“Induction of Labor: What, When, Why, and How” – with Dr. Michelle Santoyo

In this episode, Dr. Michelle Santoyo explains the induction of labor, including the three main reasons for inducing labor, what the process is like, and more.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics and women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN 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.

All right, Michelle Santoyo, welcome back to “Healthful Woman.” How you doing?

Dr. Santoyo: I’m very good. Yourself?

Dr. Fox: I’m good. How’s the quarantine been treating you? I know it has curtailed your travel activities, which is a big bummer.

Dr. Santoyo: It has. That and the gym. Yes.

Dr. Fox: Yeah, no gym, no travel. It’s like you’re out of your sorts here.

Dr. Santoyo: I created a makeshift gym at home. Yeah, I really did.

Dr. Fox: Yeah. I heard about that. Yes. Sarp said he was working out in your apartment.

Dr. Santoyo: In my living room literally.

Dr. Fox: It’s amazing. Listen, I hear you. It’s so hard. I mean, I’m normally in the gym, like every morning doing something and now it’s, you know, it’s makeshift. You do what you can. So.

Dr. Santoyo: I spend most of my time on the internet trying to google workout activities to do at home.

Dr. Fox: That it’s always a workout. Well, you look well, it’s nice to see you in person. And we’re talking today about a topic that’s really common in obstetrics for better or worse based on how you look at it, which is induction of labor. So obviously this is something that you talk to patients about every day, all the time. I mean.

Dr. Santoyo: It’s a frequent conversation. Yes.

Dr. Fox: Yeah. I mean, I don’t even know what the numbers are in our practice. I think in like nationally about 25% or a third of women end up getting induced or pregnant women end up getting induced. I don’t know if the numbers are same in our practice. I guess we’re a little more high risk. So maybe we do, I don’t know.

Dr. Santoyo: Feel that we’re higher, but because of that, because we have more high risk pregnancy, so we have more medical indications for induction.

Dr. Fox: We don’t do a ton of, and we’ll talk about these things, “elective inductions,” just because it’s, first of all, it’s hard to do in busy hospitals because there aren’t slots for it. And even if you wanted to do it, you know, there just isn’t room. But also it’s sort of just not our style. It’s never been. For some patients, may be, but not typically. So the idea of inducing labor, someone’s not in labor and you do something to them to put them into labor. Why would anyone ever think of doing that like as opposed to just like waiting, you know, until someone goes into labor?

Dr. Santoyo: Besides an elective induction, the main one would be a medical reason. So that could either be for maternal reasons or for fetal reasons.

Dr. Fox: Right. And that’s a really good point to sort of differentiate the other than, again, we’ll talk about elective, which has really no reason so-to-speak. The main two reasons we do is either we’re saying it’s better for the mother’s health to no longer be pregnant versus continuing pregnancy, or it’s better for the baby’s health to come out now rather than waiting. And sometimes, often those two are in cahoots meaning if it’s good for the mom, it’s good for the baby and vice versa. Occasionally there’s a conflict where it’s better for one and not for the other, and we have to…a mom, usually wins that argument, but we have to sort of, you know, it depends on the circumstances. And so just, you know, like for examples of like fetal reasons, what are reasons we would say again, in broad strokes that it’s better for baby to come out rather than staying in?

Dr. Santoyo: I think a common one would be growth restrictions, so if the baby was measuring very, very small or if we were starting to see signs that the placenta was not functioning at the capacity it should, which tends to be associated also with smaller babies but not always, you can see that in other ways. Another reason is if the amniotic fluid was low, otherwise known as oligohydramnios, these tend to be, you know, sonographic findings or the things you’re kind of finding along the way. I feel like those would probably be the more common reasons why.

Dr. Fox: For the fetal side, you know, one of the complicating parts of pregnancy is that for all women who are pregnant and they’re getting towards the end of pregnancy, there’s this very small, but very real risk of stillbirth. We don’t talk about it a lot with women just because it’s so terrifying. Yeah, you can’t have that conversation in a way that’s not gonna freak someone out. Understandably, it’s a horrifying thing to think about, but there is a risk and it’s small. It’s well less than 1% at the end of pregnancy, but there are situations where that risk starts going up. And so, for example, like you said, if the baby’s size is very small, or this is an abnormal amount, sometimes too high or too low, a fluid, and it’s not like that we know the baby’s in dire straits and something horrible is gonna happen. It’s just well, if the risk of that is going up, it may not be worth it anymore to stay pregnant. Why take any extra risk?

And it’s hard to always quantify these things for people, but certainly once it starts adding up that the risk is still worth is going up to the point that it’s, you know, just a little too much to tolerate, we usually recommend induction. And there’s a lot of risk factors. You know, some of the medical problems that moms have, like if she has high blood pressure, diabetes, even if she is well, and she is stable, the baby’s at increased risk of stillbirth in those circumstances. So we usually deliver early. Like twins, for example, that’s classic one, mom may be doing great. Usually by 37, 38 weeks, moms with twins are begging to not be pregnant anymore. Otherwise there is an increased risk of stillbirth. Once you start going well past the due date, there’s an increased risk.

And so these are reasons sort of, even if it’s not definitive saying your baby’s in trouble, your baby needs to be delivered, that’s actually the exception. Usually it’s, “Hey, the risks are starting to add up. It’s probably time, you know, to induce the labor and have a, you know, have the baby.” And it does not mean you need to C-section it just means, you know, we’ll try to get you into labor. So that’s on the fetal side. What would it be like maternal reasons that the mom’s health?

