“Induction of Labor: Everything you need to know” – with Dr. Sara Kostant

Dr. Sara Kostant returns to Healthful Woman to discuss induction of labor, a common occurrence with about 25-30% of pregnancies ending in induced labor. In this episode, she and Dr. Fox discuss why induction is necessary, C-section rates in induced labors, and more.

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Dr. Fox: Welcome to the “Healthful Woman” podcast. Today is Monday, March 8th, 2021. I’m joined today by Sara Kostant to talk about induction of labor, everything you need to know. Currently, about 25% of pregnant women in the U.S. undergo induction of labor and that number is on the rise. Sara and I talk about why we might recommend an induction and what our thought process is in coming to that recommendation. 


Also, for anyone who is scheduled for an induction, we go through the process step by step to give you a sense of what to expect. I have found that the process can be a lot less anxiety-provoking when women have this knowledge up front. 


On Thursday, our “High Risk Birth Story” is a really powerful one. I’m gonna be joined by Julie Matuda [SP] who’s going to tell the story of her delivery in the height of the pandemic. Next week on “Healthful Woman,” I’m going to be joined by influencer Fortune Dushey to talk about influencers and wellness. Reminder, we’re gonna have a “Healthful Woman” podcast every Monday, and a “High Risk Birth Story” every Thursday, so be sure to subscribe to both. And if you’re on Apple, we would really appreciate you giving us a five-star rating for both podcasts. Thanks for listening. Have a great day. 


Welcome to today’s episode of “Healthful Woman” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Sara, welcome back to the “Healthful Woman” podcast. So nice to see you. 


Dr. Kostant: Yeah, good to see you, too. 


Dr. Fox: Fantastic. So we’re gonna be talking about induction of labor, which is really common. And we’re gonna cover what it is, why we do it, how it’s done. But also be kind of practical for our patients what to expect with an induction of labor. Because I know a lot of people heading into it have a lot of questions and it’s uncharted territory for them. And a lot of them are actually tuning into this podcast just to hear what it’s like. 


Dr. Kostant: Absolutely. Like, we were talking last time I did a podcast, we need to do something like, you know, pregnancy and labor-related. I covered pre-pregnancy, post-pregnancy recovery, and now we’re actually getting into the delivery. 


Dr. Fox: We’re working our way towards the middle of pregnancy. 


Dr. Kostant: Exactly. 


Dr. Fox: So for induction of labor, essentially, it happens a lot in pregnancy, it’s pretty common. You know, every practice is a little bit different but, you know, in the U.S., I think like 25% or 30% of women who are pregnant ultimately get induced at the end of pregnancy. And I’m not sure if people are aware of that. Do you find that people are surprised that they’re getting induced? 


Dr. Kostant: Actually I find more patients almost expect…and again, this does vary city to city, practice to practice. But I feel in our practice, many patients feel like most likely they’re gonna…and they’ll tell me, “I’m probably gonna end up getting induced.” And I’ll kind of like ask them why. And I think a lot of it is, you know, for a variety of reasons that we’ll kind of touch on, it has become more common, and when patients talk to, let’s say, friends or family members, I think they just hear about it. 


It’s almost the expectation for…and in particular, in our practice, we do have a more higher-risk patient population that has more medical issues. So I think for that reason, a lot of our patients, you know, kind of feel that at some point…like when I talk about timing of delivery, some patients will even be surprised when I talk about, you know, “Usually, if everything is going well, you know, maybe like a week after your due date, if you haven’t gone into labor, we’ll have you scheduled or, you know, we’ll talk about an induction.” And they’ll be like, “Wow, I’m gonna go that far in pregnancy?” 


Dr. Fox: Some of them are not only shocked and surprised, and some are quite dismayed. 


Dr. Kostant: Right. It’s like, “I didn’t want to be induced early but I don’t wanna go that far.” 


Dr. Fox: I think part of it is because of the reason someone would get induced. And I think a lot of time people’s perception is, “Oh, the reason I’m getting induced is because well, you know, enough is enough. And the doctor is like, you know, ‘we’re through with you and you’ve been pregnant long enough, or it’s more convenient for me and more convenient for you.’” And actually, that’s not why we do it. It’s almost never why we do it actually in our practice. And it’s really, we’re trying to balance the risk of staying pregnant versus the risk of an induction, and that’s a complicated, I guess, calculus. 


And so in our practice, since we tend to have more higher-risk patients, there can be risks with an ongoing pregnancy, either to the mother or to the baby. And that’s why we’re more likely maybe than others to recommend an induction. But again, it’s not just because, like we’re usually, you know, giving a reason for why we’re doing it. 


Dr. Kostant: Yeah. And that’s one thing I also stress to patients is that, you know, we’re a larger practice and we have a 24/7 call schedule. So we really base the decision on what’s best for the patient and her baby. I don’t tell people, “Oh, you need to…or I recommend you be induced on Wednesday night because I’m there the next day.” You know, I never do that. You know, some patients will say if they need to be induced, they’ll wanna maybe be delivered on a particular day if there’s someone that they wanna deliver with. But we really focus it completely on, you know, what’s best for the patient. 


And usually, when I talk to patients also about induction, even if it’s for a medical reason, we give a range of time. Like, it won’t just be, “Okay, you know, this particular day.” We’ll say, “You know, any time from, let’s say, like, you know, 39 weeks to 39 weeks and 6 days.” So it does give at least some range of time for the patient to figure out what’s best for her. But yeah, I don’t push patients into induction just because of any convenience on our part definitely. 


Dr. Fox: Right. That’s a good point that, you know, in practices like ours, and many are structured that way nowadays, since there’s always someone who’s assigned to cover labor and delivery, and that person gets relieved by someone at a certain time. It’s not like, you know, people think, “Oh, I have theater tickets and therefore I’m inducing you,” or, “I’m going out of town and therefore I’m inducing you,” it really doesn’t work like that. You know, we’re there every day, one of us is there every day. So it doesn’t really matter for our schedule. It’s much more so for the patients. 


