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Induction Labor

[00:00:00] Hi everyone. It's Easter. Crazy. What crazy times. I decided in honor of Easter, I put on a little bit more bling. I actually put on one of my leather cuffs that I haven't been wearing in weeks because of the fact that it's just one more place for the fomites to rest. Um, but I'm not leaving until maybe tonight. 

I'm back on call tonight, 8:00 PM It's my week of call. So you guys are gonna get a whole lot of hospital stuff for better or for. You know what that means? I'm gonna be spewing a lot of information, some of which is gonna be amazing and fun and beautiful, and some of which I'm admitting it's probably gonna be angry stuff. 

All right. So I decided that we would talk right now about labor and delivery and inductions. This, um, can apply right now to the Covid times, but it also just applies generally because you might know if you are pregnant, that there's actually a bit of controversy with regard to inductions. And so induction just to be very basic means we need to give you [00:01:00] medication to put your body into labor as opposed to augmentation. 

So we're not gonna really discuss that, but that is if your body's in labor, but you need a little extra. Okay. Very appropriate times to be induced would be your water breaks. You have no contractions. Okay? We give you contractions with medication. I don't personally consider that induction in the sense of like, we have no choice. 

Your water broke. If your body doesn't do it on its own, we have to do something about it. Um, other very appropriate times would be in the setting of. Hypertension, diabetes, twins, growth restriction, certain fetal issues or maternal issues that if we do not deliver you, you are potentially more at risk. 

And depending on what those issues are, there are different times throughout the end of the pregnancy that might be appropriate. For example, if you have been completely fine with your blood pressure and suddenly develop pre-eclampsia, which is where you have high blood pressure and you're putting protein into your urine, Then you might need to be induced anywhere after 37, 38, 39 weeks, depending on how severe your preeclampsia. 

On the other hand, if [00:02:00] you're a very well controlled diabetic, for example, you may be able to go to between 39 and 40 weeks depending on your doctor. So you should talk to your doctor about it because even in this realm, there are no strict a thousand percent guidelines. There are general guidelines that we try to adhere to Again, To keep mom and baby safest because there's always a balance between when is the baby happier outside than in and when is mom's body happier, no longer being pregnant. 

And I don't mean happy emotionally cuz I think the majority of us would say we're happy not being pregnant anytime after 35 weeks. Okay. That said, when it comes to induction at the end of pregnancy, assuming everything is fine and healthy, assuming there is no medical indication to induce, when should we induce? 

Well, as of 20 plus years, , as long as I've been a doctor, which is 21 years, the data from a very widespread study had shown that if we in. Prior to about one week past the due date, and the [00:03:00] due date is 40 weeks. So one week past the due date, about 41 weeks. If we induce prior to that electively, again, not for a medical indication, cuz that's separate, but now we're talking elective inductions. 

Your body's just not going to labor. We induce you. What would happen? Well, if you're prior to 41 weeks, the data showed that we were only increasing the C-section rate. Now if we waited until after 41 weeks, the C-section. From the induction was equivalent. Listen to this part from what would happen if we allowed you to go from 41 to 42 weeks in spontaneous labor. 

You had the same C-section rate as if we induced you at 41 weeks, but the indications were different. So if I induced you at 41 weeks and your body wasn't ready, The C-section was because your body wasn't ready. If I waited for you to go into labor between 41 and 42 weeks, then the indication for the C-section was often fetal distress, meaning the baby and the placenta were no longer doing what they needed to do, so the placenta was not feeding the baby, and therefore, [00:04:00] during labor, the baby's heart rate would drop and we would have to take the baby out. 

So equal rates of C-section, but for different reason. And as you can imagine, we would rather the reason be, oh, your body's not ready than, oh, we're putting the baby in distress. So the bottom line for the 21 years I've been a physician has been, you don't induce electively prior to 41 weeks. Unless you had a medical reason, then it's not elective. 

Otherwise, you wait till 41 weeks. The caveat to this was if your cervix was dilated enough and soft enough, and there's a certain score called a bishop score that has to do with dilation and the position of your cervix and how thinned out it is. So if it was dilated enough, Then your likelihood of a vaginal delivery from the induction was high enough that you could electively induce after 39 weeks if the lungs were ready. 