Dr. Santoyo: Some of them you kind of touched upon because a lot of them kind of go hand in hand, but could be gestational diabetes or if someone was already a pre-diabetic, it could be if someone was having some elevated blood pressures, whether underlying from prior to pregnancy, hypertension or newly developed during the pregnancy, or even newly developed at the very end with preeclampsia and whatnot. Those, I would say are common reasons. Could also be the mother’s age, the advanced maternal age, and when we would undo what also depend on the exact age of the mother too. So it’s different if you’re 36 years old versus if you were 44 years old.

Also, again, if the mom has any underlying issues. So whether associated with the pregnancy like placental malpractice, mentation, like a previa that would run an earlier delivery, or if mom has some autoimmune process or anything like that, that would also warrant sometimes an earlier delivery.

Dr. Fox: You know, with the maternal age, most of that is on the fetal side because there’s an increased risk of stillbirth though there are moms who sometimes have hard time tolerating the pregnancy, so to speak. And that’s more common as you get older. So like preeclampsia is a classic one where once the mom’s blood pressure starts going up, it’s really dangerous to her potentially. It’s also dangerous to the baby, so it ends up being sort of both of them benefit, but certainly to the mother. And then, you know, there are, when women get pregnant, their whole physiology changes, everything in their body changes. And most of those are well tolerated, benign, not a problem for her is just sort of how pregnant women are different, but some women don’t do so well with them. Some women have a harder time breathing. Some women have different pains that they didn’t have before getting like blood pressure. Sometimes, you know, blood indices like platelet counts start changing. And some of those might be reasons where for the mother it’s better to deliver.

And then the third reason is elective, which is people throw around that term in different circumstances. I view elective as there’s really no reason to deliver other than the mom says, “I don’t wanna be pregnant anymore,” or the doctor says, “I want you to not be pregnant anymore because, you know, I’m going out of town on Monday and I wanna be the one to deliver your…” things like that, which is just purely like a social scheduling type of circumstance. And is that something that you see a lot of are people asking about?

Dr. Santoyo: Not really, not in our current practice? No. I mean.

Dr. Fox: Right. Did you see it in your formal practice before?

Dr. Santoyo: In my former practice, yes. In my former practice, I would say I did a lot more elective inductions, not because I wanted to is because my moms were tired or maybe they lived a certain distance away from the hospital. And even now, if I see that, I feel like that tends to be the situation where it’s not someone’s first baby, it’s their second or third child. They already have an advanced cervical exam. They’re tired of being pregnant in addition to that, and they’re further away from the hospital, they’re getting more anxious. And sometimes some people just want a plan and that in and of itself gives them a sense of control over a situation, even though it’s, as I refer to pretend control because we can’t really control the baby or their labor, but that gives them some sense of reassurance. And ultimately, that’s what they want. They understand those associated risks. That’s okay. They have every right to do so.

Dr. Fox: I think one of the big changes, and we’ll talk about this, that before the elective induction, it’s ironic. It was much, much more common like in the past, but also at the time we thought it was a much less wise thing to do, meaning the risks were higher because, and we’ll talk about this. One of the…

Dr. Santoyo: And yet we did them more. I mean, and now it’s kind of opposite kind of fine, it’s funny also.

Dr. Fox: It’s a very strange thing. It was done more, but the risks were thought to be higher and now actually the risks are thought to be lower but it’s done less. It doesn’t make sense.

Dr. Santoyo: It’s done less. Yeah.

Dr. Fox: Yeah. That really came from the idea, and we’ll talk about is the biggest risk that people think about with inducing labor is if I induce the labor, I’m gonna increase the chance you’re gonna end up with a C-section. And that was basically like rule number one in obstetrics is if you induce someone’s labor, you’re increasing the risk of C-section so you better have a really good reason to do it like a maternal indication of fetal indication otherwise you’re just practicing bad obstetrics. And that was sort of the tenant. It was done all the time, but everyone would sort of hold their nose up at people who did it saying, “Oh, it’s an elective induction. What are they doing? They’re increasing our risk,” and so forth.

And the reason that was thought to be the case is when they looked at studies, they would look at women who were in labor on their own, and they would look at women getting induced and they would see the women in labor on their own had a C-section rate of let’s say 15% and the women who got induced, it was 30%. And they said, okay, you have a double the risk of C-section. But the problem is those studies weren’t done well. And they compared women who are in labor to women who are being induced, which isn’t fair. Because if you’re really gonna decide is inducing labor are gonna increase the risk, you have to take your group and half of them induce, and half of them wait, right? You can’t take the other half and have them be in labor. You have to wait.

And so when they did that study, a very big study where they took thousands of women, randomly divided half of them to be induced is our first babies, and the other half to not be induced into weight, the overall C-section rate was exactly the same because the women who wait, they may go into labor in two days, but they may…their blood pressure may go up and need to be induced a week from now or the baby gets bigger.

And so we’ve learned that in fact, it does not appear that inducing labor increases the risk of C-section, which makes the elective induction less elective. And the thought is, okay, if there’s really no risk and do it, and we’ll talk about other downsides, but there’s no like big risk of C-section. And since there’s some risk of stillbirth, even it’s very, very low, maybe everyone should get induced at 39 weeks. And there’s reasons we don’t do that and a lot of them are logistical, but that’s been a change in the past few years, which has definitely changed the conversation around induction whereas we’re not as I would say religious against it, religiously against it in that sense.

Dr. Santoyo: And I also think there’s another component to this is that I think in more recent years, you know, women in general are trying to take more control over their labor experience and rightly so. And they’re looking for a “more natural experience.” Now, what natural means to each woman is very, very different.

Dr. Fox: Very different.

Dr. Santoyo: So whenever they tell me that I’m like, well, define natural, right?

Dr. Fox: I want a natural birth. With an epidural? So natural, or I want it right. I mean, does yeah. Some for some women, it means delivering vaginally for some women. To me, it’s not an epidural somebody’s mood is not getting induced.