And, you know, when we’re trying to think of risk, I mean, there’s a couple of big ones to staying pregnant. And the biggest one, which is, you know, the hardest to talk about only because it’s so scary is the risk of stillbirth, right. With every pregnancy, as it progresses, there is a small risk of stillbirth, of the baby passing away inside. Now, again, it is small. But as you get more pregnant, particularly when you start passing your due date, that risk starts to go up a little bit. 


And if there are other risk factors on the table, you know, twins, high blood pressure, diabetes, other medical problems, the baby’s not growing so well, the fluid is low, whatever it might be, that percentage starts creeping up to a number that it gets uncomfortable. And you’re like, you know, we can wait and, you know, most likely everything is gonna be okay. But we really try not to use most likely when talking about the health of the baby. 


And so based on the risk factors and based on the circumstances, our breakpoint for when we’re more comfortable delivering than waiting changes. And sometimes it’s a week after the due date, like in the lowest risk of pregnancies, and sometimes it’s at the due date, sometimes it’s a week before the due date, sometimes it’s two weeks before the due date. And so different people get different recommendations for induction based on their specific circumstances and their pregnancy, both their risk factors and how things are going along for the baby. 


Dr. Kostant: I would say what you mentioned, the risk of stillbirth is uncomfortable to talk about is what drives some of this…most of the decision-making regarding induction of labor. And the one instance that would also from a maternal standpoint, from the mom getting sick is women with high blood pressure or women who develop pre-eclampsia, there’s a risk to the baby. But there’s also actually a risk to the mom to staying pregnant longer because pre-eclampsia is something that can be very dangerous for the mom. 


So in a woman, let’s say, who has well-managed chronic hypertension comes into the pregnancy with it, but her blood pressure stays normal throughout the pregnancy, maybe she’s on a, you know, medication during the pregnancy and everything is going well, there is a point where we will say you know, “Even if things are going well, we don’t recommend going past this point in the pregnancy, not just because of risk to your baby of stillbirth but also risk to you. Because if you get pre-eclampsia, that could make you very sick, and that could be potentially life-threatening for you.” So there are some issues that we will recommend induction for that are really just related to the risk to the baby. But that’s one instance where it’s also related to the mom’s health as well. 


Dr. Fox: And I think it’s important for women who are getting a recommendation for an induction of labor and they don’t really understand why or maybe they’re not comfortable with it or even opposed to it, it’s important to speak to your doctor and say, “Why are you recommending this?” I mean, what is it that you’re concerned about that is making you recommend an induction and to sort of, you know, “end the pregnancy” at a certain point in time? And you know, you may end up hearing something, well, I’m concerned about stillbirth, which can certainly be freaky to hear, but you may hear something like, well, you know, it’s for your health or whatever. 


And I think it’s important to get that understanding because when people, you know, talk about induction, you know, they often even don’t understand what’s going on and why it is. But typically there is a good reason for why it’s being recommended. And the only reason you may not wanna talk about it is if you just don’t wanna talk about the idea of stillbirth because it’s just too painful to think about, which is understandable, which is also why we try not to just drop that on the table towards the end of pregnancy because there has to be some, you know, art in bringing that conversation up without scaring people too much. But if you don’t know why it’s happening, just ask and your doctor will tell you. 


Dr. Kostant: I’ll look up and bring up statistics specifically just so patients can understand when I say there is an increased risk of something, some patients will ask, “Okay, well, like what’s the degree of increased risk?” And I’m happy to actually, you know, show the numbers. And for some patients, they’re like, “Okay, you know, that actually makes sense to me now, as opposed to just saying that, you know, it’s just an increased risk.” You know, some patients, I’ll bring it up and they’ll say, “Okay, fine, like, that’s totally…” Especially, you know, some patients… 


Dr. Fox: They’re happy to be done. 


Dr. Kostant: They’re like, “Thank God, great,” 39 weeks, 38 weeks, you know, if there’s a medical issue. But there are some patients that really…you know, they understand that they may be higher risk and we’re recommending delivery at a particular time. And we’ll again go into this a little bit more. Like, they really wanted to go into labor on their own. And so for them, I think it’s a little harder to, you know, go along with the idea of an induction. And it does take explaining, even if the patient knows that she has a medical issue and suspected that this would be the case. 


Dr. Fox: When you and I were training, there was this rule in obstetrics that if you induce someone’s labor, you’re increasing the risk of a cesarean. And because of that, we were very hesitant to induce people unless it was absolutely necessary because we don’t wanna increase the risk of a cesarean. And that is definitely the thought amongst women, amongst, you know, the lay press, amongst pop culture, amongst online, whatever it is. 


But what’s interesting is, in the past few years, a massive study was published showing that that’s not the case. And if you look at women at 39 weeks, and you induce them versus not induce them, the C-section rate is exactly the same. And we’ve discussed this in other podcast and why that is, and essentially, it’s because the older studies were not well designed. They compared people being induced to people who are already in labor, which is unfair, right? Because if I’m deciding whether to induce someone, the alternative to inducing her is not she shall be in labor, it is, we’re just gonna wait. And when you wait, she may go into labor, she may end up getting induced a week later, something might happen. 


And so when you do the study properly, there was no difference. And it’s been shown in other populations in women with hypertension and women with ruptured membranes. And multiple, multiple populations of women, it does not make a difference in terms of C-section rate, again, provided that you are patient and let things happen. So it’s removed some of the concern for induction of labor, certainly amongst the doctors, and I think it’s trickling down to the women as well when we explained to them that, no, we’re not increasing your risk of a cesarean because that’s typically one of the biggest hesitations there is. 


Dr. Kostant: That’s probably the number one hesitation that women bring up to me whenever I bring up the idea of an induction is, “I don’t wanna end up with a C-section. And I bring up that trial, which is known as the ARRIVE Trial, interesting enough. 


Dr. Fox: All big studies have to have a fancy acronym, that’s the rule. 


