care providers should consider whether relaxing monitoring guidelines is possible for their patient, given the individual circumstances of the induction. This is dependent on the indication for induction, where the mother is in her labor process, and how long it has been since she has received an induction agent. For example, often with a misoprostol induction, the mother’s labor progresses to the point that no additional doses of medication are necessary or a simple amniotomy will be sufficient to continue the labor. The half-life of misoprostol varies according to mode of administration, with vaginal use associated with a longer half-life than oral use; however, for both modes of administration, within 4 hours, the serum concentration of the medication is low enough to render the effect on the fetus negligible.¹⁷ Provided fetal monitoring has been reassuring to that point, it is reasonable for a woman induced for a lower risk indication to labor in the same manner she would have if her labor had begun spontaneously, once she is out of the window where the induction agent is likely to have a fetal effect.

If the laboring mother is not outside that window or there is a medical indication for continued monitoring, hydrotherapy can still be attempted utilizing previously discussed alternative monitoring techniques, specifically using taping as a seal against the water. More frequent intermittent auscultation of the heart rate could also be considered in this setting; however, alternative regimes of intermittent auscultation in higher risk patients have not been studied and most providers are unlikely to feel comfortable utilizing intermittent auscultation methods during an induction. Yet, even in higher risk settings, providers should ask themselves how likely it is that anything is going to change in regards to the fetal status in 5, 10, 15, or even 30 minutes. Furthermore, even if a change occurred, how likely is it that this would alter management or require emergency delivery, especially if the fetal monitoring had been reassuring up to that point.

Patience is also incredibly important during all inductions, but particularly so for inductions in naturally laboring mothers. Inductions, no matter how they are performed, are long, taking, on average, 8 more hours than a spontaneous labor.¹⁸ In a typical, medically managed induction, the goal is to safely achieve delivery, as efficiently as possible. However, a less efficient mode of induction or management style, in keeping with the stepwise model for medical intervention, may be the one that enables a woman to have an unmedicated delivery and maintain her sense of control over the process. Unless there is a more urgent need for delivery, there is no rule that says inductions must be completed in 24 hours.