Dr. Santoyo: Everyone’s different and that’s okay. But I think that has partly driven a lot of women to not necessarily push for an induction because they’re looking to have the epitome of that “natural birthing experience.”

Dr. Fox: The experience of labor, yeah.

Dr. Santoyo: That would therefore not involve any intervention in the beginning. But with that being said, plenty of patients also understand that if there’s an indication, there’s an indication and no good mother is gonna put their baby or their own health at risk. And of course, they’re gonna go with the induction, but if it wasn’t for that, I’m sure they would choose to continue to wait.

Dr. Fox: Right. I think a lot of it is just, people have to be flexible with these things and the pregnancy, like you said, you can’t really have control because there’s so many variables in the change. And so certainly we can have a plan and an ideal and what we’re looking to do and what would be the best case scenario. And that’s great. And I’m totally on board with that, but sometimes things come up like, okay, the plan has to change if we’re concerned about the baby or the plan has to change if we’re concerned about the mother. Or on the flip side, if we thought we’d have a concern and we ended up not having a concern, that plan can change back. I mean, and you have to be sort of flexible and malleable with this in order to go through it.

And a lot of that is based on, and this is such an important part of this that I’ve found that if you have a relationship with the doctor, if the doctor and patient, they know each other, they understand each other, they trust each other, they sort of patient views the doctor as her advocate, as someone there to help her and get through this, as opposed to just some person, those conversations are much more meaningful as opposed to just some random person who walks in says, “Hey, you need to be induced tonight.” And she’s like, “What? Like, who are you? Like didn’t even know me. You don’t know what I want.” And so that’s sometimes challenging, but it’s ideal. If you can really have developed that relationship over the course of pregnancy, then these conversations at the end of the pregnancy are much more collaborative as opposed to potentially combative in either direction.

Right. Sometimes it’s the woman who wants to be induced and the doctor doesn’t want it. Or sometimes the opposite, the doctor wants induced and the woman doesn’t want it. And both of those are challenging situations. I’ve been in both of them. And it’s difficult. Aside from C-section and not having the experience of a natural sort of labor process, what would be the downside to being induced? Like what else, if it’s not gonna increase the risk of C-section and a woman, let’s say, doesn’t really care either way. If she goes into labor on her own, it gets induced, what would be a potential downside?

Dr. Santoyo: So the main thing I tell, I mean, all women in labor, but especially women who are undergoing an induction is I just tell them the biggest favor you can do yourself is be patient. Because as long as you’re patient, we’re gonna be patient with you and we’re gonna be in it for the long haul, knowing we’re trying to get to the same goal, which is a healthy mom, healthy baby, and ideally should be a vaginal birth. It’s just gonna take longer.

And one of the ways I also kind of give even just a general example of that, just so people can grasp it is assuming you went into spontaneous labor. By the time you’re ending up at the hospital, being done admitted, let’s say getting an epidural because now you’re, you know, you’re 4 or 5 centimeters, there was still another potential anywhere between 4 to up to 12 hours of labor that happened before that, but that was happening at home. And I have to explain to people that, that whole part of labor, when you’re gonna be induced is now happening in the hospital. So it just feels like it’s longer, but what ultimately happened, it’s just that, yeah maybe you have been at home on the couch, on the TV or someone rubbing your back or, you know, a different scenario or a different, you know, you could have been, you know, in your own home environment. Here you are…

Dr. Fox: Or also it’s drawn out sometimes, you know, when you’re at home, it’s a very slow process over a day or two, whereas you’re getting induced, it starts a little more quickly, so it’s condensed.

Dr. Santoyo: Yeah. And these are not absolutes either. I mean, there’s definitely, absolutely. I mean, there’s individuals who sometimes are in prodromal labor for a couple of days, and the notion of induction, boom, finally, they’re in labor quickly and they wished that would have happened sooner. So that’s one of the things I usually tell them with inductions is just, you just need to give time. As long as you’re patient, we’re patient too. I always try to give patients an idea of what to expect when they’re walking into the hospital. Like what’s gonna be a timeframe of events.

Dr. Fox: Right. Yeah. That’s such a good point. I mean, when someone comes in and labor on their own, you know, they’re usually, it’s almost like you could think of, you know, they hit the ground running. Like once they get admitted, they’re already contracting every three or four minutes. Their water may or may not be broken. They’re four centimeters dilated. So like they’re in labor. For our inductions to get to that point, it takes 3 to 12 hours. Whatever your labor is gonna be tack on up to 12 hours, so if you thought you were giving the hospital for 12 hours, you’re gonna be there 24. And so for some people to like, Oh, I really don’t wanna be in the hospital for that long. I don’t wanna spend a night in the hospital if I don’t have to, you know, while you’re in labor. And so that’s it’s not necessarily a bad thing, but it’s a consequence of getting induced.

And also I tell people, it’s usually, if you were planning on laboring without an epidural, it’s generally harder to do that if you’re getting induced possible, but only because, you know, again, if you’re gonna labor at home, that beginning part to get to four centimeters usually is drawn out over a long time. And most women who are not planning epidural can sort of make it to that point and then see how it goes. But if you’re getting induced, generally, you’re gonna start having contractions every three minutes from the second minute we start the medicine. And so it’s a little bit more condensed and it’s not that the contractions hurt more pound for pound.

Dr. Santoyo: And that’s, I was just gonna make that clear.

Dr. Fox: It’s just, they start earlier.