Dr. Kostant: And it always has to kind of match the…like what the trial is talking about, it’s like arrive. Yeah, I’ll bring that up and I’ll go over with them that the reason why I think that that’s the case is that when you induce someone, and you give the induction the time that it deserves, and you’re familiar with how much time each stage of labor is supposed to take, then the induction itself should not increase the risk of a C-section. 


I think that they’re probably…and a lot of this is what patients have heard from friends and families, you know, in the past, I think sometimes if an induction was taking a longer period of time, sometimes some physicians might have said, “Well, it’s not going anywhere,” and kind of ended things a little sooner. And I think…you know, I’ll hear from patients who will say, you know, “My friend delivered or when my mother delivered us,” and they’ll bring that up that they hear these stories about how, you know, at a certain point in the day, it’s like, “Okay, we’re not continuing.” And so I reassure patients. 


And again, I think that in our practice, because, you know, again, we have a call schedule, you know, we’re on call to a certain point, someone new will take over that also knows the patient. But the deadline, if we even set a deadline, only has to do with the mom and the baby’s well-being. And it’s a point where we say, “Look, if we haven’t progressed past this point, we’re not gonna get anywhere and there’s actually risk to continuing.” As opposed to, you know, it’s a certain time of the day we expect things to have been done by now, and if it’s not, like that’s it. We actually give more time than patients, you know, expect to inductions. 


Dr. Fox: And it’s really important because, again, in this study, they were patient and so it really is only applicable if you are also patient as doctors. Meaning, yes, if I induce people and say, “All right, it’s been eight hours nothing has happened, let’s do a C-section.” Sure, you’re gonna, you know, do C-Section of 50% of people getting induced, but if you’re patient, it really doesn’t happen. And if ultimately an induction leads to a cesarean that’s likely what would have happened anyways, you know, five days later when she went into labor or a week later, we’re gonna induce her for another reason, or whatever it is. And I think that that’s important. 


But it does bring up one of the downsides of induction is it takes a long time. And that’s really important for people to understand that, you know, when you come in labor on your own, basically you’ve hit the ground running, right? Most people, when they show up in labor, they’re contracting regularly and painfully, their cervix is 3 or 4 centimeters open or more, their water may be broken already, you know, they’re booming. And to get to that point could be 6 hours at home, 12 hours at home, 3 days at home, it could be anything. 


And when we’re inducing, we’re taking that pre-period, that 6, 12 hours, 3-day period, and condensing it into overnight. And so it takes more time to get to the starting line, so to speak. And that’s why inductions frequently will take 12, 18, 24, 36 hours, whatever it is, and that’s important for people to know, on the front end. 


Dr. Kostant: That’s the one thing I will always acknowledge to patients about induction is…and I will admit to patients when…because they’ll bring that up too and I will tell them, that is true. You know, just to get you to the point where you’re starting early labor will take several hours. And sometimes during inductions, I’ll actually offer it as a point of reassurance, though, that some patients will say to me, you know, “I’m 3 or 4 centimeters, I was hoping I would be more dilated.” And I’ll say, “Actually, I wouldn’t have expected things to have progressed past this point. Like, you’re kind of exactly where you should be.” 


So that is one disadvantage. Again, for medically indicated induction, the benefit is still gonna outweigh that for many people. But, you know, it’s something I bring up if someone does wanna be induced like earlier, and we’ll talk more about that, that’s the one disadvantage, I’ll say, is that you will just have a longer time in the hospital, and the process of just getting you into labor may take longer. 


Dr. Fox: And I think what you’re getting at is idea of this elective induction, that people just choose to be induced. And there’s actually new debate about whether we should even be calling it elective induction. Because, again, after 39 weeks, there really isn’t any known benefit to the baby to staying inside longer. Under 39 weeks, there seems to be benefits, and the earlier you are, the more benefit there is to the baby to staying in. But after 39 weeks, that sort of peaks. 


And so the thought process is, well, since induction does not increase the risk of a cesarean, and there’s some risk of stillbirth, it’s not really elective. You’re inducing for the same thing we said before, you’re taking sort of, you know, a very low risk of stillbirth and saying, “Well, fine, I’ll induce because there’s not an increased risk of cesarean.” And so for that reason, some people aren’t calling any induction after 39 weeks elective anymore like just by choice, patient choice, doctor choice, whatever. 


And I think that’s true. But ultimately, there is some issue with that because if every single person got induced at 39 weeks, you’re essentially doubling the time someone’s gonna be in a labor room, and there may not be enough labor rooms. And then you’re gonna have people showing up and, you know, delivering in a hallway or whatever because there aren’t enough spots. And there is a logistical concern to that. But I do agree the idea of getting induced after 39 weeks should not be one of, like, shame that you’re doing something, you know, purely elective, and it’s a bad idea. It’s fine, it just takes longer compared to doing it spontaneously. 


And so we tend to do it only when there’s other risk factors only because they wouldn’t get a spot at the hospital. Like, there just wouldn’t be one available, even if someone wanted to get electively induced at 39 weeks because all the other people waiting to do it would take priority over her. 


Dr. Kostant: Yeah, I agree. I think that my threshold for offering induction starting at 39 weeks where there’s not, as you were saying, like a medical indication of the sense of like high blood pressure, or diabetes, or low amniotic fluid. I have a much lower threshold to discuss that and offer it, which is, again, such a change from residency where, you know, it was like, no, like actively discourage patients from even considering it. I don’t do that now. 


You know, we both have patients that will bring up concerns about going past 39 weeks either logistically that they live very far away, they’re worried that their labor will go quickly, you know, they’re extremely just uncomfortable during the pregnancy. All things that as a resident, we would still…like we were still kind of taught, we’ll encourage patients to, you know, not get induced unless, again, there’s one of these medical criteria. 


And now I feel very comfortable bringing up, you know, “We could arrange for you to be induced once you cross 39 weeks as long as everything stays okay, if you have concerns about getting to the hospital on time.” You know, if someone is worried that their labor is gonna go quickly, if they have had a lot of, you know, just chronic pain issues, you know, flaring up in the pregnancy, sometimes even for those we may need to induce patients earlier. And some patients are surprised actually that that’s even an option. 