Let's put that aside cuz we're not talking about that. We're talking patient walks in. Cervix is closed. Should we induce her? Up until this last year, the answer was no, because I'm increasing her risk of a [00:05:00] C-section and I'm not improving the baby's outcome. So give her until 41 weeks. And I think most of us would've said, like I usually say to patients, seven to 10 days past your due date, then we'll figure it out together. 

And occasionally patients wanted to go past 10 days past their due date. Never know why, but they do sometimes and we would let them as long as we continue to monitor and the baby shows us that the baby is thriving inside still. Now, the conundrum of medicine, what happened about 11 months ago, I wanna say a huge trial came out called the Arrive trial, multicenter trial that actually examined everything and. 

Ironically, the polar opposite, which is if we induce everyone at 39 weeks or earlier if there was a medical indication, but everyone comes in at 39 weeks, cervix is ready, cervix is not ready. First baby, second baby, doesn't matter. Induce everyone at 39 weeks. We would actually have higher vaginal delivery rates with a lower risk of the very rare, but very [00:06:00] upsetting. 

Intrauterine fetal demise because there is that window somewhere between 39 and 41 weeks where there are some babies that unfortunately just don't get all the nutrients they need from that placenta. And it's not usually predictable. It's not the patients you would've expected who had other high-risk issues. 

So you would actually be saving those babies and you would actually. Believe it or not, have a higher vaginal delivery rate. Flu in the face of all the data that I've trained with. Right? How can this be on top of it? And this is where I'm gonna tie it to Covid. It's added this level of conundrum, which is if I take you with your cervix, which is closed and not. 

Soft and I induce you. I know that I am basically keeping you in the hospital for an extra 1, 2, 3, sometimes four days to allow all these medications that we use to put your body into labor. So what do we do with that? We don't even have the woman power. I'm not gonna say man, cuz the nurses on labor, liber women, um, and the doctors are [00:07:00] predominantly women. 

Other than in my practice, we don't have the power and the rooms and the beds and the time to have everybody come in. So it's been a bit of a controversy in the ob gyn world across the nation as to whether or not hospitals adapt the arrived trial or not. Whether or not we kind of believe in it, whether or not we think that it actually makes logistics sense. 

The truth is that a lot of patients aren't gonna want to be induced at 39 weeks. Right now at the conundrum of. Now I have patients where at least in the last couple months, I could have said, listen, if you wanna be induced, I mean, in my mind, I'm still used to wait till 41 weeks. Not because I liked pregnancy, I hated it, but that's what we were taught. 

Now all of a sudden, I have this arrived trial, so I could kind of let you decide with me, do you want to be induced at 39 weeks? Do you wanna wait till 41 weeks? As long as you're okay, let's have a conversation. Well, COVID came about, and guess what? Most hospitals do. Have the capacity to electively induce patients, meaning prior to 41 weeks, like seven to 10 days past your due date, unless you've gotten to that point, [00:08:00] most hospitals can't electively induce you, and it's not because we're being mean, it's not because we're being lazy, we're all working. 

It's because if we take up a labor room with someone who's gonna be in there from 1, 2, 3, 4 days without actually being in labor, but just for this induction process, then we're gonna have a conundrum now. Couldn't you go home from the induction? Couldn't we give you the medicine and send you home? Well, now we're getting to the medical legal territory. 

If I give you medication that makes your cervix softer and I send you home, and God forbid the baby's heart rate dropped or something happens, we are on the line legally. So you see how there's so many different factors that are adding into this. So I say all this so that you guys. When you and your doctor have this conversation about induction, there is no quick, easy answer at all. 

So it really has to be a discussion, which is hard, right? So for those of you at our hospital, we're asked at least in these several weeks not to do elective inductions. And frankly, as much as I wanna put everyone out of their misery, I really support [00:09:00] that, um, victim because we just cannot be taking up rooms and space and nursing staff with a situation that is considered very elective. 

I know everyone's anxious. I know they just kind of like wanna get the baby out. And I get it. Like I got it prior to Covid, I hated being pregnant. Um, but now I just have to be more cautious. So that is my long-winded way of saying induction is neither good nor bad. Like everything I talk about, there's good, there's good aspects of induction, there's bad aspects of induction. 

And each person is individual, so I urge you pregnant lady ladies, don't look at it as I have to be induced or I shouldn't be induced. There is never all good or all bad. That's just the way of the world. And the sooner we all accept that, the better. All right. Happy Easter. I hope you're all safe and I talk to you. 

And talk to you later.