Dr. Santoyo: It has to be very careful because a lot of people also have this false assumption. I feel that they think Pitocin or an induction is more painful. And I disagree with that in the sense where I try to explain to people that when you go into labor on your own, something has happened slowly. Every 15 than every 12 and every 10 and every 8 and is happening gradually over time with the intensity evolving versus an induction, a medication, which is typically Pitocin is being given and at a titrated dose. So it’s not this immediate dose that’s given to you, but rather it is titrated over time. But the goal is to get you into an adequate contraction pattern of typically every three minutes. And this is now being done with the medication as an intervention. So it’s gonna get you to point A to point B much faster so that it seems as if it’s more intense, but you would have been there regardless. It’s just that instead of getting there over 10 or 12 hours at home, you’re now potentially getting there within a couple hours in the hospital.

Dr. Fox: Yeah. And I totally agree. I tell people pound for pound, the contractions are the same, whether it’s “natural” or Pitocin-related. They don’t hurt more with the Pitocin. They hurt as much as contractions and active level hurt.

Dr. Santoyo: With normal hurt.

Dr. Fox: But they’re gonna start right away. You’re not gonna have that sort of warmup period. And so it’s almost as if you’re in active labor.

Dr. Santoyo: You’re gonna go from zero to 60 very quickly, yeah.

Dr. Fox: So that’s the reason I think a lot of women, again, and not everyone, but it seems to be that women are more likely to end up with epidural if they’re getting induced and also it’s gonna be more time in the hospital. Again, ultimately it’s a decision. We don’t require people to get the epidurals get induced. Some do, some don’t. I would say most do some don’t, but that’s true with labor in New York City also. Just most women get epidurals, but they don’t necessarily have to. It’s just as a choice. That is another one. It’s just that more time in the hospital. And that’s, and it’s gonna be a little bit longer. That’s important for people to know, but as you said, it’s important for everyone to be patient. Part of the reason in the studies induction did not increase the risk of a caesarian is in the study that doctors are very patient. And so on average, those inductions and labors are 18 plus hours on average.

So that’s an important thing to realize that if you are a doctor, who’s not patient and you’re gonna save, you’re not delivered within 12 hours. And we started doing a C-section then yeah. Induction is not gonna work. It sort of, it has to be induction plus patients equals not increased risk of C-section. And so that’s important stuff. And, you know, one of the ways we always talk about this as women is to try to put this all in perspective is we have to balance the risks of keeping the baby inside versus taking the baby out. Meaning is your baby better off inside or are you better off with your baby inside or outside? And that’s an ongoing thought process. And if we’re at the point where like, listen, it’s better to have the baby now, generally that mean induction, occasionally needs a C-section, but usually for different reasons. But typically it means an induction. And fortunately, what we’ve learned is it does not increase the risk of a C-section as long as you’re patient and everyone understands what it means. And so when do we typically induce women in terms of like how far in pregnancy usually?

Dr. Santoyo: I mean, it depends of course, but typically, usually not earlier than 39 weeks.

Dr. Fox: Unless there’s a really good reason.

Dr. Santoyo: Exactly. Exactly. So usually anywhere between 39 and 41 weeks I would say.

Dr. Fox: And that’s because earlier than 39, there is some additional risk to the baby being born.

Dr. Santoyo: To the baby.

Dr. Fox: Even though it’s not technically premature until you’re earlier than 37 weeks, babies who are induced and born at 38 weeks have a higher chance of going to the NICU and this. So again, the bar is still there meaning if the concern is high enough for the maternal health or the baby’s health, then we’ll do it earlier. But if it’s really kind of like, “Oh, it’s just probably a little bit better,” usually we’ll try to wait till 39 weeks. And so there are valid reasons to deliver before 39 weeks, but they’re a little bit better defined in terms of like, we know there’s a risk, there’s definitely a risk. And so we’re willing to take that additional risk to the baby in order to do it. Whereas once you get to 39 plus weeks, there isn’t really any advantage to the baby of being pregnant.

Dr. Santoyo: Of prolonging the pregnancy. Yes.

Dr. Fox: Right. Because once the meaning, the likelihood going to the NICU is the same at 39 weeks and 40 and 41.

Dr. Santoyo: 39 verses 40, yeah.

Dr. Fox: In fact, it goes up a little bit at 41 weeks and the likelihood of a complication like a respiratory complication or an infection, things like that for the baby plateau around 39 weeks. And so we generally don’t feel compelled to keeps pregnant more than 39 weeks, again, unless it’s sort of something she wants to do and this, that. And there’s also some logistics involved and meaning, you know, in order to do someone, they have to come in and have a room and a bed and hospitals are busy. And so mostly before as we’ll have schedules for inductions and there’s prioritization that people have, the bigger, greater reasons will take precedent over the people who are more elective, which again, all of this makes sense. And a lot of times when people are trying to figure out, I want to be induced, I wanna do this for like, well, we’re there every day. It’s just, the hospital has to have a spot for you. Unless there’s something really emergent, they’re not gonna bump some woman from her scheduled induction, unless there’s a good reason to. And so there is some also understanding of the, just the system that has to take place with that.

When women are induced earlier than 39 weeks, so it’s like 38, 37, 36, there are times when we sort of prepare for that, like maybe give steroids or this again, generally, if it’s under 37 weeks or even 34 weeks, that’s to help the babies. But in terms of the induction process itself, it’s the same.

Dr. Santoyo: Yeah. The process itself is the same.

Dr. Fox: Right. And so what would be the process? Walk me through what a woman would experience. If she’s scheduled for induction, let’s say we wanted to deliver tomorrow, right? So what would happen?

Dr. Santoyo: So usually the way I counsel patients, and again, this is assuming a typical situation with the typical goals that a mom wants, which also means that most moms want an epidural. So I’m prefacing with that. Usually I would tell people you’re gonna be coming in the night before. The time is dictated by the hospital. So it could be anywhere between 8:00 p.m. to even as late as possibly midnight, but somewhere between eight to 10:00 p.m., typically you’re gonna come into the hospital. Once you’re in the, usually the nurses will first kind of get you tucked in. They’re gonna ask some general questions to get you admitted. And then you may even also see a resident who will also take some information from you.