So I think it can be a good option for many patients, especially, and if someone has had a baby before the induction would probably go more quickly. But even someone who’s never delivered before 39 weeks and, you know, wants to discuss induction, you know, like, I think we’re fine with it. And as long as we can find a spot at the hospital and as long as the patient just understands that the time it may take to have a successful vaginal delivery, you know, we’ll be there and we’ll do it. 


Dr. Fox: And we function under the constraints of our hospital, like everybody does. And like you said, we’re there every day. So for us, it’s not inconvenient or convenient for someone to get induced, it’s just it is, like, it’s fine. But at the hospital, you know, there’s a lot of people being delivered. And if, you know, there’s five people getting induced at night, all of whom have a stronger reason than, you know, our patient, she’s gonna have to wait, essentially. And I explain that to people also that we’re okay with it, but just, you know, we have to operate, you know, under the constraints of our hospital and volume. And that’s true everywhere, it’s not unique to where we deliver. 


And under 39 weeks, it’s a little bit…there is a higher bar, because, again, like we said before, there is some upside to the baby to waiting to 39 weeks. So if there’s no reason whatsoever, we’re not gonna typically induce before 39 weeks. But there are many medical reasons for the mother or baby that we do deliver under 39 weeks. 


And again, it’s just a matter of…it’s the same idea that we’re balancing, but the bar is gonna be set differently when you’re under 39 weeks because you are potentially increasing risk to the newborn by being either premature or mature, like term, but less term. And so you really have to have a good reason to induce beforehand. And that’s been a big push in the past several years, for good reasons, to not induce people for sort of mediocre reasons prior to 39 weeks. 


Dr. Kostant: Many patients are surprised because they’ll know that, you know, 37 weeks is what we consider term. But even at 37 weeks, some babies that are delivered even if it’s spontaneous, you know, labor, like mom goes into labor delivers. You know, some occasionally will have some breathing issues, or, you know, some issues with jaundice or feeding, very mild, and those babies usually like do very well, we don’t expect any long term issues. But after 39 weeks, the risk of that pretty much is eliminated. 


So between 37 and 39 weeks, if someone otherwise is doing fine, there’s no reason to induce, you know, we won’t. Obviously, if there’s any issue that could pose a risk to the mom or baby, you know, we’ll go ahead. But that’s why if things are otherwise going well, 39 weeks is really, you know, what we try to get to, especially if there’s really no medical issue. 


Dr. Fox: Right, so we spent a fair amount of time talking about sort of the concept of why someone would get induced or get recommended to be induced, and sort of our thought process of why we recommend it versus our hesitation, and how we decide who needs it, and when to do it. And that’s all very important. And I wanna shift now to sort of the second aspect is just, how do we do it? Like, what is it that we do to induce labor? And then the third part is sort of, what to expect, you know, from the patient’s perspective? 


So in terms of how we do it, the way to explain to people is, you know, when someone is going into labor on their own, there’s a slow process where the cervix, over time, softens, and shortens, opens a little bit. And at the same time, the woman is gonna have contractions that are getting closer together and getting stronger. And they don’t always happen at the same time. Sometimes she’s contracting before the cervix opens, sometimes her cervix opens before she contracts. Sometimes they happen simultaneously, but it takes a while. 


And the point of the induction is basically to take someone who none of that is happening, and to get her to cervix open, contracting, you know, artificially. And there’s different ways that we can do that, but all of them require something, right. We have to either give them medication or do something physically to the cervix. So what are the options that we have to induce labor? 


Dr. Kostant: The first options are kind of in the category of what we call cervical ripening agents. And we use these for our patients who come in, who have a cervix that is closed and fairly thick, which is, I would say most of our patients, especially if they’ve never had a delivery before. Probably the option that we use the most, which I actually like the best for a number of reasons, is a cervical balloon. 


And what we basically use is a thin…it’s like a thin rubber plastic catheter that you place in the cervix while the…like I’ll do it or one of the residents will do it while they’re doing an exam. And it’s placed into the cervical canal, and then there’s a balloon at the tip that’s inflated with usually water or saline. And mechanically, as it’s being inflated, as you can imagine, you know, the cervix is a fairly pliable softer structure. So when the balloon is inflated, it will push open the cervix. 


And we leave that balloon in as long as it needs to stay in to just mechanically open the cervix. Now, we’re not trying to have someone go from closed to 6 centimeters with this balloon. The balloon fills only to a certain point. And I would say by the time it slips out, by the time it’s dilated the cervix enough, the cervix might be 2 or maybe 3 centimeters dilated. 


The other thing that the balloon does is it will trigger the release of certain chemicals in the cervix that may also help further soften the cervix. So our goal after placement of the balloon is that by the time it falls out, which can be anywhere from…I’ve had it fall out 20 minutes later. I’ve had it take six or seven hours. Most people, I would say, it’s probably in for like two to four hours before it falls out. The goal is that we now have a cervix that’s maybe 2 or 3 centimeters dilated and a little bit softer and ready for the next step in the induction process. 


Dr. Fox: Right. I mean, essentially, the balloon at the tip of this catheter is about the size of a golf ball, give or take. And it’s actually the same catheter that we’ve used for a long, long time for urinary bladder, it’s called the Foley catheter. And the concept is when you slip it in, it’s nice and skinny. And then you can inflate this balloon from the outside, but the balloon inflates on the tip all the way at the other end. 


And so you put in this thin catheter, inflate that balloon, and then when you put tension to like pull it out, it slowly gets pulled out of the cervix. It’s like pulling a golf ball out of a cervix basically. And so by the time, it comes out, like you said, the cervix is open to some degree and usually softer, and frequently, she’s started contracting a bit as well, but it takes time. And you’re gonna probably go into some of the other ways you can get the cervix to soften and open for induction as well. 


Dr. Kostant: Another effective way, which I’ve also used in the past, is there’s a medication called misoprostol. It’s also known as Cytotec. It’s actually a medication that used to be used or still used for stomach ulcers in obviously non-pregnant patients. Because it was also found that it helps soften and dilate the cervix as well. 