Once you’re kind of tucked into the system, they’re gonna give you an IV. Once you have an IV, they may then, of course, give you some IV fluids to go with it. If you did not want that, that is possible. But again, most people are okay with receiving IV fluids. At that point, I usually tell people if you’re planning on having an epidural, you don’t get brownie points for waiting. There’s no reward for being a hero here. If you know your plan was to get an epidural, then get an epidural first because there’s no bonus or gain. And there’s no downside in doing that first so that you’re comfortable.

Dr. Fox: Right. I just want to pause it for one second, just to talk about that. And that is important because, again, if women are planning to not have an epidural, fine, don’t get an epidural.

Dr. Santoyo: Then don’t get an epidural. Yes.

Dr. Fox: Yeah. That’s great. But if you’re planning to get it, a lot of people say, well, should I wait till I’m in active labor?

Dr. Santoyo: No.

Dr. Fox: Right. You can. I mean, you’re welcome to, it’s not, you know, they’ll do it at any point you want, but it doesn’t help. It doesn’t speed up your time to labor.

Dr. Santoyo: No it doesn’t. And that’s the thing because a lot of people feel that they want to wait until they’re in active labor because they think they’re gonna slow down labor. And then that’s when I tell them, but you’re not in labor. You’re being induced. We are giving you medications to bring on your labor. So there is no slowing down of your labor. We’re the ones that are helping to create and make that happen.

Dr. Fox: And this has been studied. There’s no difference on the, you know, if you’re getting induced, even if you’re not gonna induce, but you’re talking about induction, when you get your epidural, whether it’s before in the beginning or late, it does not change your time to delivery, and it does not change whether you end up with a C-section or not. I would I tell women the only downside potentially for getting it earlier is if they wanted to maybe have the ability to be more mobile, right, because once you have the epidural, you’re pretty much lying in bed. But since it’s over night, most people want to just sleep.

Dr. Santoyo: And that’s gonna lead me into the next thing that I tell people to do. But they get the epidural. Once they have an epidural and they’re comfortable, then the next plan is typically to place what’s referred to as a cervical balloon, which is a tiny catheter that’s thread through the cervix. And the balloon is inflated with sterile water, essentially. And then it applies basically the way as I say, it’s just mechanical traction on the cervix. In addition to that, then we’re also starting Pitocin, which is a medicine via the IV. So it’s not something you’re orally taking. It’s via the IV. The nurse will continuously titrate and control that medication. So it’s not anything you need to worry about. It’s just being given and that’s it.

And then I tell people nothing will happen for a long time. So if you have an epidural, that means you’re not gonna feel the pressure of the discomfort of having the balloon the way you may feel it sitting in your pelvis, nor are you gonna feel the initial cramps or contractions from the Pitocin and your goal is to sleep. Now, of course, it’s…

Dr. Fox: Yeah, it’s over night.

Dr. Santoyo: Yes. Now, it’s hard to sleep in a hospital. You know, there’s a lot of bells and whistles and deans that you’re hearing, but at least dim the lights, don’t try to turn on the TV. Don’t try to start reading a book, you know, just close your eyes and rest because even if you’re resting that’s still good because the next day you’re gonna need to energy. Because that’s when the time comes to push, you don’t wanna be hope like wishing, “Oh man, I wish I would have slept overnight.”

Dr. Fox: Right. Yeah. And that’s all really good points. And, you know, it’s hard sometimes to explain like on a podcast, exactly what happens with the balloon. This is something you could Google image, but basically a cervical full. You said that the fully catheter is something that’s normally placed in a bladder like when people have surgery or this people heard of a fully, but instead we place it through the vagina, through the cervix and inflate a balloon and we put it on traction. So the thought is we’re sort of like slowly pulling that balloon, which is about the size of a golf ball, give or take, through the cervix. And so when it eventually comes out the cervix, which can be one, two, six, 10 hours later,…

Dr. Santoyo: And that’s what I tell…

Dr. Fox: Your cervix is dilated as a golf ball, which is three to four centimeters.

Dr. Santoyo: Yes. Exactly. And that’s what I tell people. I tell people, you can be lucky and maybe the balloon is only in for an hour or two or the balloon could in theory be up to 10 to 12 hours. So I’ve seen it in both ways. However, the average I would say is somewhere around four to six hours for most people. And then I tell people, and even once the balloon comes out, guess what? You’re a whopping three to four centimeters dilated and the cervix is typically, still not thin down.

Dr. Fox: Right. It’s long. Yeah.

Dr. Santoyo: So you’re dilated, but still not you face are not thinned out. And so I explained that even once the balloon is out, you’re still in what’s considered early or late infused labor.

Dr. Fox: Right. You’re not the same as the three or four centimeters of the woman who comes in in labor…

Dr. Santoyo: And labor with, you know…

Dr. Fox: Her cervix is all thin and contracting.

Dr. Santoyo: Exactly. And so then the next plan ideally, would be to break water. And so I usually mention that either immediately after the balloon comes out or anywhere between one to two hours after the balloon is out, we’re breaking water. And the reason is to continue to augment and induce the labor. And the Pitocin continues during this time totally unchanged. And once we break water, that’s it. There’s nothing else to do, but continue to wait. And once, usually for someone’s first baby, I would say, once they’re hitting six centimeters is ideally when now their labor will feel like it will start progressing at a much faster rate. So I tell people to get to the six centimeters could still take anywhere. I mean, listen, again, if you’re lucky, it could be 2 to 4 hours, but could take anywhere between 6 to 12 hours and that would be normal and that’s okay. And once you’re six centimeters though, going from 6 to 10, this is where you’re gonna feel, “Whoa, this is different than what’s been happening this entire night morning.”