When we use it, it can either be taken by mouth, or it can be placed actually in the vagina. And it’s just a pill or rather even a piece of a pill because the pill will be cut up into small pieces. And every four hours it can be placed in the vagina and then it gets absorbed, and it will help the cervix, again, soften and dilate. 


I tend to find it most helpful if a woman’s cervix is so closed that I couldn’t even place a balloon in her cervix. The reason I try to use the balloon…and, again, this really varies from place to place. And there’s no right or wrong answer to this. But I tell patients, I like using a balloon because there’s a little bit less of a risk of a patient having almost too many contractions. With the misoprostol, it can be very effective, but some women are very sensitive to it. And once it’s placed, they’ll go from not contracting to sometimes contracting every minute. I’ve even had to give medication to reverse the contractions. 


So a lot of patients will actually ask about it because to them, because it’s more of a pill, they actually request it. And I’ll explain to them, you know, the reason why I prefer the balloon. And if a patient really, you know, didn’t feel comfortable having a balloon, you know, we could talk about it. But I think a lot of patients see it as it seems like a more gentler option. 


And, again, it can be very effective and very helpful in many cases. What I always tell patients is that the one downside to the misoprostol is that it can sometimes cause what we call hyperstimulation of the uterus or, you know, too many contractions. 


Dr. Fox: Yeah, I agree. And when I was training we did the misoprostol for everybody. 


Dr. Kostant: We did, too. 


  1. Fox: Every three hours, you know, as the intern, you’re just going around the floor putting them in, you know, midnight 3 a.m., 6 a.m., you’re doing that. And it’s fine, it works. I find that the balloon…I prefer the balloon also. And I find that number one, I think it’s more predictable, right. The misoprostol, sometimes you put it in, and three hours later they’re off to the races. And other times, it’s you keep putting them and putting them, and you’re not really sure what’s going on.


And I find that the balloon, even though there is a range, like you said, it’s more predictable. For most people, it’s gonna be out 4, 5, 6 hours. And then at that point, since their cervix is open, you can like do phase two, which is break their water, which is really the next part of the induction process. And I also agree it gives you some more control. You don’t have that stimulation of the uterus to the same degree, you don’t have that same risk of the contractions happening. If there’s an issue, you can just deflate it and remove it. Whereas once the misoprostol is in, it’s in, nothing you can do about it. 


And so in our practice, we use the balloon probably 95% of the time. Like you said, there’s the occasional patient who just can’t get the balloon, her cervix is too tight, or it’s too uncomfortable, and she doesn’t have an epidural, she doesn’t want one, or whatever. But most of the time it’s a balloon and it’s well tolerated. It’s quite effective because once it’s out, we can give Pitocin so she’s contracting. That’s an intravenous medication to start contractions. We can break the water. 


And then since the Pitocin is intravenous, we can titrate the dose to give her more contractions, or we can back off to give her fewer contractions. Whereas the misoprosol, it’s all or none. You put it in, and then it’s there. And so, I find it’s a little bit more user-friendly, and I prefer it as well. And so that’s what we do. 


Dr. Kostant: No, I agree. And as far as the comfort…the one disadvantage, which you mentioned, is just to put the balloon in. I have to do an exam, check out how dilated the cervix is, and then place the balloon in. And many women…if let’s say someone doesn’t have an epidural, they’ll feel maybe a little discomfort from the exam. And they may have some cramping, you know, right after the balloon is placed because it can sometimes stimulate some cramping. Again, many women tolerate it very well. 


A whole other topic is just, you know, epidural, when to get an epidural. And some patients will ask me about that. And we do offer patients the chance to get an epidural even before the balloon is placed if they just wanna be comfortable and sleep through the rest of the night, especially if they were planning on getting an epidural at some point anyway. But I don’t tell patients that they have to. 


And some women, even if they think they’ll likely get an epidural later, they still like to defer it and wait just because that way, at least you know, they can still, you know, get out of bed even with the balloon in, it’s taped to their legs. So they could get out of bed if they wanted to stand or stretch or walk around a little bit. So I leave that up to the patient. I’ll tell them, “Look, this is probably what it’s gonna feel like. Most people tolerate it fine, you have the option of getting the epidural, but you don’t have to.” 


Dr. Fox: I think there’s two important things you said. The first is that, from our standpoint, and from a medical standpoint, and from a labor standpoint, it doesn’t matter. Meaning if she gets an epidural before we do anything to her, if she gets an epidural sometime in the middle of this, sometime later in labor, or not at all, it’s not gonna change when she delivers or how she delivers, right. The epidural does not have an effect, A, if she gets it or doesn’t get it, or, B, when she gets it. And so that’s very, very important. I mean the decision that she’s making about the epidural is only what she prefers. 


And so in New York City, 90% of women plus get epidurals. Some don’t and that’s great, and they don’t have to if they’re getting an induction. But it might be more difficult because, again, it’s a longer time and you’re not, you know, at home doing something over many, many days, you’re sort of compressing that into six hours. And so for many women, it might be more uncomfortable than spontaneous labor only because, again, we’re sort of like hitting the gas quickly. But it’s up to her. 


And I tell them the same thing. If she wants an epidural before we start, great, we can put an epidural then put in the balloon. Since we usually start at night, she can sleep potentially, because she won’t feel any pain. And then it’s there for her labor and that’s fine. The epidural will last as long as we want it to because it’s a continuous infusion. There’s no, like, endpoint on epidural. If she doesn’t want an epidural at all, fine, great, no problem. And if she says, “I want one but I wanna wait till the morning,” also fine, it’s all good on our end. 


And it’s not a decision she has to make before she comes in. She can decide on the spot, or whatever. Most people know if they’re gonna get it beforehand because they’re gonna, you know, decide before we start they’re gonna get it. But ultimately it’s not a decision that “matters” in terms of her labor, it’s really what experience she’s looking for. Less pain, you know, then she’ll get it earlier versus she wants, you know, to feel the contractions and have more mobility, then she’ll wait or not get at all, which is fine. 