Dr. Fox: Now I’m in real labor. Yeah.

Dr. Santoyo: Yes because going from 6 to 10 centimeters can take anywhere between 2 to 4 hours, sometimes a little bit longer. But, you know, that’s when you’ll progress at a more rapid pace. But I also will then warn people even once you hit 10 centimeters, that still doesn’t mean immediately pushing so because we’re also waiting for the head to come down. So ideally, once the head is nice and low and at that point, most women are having an urge to push they’re feeling some sort of pressure or rectal pressure or feeling almost as if, as they would say as if I have to poop. And that’s our cue. And hopefully the baby’s now in good positioning to then start pushing.

Dr. Fox: Right. I mean, once women get to sort of that six centimeter mark and for some it’s earlier, some it’s later, but around that time, usually at that point, their labor is no different from someone who wasn’t getting induced. You sort of put them in labor and many times we can even turn down or turn off the Pitocin at that point because their brain is sort of kicked in and they’re making their own Pitocin. And in terms of the expectation of timing, it’s very similar as to someone comes in in labor and it is variable. I usually tell women that from the time the balloon comes out and you’re about 3 to 4 centimeters and we break your water and we have you on Pitocin, typically on average, you should expect to deliver it around 12 hours. Some women are lucky and it’s four to six hours from that point. Some women, it takes 18 hours. But usually from the point, all those three things are done, balloon is out, broke your water and you’re on Pitocin, it’s about 12 hours. So if you think of the timing of song comes in at 10:00 p.m., they get the balloon that let’s say midnight or 1:00 a. m. It comes out at five or 6:00 a.m. and we break your water. You’re gonna deliver in the early evening. And I would say that’s, and this is for first babies. Usually, if it’s not your first baby, all of these things will be faster.

Dr. Santoyo: Yes, all these will be faster.

Dr. Fox: All things go. Every single…

Dr. Santoyo: Sometimes you don’t even need a balloon if it’s your…you know, because you’re already, you know, two or three centimeters dilated and in your face, the balloon’s not gonna give you much more gain. So I would just break water and start Pitocin at that point.

Dr. Fox: Right. The balloon is part of these things. We call cervical ripening agents and that’s for someone who cervix is more closed, more long, they need something to get the service long. If someone walked in to be induced and they’re already three centimeters dilated, which people are, they don’t have to be in labor, they can be walking around. Then we wouldn’t do a balloon. We would say, okay, let’s start the Pitocin and break your water and that chops off all that early time. But then could be 12 hours.

There are other things available for cervical ripening. Like we use the balloon in our practice. We use it, most people in our hospital use it. There are other forms of prostaglandin something called misoprostol or cytotec. There’s something called cervidil. I mean, there’s other things, but those are medicinal ways to get the cervix to shorten and open a little bit, you know, there’s sort of similar efficacy to the balloon. We prefer the balloon because there’s a little bit more control. It doesn’t affect the baby’s heart rate or the contraption, so you have more control over the contractions. Because the Pitocin, you can titrate.

You could always take out a balloon if there’s a problem. Whereas once you put in a medicine it’s being, it’s absorbed. So, you know, there isn’t a right or wrong here. We prefer the balloon. That’s how we do it. I’ve done it both ways in my practice and I happen to this way. But, you know, if you’re at different hospitals, different people do it a little…

Dr. Santoyo: Different. Yeah.

Dr. Fox: Yeah, at the beginning. The Pitocin is the same everywhere. Yeah.

Dr. Santoyo: Yeah, the Pitocin is the same, but the cervical ripening agent could be cervidil cytotec or the balloon and even the cytotec can also be given vaginally or orally. So there’s also two modes. I mean, my prior practice, it was more of the misoprostol the cytotec that we use as a cervical ripening agent.

Dr. Fox: Vaginally or orally?

Dr. Santoyo: Initially was vaginally and then ultimately the hospital then transitioned into orally.

Dr. Fox: And a lot of, I remember when I was a resident, you would go every three hours you’d make rounds and give everyone their cytotec.

Dr. Santoyo: Cytotec, yeah.

Dr. Fox: Because it was, it was dosed every three hours. Like at midnight 10 people and like…

Dr. Santoyo: You tie everything. Every 15 minutes, you’re going from one room to another.

Dr. Fox: Right. The balloon just goes in once and then it comes out.

Dr. Santoyo: Comes out.

Dr. Fox: And a lot of times, you know, and again, always it’s different based on what kind of hospital deliver in. A lot of the times this cytotec or the balloon, it’s gonna be placed potentially by your own doctor. But that’s probably the exception. A lot of times it’s placed by one of the resident doctors, one of the nurses potentially a physician assistant, a nurse midwife. There’s a lot of people. And because, you know, if you think about it, if you’re being induced and you come in at 9 or 10 at night and you’re not gonna deliver to 9 or 10 the next night, you really don’t want your obstetrician being there the entire time. And because then by the time is to deliver, you don’t want him or her to be falling on their face exhausted.

So usually it’s gonna be someone else, you know, whatever. But that’s a very typical thing. And people worry about that. And I say like, I haven’t put in a balloon myself in 10 years. Like the residents put them in for, you know, if I’m there, I’ll put it in because I can. But, it’s not a thing that requires, you know, the greatest skill in the world.