In terms of the cervical ripening, so that happens, and then as we were talking about before, after that happens, we really have to continue typically some medications so that she’s contracting. Not always, sometimes, either the misoprostol or the balloon will put someone into labor, and then she’s contracting on her own and we don’t have to do anything. But I would say that’s the exception, most people will end up getting Pitocin, which is the sort of commercial name for oxytocin, which is the…basically it stimulates the uterus to contract. It’s the same thing that her brain makes naturally when she’s in labor. 


But we give it intravenously, we give it on a pump, it’s titrated. The dosing is very precise, you know, we go up by certain amount, you know, so that it’s safe. And we’re just giving her the dose, it gives her a normal contraction pattern, which is about every three minutes or so, it could be every two or every four, but around every three minutes. 


And the other thing that I always, always go over with women before an induction, particularly if they’re doing the balloon, it’s not just the balloon, it’s the balloon plus breaking the water. People are like, “Oh, can you wait to break my water?” I’m like, “Well, we can wait, but it’s like literally putting the brakes on the induction. It’s like a pause and if you wanna wait six hours in the middle, you know, and do nothing, okay.” But nothing is going to happen really unless you break the water because it’s the next step in inducing labor with that balloon. 


And that’s a really important point because some people hear otherwise. And they think that once we break the water, that there’s some clock that gets started and they have to deliver in a certain amount of time. And that’s not true, it’s just part of the process of inducing the labor. 


Dr. Kostant: It’s a big topic when I discuss inductions. And I’ve also had some patients…some patients will request not to break the water to continue the Pitocin longer. And then I’ll actually have some patients that will say, “Can you break my water but not start pitocin?” And so I’ve had both discussions with patients. 


The patients that ask about just breaking the water many times have had a prior delivery, where their water breaks, and they’ll tell me, you know, “And I delivered two hours after my water breaks with all my kids.” So there, that’s a little bit of a different story. I’d say for the average patient who’s coming in for induction, I do recommend both and both simultaneously. You know, we always honor…or we won’t do anything without our patient’s consent. 


So if I discuss breaking the water, and a patient says, you know, “I don’t want you to do it. I understand why you’re recommending it, but I don’t want you to do it,” we will start or continue the Pitocin. But I do tell patients that it will end up prolonging their time, you know, on the labor floor. Especially if it’s a first baby, usually Pitocin alone, even when we’re…again, like you said, you know, slowly increasing it, we’re not trying to make the patient over-contract. But often what breaking the water does is it helps the baby’s head press down more on the cervix so that when the uterus contracts, the head actually acts to push and help dilate the cervix. 


And when the water is not broken, even if the head is just, you know, gently resting on the cervix, it’s just not putting as much pressure, which is one of the reasons why breaking the water can help. And also breaking the water helps even release more, you know, chemicals that, again, can further soften the cervix and further help potentiate or just increase the effect of the Pitocin. 


I recommend doing both at the same time. I reassure patients, I explain how I break the water, I’ll explain it’s not gonna hurt you or the baby. It’s basically…you know, it sounds kind of funny to say that it’s similar to popping a water balloon. That’s basically what the amniotic sac is, and some of the fluid drains out slowly. Not all of the fluid comes out at once, there’s still fluid around the baby. Usually, the baby’s head will drop down almost act as a little bit of a plug. And then as the cervix dilates more, a little more fluid will keep coming out. 


Dr. Fox: I always remind people, the reason we’re doing this is to get you from not being in labor to being in labor, right? That’s when an induction is, right? That’s the goal. You’re walking in, you’re not in labor, and then we want you to be in labor because we’re trying to, you know, deliver the baby. And this is part of it. Breaking the water is part of that process. If someone says, “I wanna be induced, but I don’t want you to break my water,” I’m like, “Well, you’re not being induced then. Like, we’re just putting a balloon in your cervix and, like, we’re not doing anything.” 


And so it’s just an important thing for people to understand that it’s like a package, right? To get someone in labor, we wanna do it. And then if you draw it out too long, then you may be getting an extra six hours of Pitocin, which can have some…you know, it’s not that it’s complicated to have more Pitocin, but there is a downside to getting more of it and there’s a downside to a longer labor in terms of risk of bleeding and infection. And so, typically, you wanna do things in the most expeditious way that remains safe, right? You don’t wanna overdo it, like you said. And that’s something that, you know, we trained to do and, you know, we sort of know how to do that, and that’s important. 


And then once that happens, you know, they’re contracting, they’re dilated, their water is broken, it’s not markedly different from someone who comes in labor, other than it’s a little bit slower, like you said. Their cervix is usually not so thinned out, it’s still thick. And you’re talking from that point when their cervix is open, 3 centimeters or 4 centimeters, they’re contracting regularly, and we break the water, it’s very typical that it’s gonna take, you know, 12 hours from that point till they deliver. It could be shorter, and that’d be great. 


But, you know…so I tell people they’re gonna come in at night, let’s say, at, you know, 9, 10 at night, get an epidural or not get their balloon place around midnight, and their water broken around 6 in the morning, it’s not remotely unusual to deliver in the evening, 6 p.m., 7 p.m., 8 p.m. And that’s fine, that’s normal timing, and sometimes longer. They might get lucky and it’s shorter, particularly, like you said, if it’s not their first baby. But that’s sort of the timeframe that it’s gonna take. I tell people to expect it to be up to 24 hours and sometimes longer from the time we start till the time the baby comes out. 


Dr. Kostant: Yes, I agree. And that surprises a lot of patients also to hear that even from the morning, when their water is broken, it could still be not till the night that they deliver. But I’ll tell them that that’s okay, like that’s even if things are going well. As for what a lot of patients bring up regarding, you know, not wanting to have their water broken or being concerned about that, I’ll tell them that we don’t expect…you know, it could really take 12 hours just, again, to get into active labor after your water’s broken. And that means being around 5 or 6 centimeters. 