Dr. Santoyo: Yeah. And I always explain that too, that usually the start of the induction is usually gonna be by one of the residents or the PAs. And that again, we’re always readily accessible and available, but that ultimately once the balloon is out, they’re gonna see me and I’m gonna be the only one breaking their water. Usually when I’m counseling patients whenever they’re even being admitted for their induction or if I saw them in the days prior to their induction and I’m going over the same exact conversation we’re having right now as to like a timeframe of what to expect and so forth, you know, usually I’ll say, okay, you’re seeing me now. I’m not gonna be placing the balloon. But as soon as you get the epidural, one of the residents will place the balloon. But once the balloon is out, you’ll see my face again. And it will likely be in this timeframe, but we’ll see, you know, based on all the factors that we talked about and then my goal will be to break your water and then, but know that even then there’s still gonna be no major action happening that really don’t expect the action until we’re finally approaching six centimeters with a thin face cervix and the head’s coming down.

Dr. Fox: Yeah. There’s a lot of stuff that’s sort of done when you get there. But then it’s a lot of just waiting.

Dr. Santoyo: Waiting. It’s just a lot of waiting.

Dr. Fox: You know, because you’re just trying to kind of get the body to go into labor and it takes time. And another thing with inductions that people always have a lot of questions about is regarding their support person, whether it’s her husband or partner, whether her doula is gonna be with her, her friends is gonna be with her, her mother’s gonna be with her, whoever it is. And either there’s a lot of, you know, confusion, like what should they do when should they come? And, you know, there isn’t a right or wrong. The in at least in our hospital, the support person is welcome to be with them the entire time and labor. You have a private room during all of this from the start of the induction until the baby is out. You’re the only one there. So someone can be with you 24/7, but sometimes it’s not, you know, sort of feeling…

Dr. Santoyo: Sometimes it’s not so people may have children at home and they’re having childcare issues.

Dr. Fox: I people that the night part, some women don’t wanna be alone, obviously that’s totally understandable. But, you know, occasionally the support person, it’s just better for the two of them, you know, if he or she sleeps at home overnight, whether it’s just to get a good night’s sleep or whether it’s to be with one of their children until the morning when the babysitter comes or whatever, and that’s fine and again, it’s very unusual that anything happens overnight. And as long as someone’s close by and we could always call or text them if there’s something going on and they need to come in, it’s not like the person has to be with them. Again, frequently they are. They usually are.

Dr. Santoyo: I feel like the majority of the time though, the support person is there from the beginning.

Dr. Fox: Yeah. But they could also like in the morning, like frequently, if I come in and I’ll break the water, and, “Hey, you’re three or four centimeters, everything’s going great.” You know, it’s all this. And I’ll say to the person like…

Dr. Santoyo: “Now’s time to go get breakfast.”

Dr. Fox: Yeah, “Go get breakfast, go get a coffee. If you live in the city, wanna go home and take a shower and come back in an hour or two, we’ll call you if anything changes.”

Dr. Santoyo: I have ordered seamless with the husbands before.

Dr. Fox: It’s just, it’s an important thing to realize this is gonna, and that’s why I always tell people that like, what should I bring them? Like bring chargers, right? Whatever devices you have, you know, bring your chargers, bring if you don’t want to, you know, watch on an iPad or your TV or TV, bring a book. You know, if you’ve got stuff to do, you could bring a laptop. If you haven’t had a drone, you could do work. I mean, you can order stuff. I mean, you can do whatever you like really. Bring snacks, at least for the support person, something to eat or drink, whether women do or don’t eat or drink in labor’s its own podcast and that’s its own thing. But whatever, based on what you’re allowed to do, bring in for, you know, him or her is with you, they should have something as well. And because again, it’s gonna be pretty wide. If someone does not have an epidural, it is gonna be a…

Dr. Santoyo: If someone is not…

Dr. Fox: Be prepared with some sort of breathing exercises, you know, a Lamaze class, a doula, something because it’s kind of

Dr. Santoyo: That person will have a support person. Whether a doula or their partner, but yeah because whether they’re massaging their lower back or helping them do the breathing techniques or being supportive. I mean, it’s really what it comes down to. Some person’s trying to manage through pain.

Dr. Fox: That person is well [inaudible 00:38:05] support person.

Dr. Santoyo: Yes, exactly.

Dr. Fox: Yeah. One of my brothers told me that and his first baby, his wife, they decided that she’s gonna have a doula. And I said, I said, you know what? I just asked him, I said why. And he said, “Well, it became very obvious that she was gonna require level of support that I am unable to provide.” He said, “So I rather than provide inadequate support, I’m gonna bring in a helper, outsource is a little busy, I’ll be there, but I know I’m not capable.” So he outsourced it, which is at the very telling.

One thing I wanted to come back to because again, this is also something because it comes up a lot. And I think a lot of women are concerned that they’re gonna be in a situation where again, either they feel like the doctor is like pushing an induction on them and they don’t want it or potentially on the flip side, they’re really wanting to be induced and the doctor’s opposed to it. And what would be, you know, let’s say you’re meeting with a patient and she’s, you know, well, before delivery, she’s in the beginning of pregnancy and she were asking you about like, what’s going to happen if that happens, like how would you approach that situation? Let’s first talk about the doctor wants or is suggesting or recommending an induction and the woman is, you know, hesitant about it. Like how would you talk a patient through that because that happens?

Dr. Santoyo: Yeah. I think the main thing is I always ask why, talk to me, tell me what’s the story. Because you can’t take things sometimes for being at face value for what they’ve said. You know, I need to understand what their thought process is as to why they came to that conclusion. And many times you’ll realize that they may have false, you know, misconceptions of, you know, they are thinking, for instance, “Oh, but the epidural will do this,” or as we talked about earlier, “But if I get induce, that automatically means I’m going to have a C-section. Or that automatically means the baby, you know, maybe go to the NICU or the,” you know, all these things and it’s now, okay, well let’s talk because now my job is to educate basically the consumer.