And then from that point on, there still could be, you know, a few to several hours before you get to be fully dilated, and then you’re pushing the baby. And as long as you remain…you know, you don’t have a fever, the baby’s heart rates fine, you know, we can keep going. I think there is a belief that once you cross 12 or 16…I’ve heard patients tell me different things. But they’ll be a certain amount of hours, like your water can’t be broken for more than this time, where you have to have a C-section. That’s not what we use to decide whether someone has to have a C-section. If we broke someone’s water as part of their induction process, and they’re otherwise making, you know, what we consider reasonable progress. 


I mean, we’ve even had some patients go overnight, of the next night. I would say that’s not common, like most people, if they’re going to deliver, will deliver earlier than that. But we’ve even had patients who started an induction, let’s say, Monday night, and they delivered Wednesday morning, and they had a vaginal delivery, and the baby did well, and they did well. 


Dr. Fox: Yeah. We just had one last week, right, where you, know… 


Dr. Kostant: I was just thinking of that. 


Dr. Fox: I mean, she came in on…it was a Wednesday night when you were on call. And then someone took over for her all day. Then Liz took over and was there all day Thursday with her, Thursday night. And then Friday morning, ultimately Melka [SP] delivered her. You’re talking it was 36 hours plus later, and healthy baby, vaginal delivery, everything went fine. It was a little slower than typical, but that’s okay. 


And again, like you said, we don’t have like an alarm clock that goes off that says, “Oh, at X point, you have to deliver from when we broke your water.” Depends on the entire picture, how is she progressing? How does the baby look? How is she doing? You know, what else is going on in terms of making that determination? And so people should be reassured that if they delay the water breaking, it’s not gonna give them more time or give them, you know, a lower chance of a C-section. It has nothing to do with that. 


What do you practically tell women, right? So they’re about to get induced, they’re coming in that night or the next day. So we went over, you know, what the process is, you know, they’re gonna come in, epidural or not, the balloon, the time. But what else should people know before they show up in the hospital for an induction like in terms of preparation at home, or things to bring, or things to expect that you tell women? 


Dr. Kostant: So I tell patients that are having an induction, because of the amount of time it takes to really…you know, to bring things that are going to keep them comfortable. The hospital will provide you, like, basic necessities. Like, if you forget your toothbrush, you forget your toothpaste, like, you know, they’ll have all of that. A couple things that I’ve specifically started telling patients is actually to truly try to get as much rest as you possibly can, especially in the early part of the induction. 


So to bring some sort of eye mask just to block out light and earplugs. Just because once you’re, you know, admitted and settled in and the process has started, there’s gonna be a lot of downtime, especially in the early stage of the induction. So to bring that just because, as everyone knows, hospitals are not the best place to catch rest. And even though many nurses will try to keep the room dark and, you know, turn down the volume on certain monitors, it helps to have the earplugs and the eye mask. 


And I reassure patients also, you know, you can definitely go to sleep, like we can see the fetal monitor that you’re gonna have on everywhere on the floor. Because some women are nervous about sometimes falling asleep because they wanna keep an eye on things. And I’ll tell them, “Don’t worry you know, we’ll see what’s going on with your baby. If we need to adjust the monitor, we will. Just, you know, try to get as much rest as possible.” 


Dr. Fox: And even in advance, you know, if they’re able to take a nap the day before…you know, the day they’re coming in, you know, before they come in, have a good meal, have a good shower. You know, like it’s important to show up, you know, as rested and full, and just ready to go because they’re gonna be there a long time potentially. 


Dr. Kostant: When you said have a good meal, that’s another thing we bring up, is that definitely before coming in, you know, eat something that obviously appeals to…I wouldn’t eat something like, you know, super heavy. But really there’s no real restriction, but, you know, just have a good meal. Because when you come to the hospital, you’ll still be able to, you know, have clear liquids to drink when you’re at the hospital. And, you know, eating in, you know, labor is a whole other discussion. 


Our general practice, with some exceptions, is that when you’re in the hospital being induced that you can definitely drink whatever clear liquids you want. And clear liquids can…you know, means any clear juice, like apple juice, cranberry juice, vitamin water, even like a clear miso, or chicken broth, you know, black coffee without milk. All those things are are clear. 


Dr. Fox: As Sam Bender says, clear liquids do not have to be clear and they do not have to be liquids. You know, black coffee is a clear liquid. 


Dr. Kostant: Jello. 


Dr. Fox: Jello is a clear liquid. It’s basically… 


Dr. Kostant: Sorbet. 


Dr. Fox: Yeah, it’s basically stuff without dairy, that’s a clear liquid. So no milk in it. The only solid food is something that usually is a liquid, like jello, then you gelatinize it. But like you said, vitamin water is good. Gatorade. If people like, you know, Seltzer, that’s fine. Broth is very good. Black coffee, like you said, for the morning. If people are coffee drinkers, you know, get… 


Dr. Kostant: Absolutely bring it. 


Dr. Fox: Yeah, bring some nice black coffee with you because the hospital coffee is also not very classy. 


Dr. Kostant: Yeah, I can attest to that. Any particular clear liquids that you think you would want, that the hospital might not have just, you know, bring them along. And some of the reasoning behind with induction is, you know, I’ve had patients with a very long induction, where, you know, in the past I’ve said, “Yeah, you know, go ahead and have more of a snack.” But the idea is that we tend to refrain from that just…and again, this definitely varies from place to place, different hospitals will have different guidelines. But the idea is that we wanna avoid as much of a full stomach as possible in case there was an emergency and, you know, a C-section was necessary. 


The idea is that if you’ve been drinking clears, the stomach is less full, and there’s potentially less risk of aspiration than if you had a, you know, full stomach, you’ve been eating the whole time. Again, this is a topic that there is some debate about, I’ll definitely admit. That’s at least the reasoning behind it, and policies change and, you know, ideas about this change all the time. 


Dr. Fox: Yeah, the current hospital policy where we deliver, they don’t want women having solid foods. That might change. Other hospitals, it’s different. We don’t make that policy. We’re just, you know, following the rules. But that’s something, if you’re not with us, you should ask about that. Say, “Hey,” wherever you’re going to deliver, “what’s the rule on eating and labor?” and they’ll tell you what the hospital policy is for you. 


So, yeah, bringing chargers for your phone, you know, for your, I don’t know, your laptop. You know, bring stuff if you’re gonna get some work, or you wanna watch movies, or you wanna, you know, do something or do emails, totally fine. Bring something to read, if you prefer, again, if you’re gonna be reading, bring your reading glasses. Like, these are things that people don’t always think about. And it’s not just you, but if someone is coming with you, your partner is coming with, he or she’s gonna need all the same things, right, and they can eat typically. 


Dr. Kostant: Yeah, exactly. Snacks for the partner you’ll kind of guiltily eat. 


Dr. Fox: When my wife was in labor I brought my bag, snacks for dad. It’s like a little bag of food that I want. And also, since it’s a long time, you know, we’re in Manhattan, people can order food to be delivered. You know, if it’s in the morning, 4 centimeters, break the water, Pitocin is starting, we’re, hey, maybe 10, 12 hours. If the partner wants to go get breakfast and come back. I mean, you know, as long as you’re available by cell phone, you know, different people feel differently about whether they wanna be there the whole time with their partner, or whether they wanna come and go, or maybe they have, you know, childcare to attend to at home. And, you know, that can be individualized. 


But typically, since this is a longer process, it’s not like coming in labor where you may deliver at any minute. We sort of can predict that, unless something crazy happens, it’s gonna be a while. So there’s a lot of options for coming and going. COVID throws a wrench into that. 


Dr. Kostant: Yes, definitely. 


Dr. Fox: So if you’re listening to this and there are COVID restrictions abound, something to ask about, whether partners, A, can come, B, can come and go, how that works. But generally in the world of the normal, partners can come and go and other people can come in, and in-laws and other family members in and out. And so that’s just important to remember in terms of planning your own induction. 


Dr. Kostant: Yeah, COVID. It’s funny because the delivery services to Mount Sinai for food have definitely been booming in business because at least at our hospital for…I think this may still be the case for now. Partners, once they were there, you know, could not leave and come back during labor. Once their partner delivered and they were on the postpartum floor, then they could actually come and go and go home and pick up stuff, and they didn’t have to stay there for the whole time. And again, you know, that could be different in the next…you know, in a few weeks or a few months. And every hospital is also different with that. 


Dr. Fox: And that’s important. And the labor floor is like a secure unit and the postpartum floor was a little more lax. It’s one of these things with what is the level of acuity there, and what’s the space and the processes. And so it is a little complex to figure this out. So definitely ask in advance what’s the most up-to-date policies for that. 


And it’s also important, you know, again, if you’re gonna have a support person in labor, like a doula, again, to ask her or him, you know, “What is the plan? Are you gonna be there for the whole induction, for parts of it?” Because, again, the doula has to rest also. And these are things to just plan in advance. But all of it is based on the idea that this is going to be longer than if you just showed up in labor. And a lot of the planning is for that. So there’s the regular things you bring to the hospital, but then the extra planning because it’s gonna be longer, potentially. 


Dr. Kostant: The one thought I had just going back to earlier in the conversation, and, again, this mainly has to do more with our practice and being higher risk, is that one thing I tell patients who are very nervous, who for a medical reason have to be induced, you know, even as much earlier than they expected, is that…you know, especially, again, when they bring up what we talked about with C-section rates, I’ll say, “Especially in your case, it may actually decrease your risk of having a C-section.” 


Not even just that it doesn’t change it because, as a patient, if you have, let’s say, again, hypertension or, especially, you know, any medical issue, which includes diabetes, lupus, anything like that that may predispose you to getting higher blood pressure at the end of the pregnancy, being able to take our time to safely induce your labor, means that we’ll be able to increase the chance of you having a vaginal delivery, as opposed to when a patient, you know, comes in and, you know, already has, let’s say, severe pre-eclampsia or the amniotic fluid around the baby is very low. Some of those situations, it doesn’t mean that you have to have a C-section, we can still try to induce the labor. 


But the chance of a C-section gets higher, because, you know, if a patient’s blood pressure is uncontrollable, we may not have the time to have them continue to have a vaginal delivery. If, let’s say, we have a patient whose baby has been very small through the pregnancy, like exceptionally small, what we call growth restricted, not just small, and there’s some signs that the blood flow to the baby is compromised, or there’s lower amniotic fluid, the longer we wait, the more likely… First of all, if we cite any outcome with the baby, that when we finally go ahead and induce labor, the baby may not tolerate the labor. 


So I actually think that…you know, again, it’s all about finding a balance. We try to find a point where, you know, we can have a successful vaginal delivery, you know, we’re not gonna be delivering the baby too prematurely, it’s really a balance. 


But sometimes trying to push things off too much to, like, the, you know, further, than we feel comfortable with the patient’s medical state, actually, could just end up…you know, they may not go into labor on their own anyway. And then when we finally induce their labor, you know, may end up having, you know, more of a risk of a C-section. So I say that to just reassure patients that when we talk about induction, you know, we’re really in it for the long haul. We want you to have a vaginal delivery, like, that’s ultimately our goal. 


Dr. Fox: Yeah, it’s a really good point that sometimes waiting either the mother’s health could deteriorate, or not the baby’s health so much, but the placenta can start to deteriorate, which makes inducing labor harder because the baby won’t tolerate as well. And that, frequently, it’s actually better to induce. So these are the things that go into our thought process. And I think that’s a really good point. 


Well, Sara, thank you so much for coming on talking about induction. This is, you know, a very common conversation we have with women. And I think that this podcast will be really helpful both for our patients, as well, as women, you know, who are not our patients, who are potentially gonna undergo induction. And maybe women who, you know, underwent one years ago and just curious about it and how it went. So thank you so much. 


Dr. Kostant: No problem. Thanks again. 


Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. 


The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.