You know, so really what are the risks? What are the benefits? What are your concerns? And many times you come to realize that you can address all the concerns they may have. And that even if they have to undergo an induction for a medical reason, for which they understand that it’s for the health of either their own health or the health of the baby, that not just mom, but their partners are also on board with that, but that they can still have the experience they want. So again, whether that’s no epidural or trying to, you know, sit up in the bed, you know, whatever it may be. It could be a lot of these little things that are important to a certain individual and that’s okay. A lot of people feel there’s a lot of absolutes and there’s not, I mean, as we talked about earlier in the podcast, it’s about adaptability. So, and just being flexible.

And I think as long as both people can come to the meet somewhere in the middle, it’s fine. But many times I think majority of the time when people don’t wanna be induced, it’s usually based on false preconceptions. And once you clarify those and then people can ask more questions, now they feel better and now they’re okay. And it’s very rarely do you still meet resistance at that point. It’s been my experience at least.

Dr. Fox: Yeah. I agree. I think it’s really just about communication on both ends. I think if a woman’s in a situation where she feels like an induction is being pushed on her, I think the two things to make sure to communicate to doctors, number one, to ask, please be very clear like, what is it that you’re afraid of such that you’re recommending an induction? Are you worried about my health? Are you worried about the baby’s health and for what reason? And then the doctor should be able to explain, you know, I’m concerned because A, B and C. Okay.

And the second thing is if the reason a woman is hesitant to be induced, say these are the things I am concerned about. Meaning I am afraid that if I get induced, it will lead to A or B or C and let the doctor say, okay, this is correct or this is incorrect or this is false. This is real. And then at least you’ll have the scales. You’ll know what is the reason we’re recommending it, what is the reason you don’t prefer to have it? And ultimately it is a woman’s choice what to do. I mean, we don’t, you know, force people and tie them down and induce them. Like it’s a choice. And if a woman says, I think you’re, overblowing the risk and you’re not concerned with what I’m afraid of and you decide not to do it, that’s okay. I would say that that’s probably not a good conclusion communication-wise but ultimately, that’s anyone’s right.

Dr. Santoyo: That’s your right.

Dr. Fox: You know, like you said, I don’t really come to those circumstances much. When I initially have a situation like that, after I’m able to better explain what my concerns are…

Dr. Santoyo: Yeah, once you explain.

Dr. Fox: I’m able to better sort of, you know, address what her concerns are. Usually it’s, “Oh, okay. That makes sense. Let’s do it.” Even if that’s not what they wanted, it’s like, okay, this is the situation. Things have changed.

Dr. Santoyo: And sometimes also what helps is a little bit of repetition. You know, sometimes things do happen suddenly where someone now, you know, let’s say, Oh, you know, we’re 39 weeks in a couple of days and you had a sonogram today, or it turns out the fluid is now yellow and you need to be induced. You know, that’s someone who also didn’t walk in that day, thinking that now you’re going to be induced today. I mean, now is that always possible? And on their mind that I could have the baby any time now, of course, do they I’m sure have their bags packed and ready for the last month? Of course they do. But that still doesn’t mean that you were prepared to walk in for a routine visit thinking, “Wait, now I’m going to the hospital. What? What?”

And so sometimes people just need also a moment and, you know, sometimes it’s just pausing, processing information. Let me now say it again. Let’s go through it again because sometimes the information sinks in the first time, and now it’s gonna sink in better the second time And also, this is where I feel it’s always beneficial to have a support person there because maybe what one person caught, the other person didn’t and vice versa. And what’s also great in our practice specifically is, you know, usually if the fluid slow, people are already seeing, you know, maternal fetal medicine, downstairs, now you need to be induced and why not.

Dr. Fox: Right. They’ve been double changed.

Dr. Santoyo: Yes. And now they’re also coming upstairs to now talk to me and they already know I’m gonna tell them the same thing, but this is still repetition. And it still is allowing a gap, a moment for the patient to process what they’re being told, and then think, do I have any questions about my concern? So now as they’re coming to me, even though they’ve already heard the information, I’m gonna still tell them everything all over again, that they can now listen almost a little bit better because that initial shock is gone. Okay, something’s okay. Okay. Let’s settling into what’s happening. So, but yeah, I mean, ultimately it comes down to communication and then I also think repetition.

Dr. Fox: I think you made a really good point also about the support person. And when, you know, when women ask me, what visits should he come to? You know, he’s busy or this, and I don’t wanna drag him or he’s a knowing or, you know, whatever it is that you know you to come. And usually the first one is a really good initial prenatal care visit. It’s good. A couple of the ultrasounds are really cool and you don’t have to see, but I would say the end, those lasts like once you’re coming every week at 36 weeks, you know, it’s, even though it may be more difficult, those are the appointments because however many questions you have, you know, your partner has same questions. What’s gonna be, how long it’s gonna take, what to expect, what’s in all these things?

And so number one, he or she gets to ask those questions as well. And number two, when things happen and that’s when things happen, right? You’re contracting, your cervix is open. It’s not the fluid, the baby, you know, your blood pressure, all these things happen. And it’s like a shock to the system. It’s much better for both people to hear it at the same time, because they can process it together. They can bounce questions off each other. You get different perspectives as opposed to having to have one person call and say, “I gotta be induced.” Like why? “I don’t get it. I don’t know.” And at that becomes a lot more scary, I would think. So I think that’s a really good point that if it’s a good time, those last visits not come alone. If you have the option, you know, obviously everyone has that option.

Michelle, this was great. Thanks for coming in discussing induction of labor. Again, it comes up a lot. It shouldn’t be scary and it shouldn’t be something that’s a shock to the system. It’s something that, you know, as long as everyone understands this is going on, usually it’s collaborative and everyone agrees, but it was also a good review. What to expect, just sort of practically is gonna happen during the induction. So thank you so much. And I look forward to having you on for many more podcasts.

Dr. Santoyo: Thank you very much.

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 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.