Birthing Options

Birthing options can include both the location where you would like to give birth as well as how you would like to give birth. In the U.S., most deliveries occur in a hospital. Many people also choose to give birth in a birthing center or at home. In NC, last year 15% more births occurred at home than the previous year. Choosing to have a baby at home or in a birthing center may not be advisable in mom's with chronic medical conditions, or if mom has certain obstetric conditions like gestational diabetes, hypertension or placenta previa, or when labor occurs before 37 or after 42 weeks. When birthing at home or in a birthing center, you can expect fewer delivery interventions like medication for pain or medication to increase the frequency of your contractions. When birthing in the hospital, you can expect access to medical interventions during delivery as well as access to providers who can intervene quickly in case of complications. Most providers only deliver babies in one type of setting, so choose a provider who will deliver in the setting that you prefer. Hospital births are more expensive than births at a birthing center or home. However, some insurance providers do not cover birthing centers and home births. Check with your insurance provider to learn what they will cover. Before being discharged from the hospital, it is important to have named a pediatrician for your new baby.

Vaginal Delivery

Safest and most common type of childbirth. Baby is born through your vagina or birth canal. With vaginal delivery, your recovery is faster and you have lower rates of postpartum infection. Vaginal delivery can happen on its own when your body is ready. Vaginal delivery can also be induced. Your provider may recommend inducing labor with medication or other steps when they think it will lead to better outcomes for you and your baby.
Cesarean Section or C-section

A surgical procedure where the baby is delivered through the mom's abdomen. C-sections are recommended in certain situations when the baby cannot be safely delivered vaginally, for example if the baby is too large or not in the right positions for delivery. If you need to have a C-section, you will have a longer recovery time than with a vaginal delivery. C-section rates in the U.S. are higher than in other countries and are highest for Black birthing women.
Vaginal Birth After Cesarean (VBAC)

A VBAC is when you have a vaginal delivery after having previously delivered a baby by cesarean. A VBAC can be an option for you if you meet certain criteria. Talk with your provider about your options.

My provider says I need to be induced. What now?

What is labor induction?

Induction of Labor: the use of medication or other modalities to bring on (induce) the onset of labor rather than allowing labor to begin spontaneously. Spontaneous labor is the onset of labor without the use of medicines or interventions. In the US approximately 25% of labors are induced. Most labor inductions result in a vaginal delivery.

Why may labor induction be necessary?

Labor inductions are considered either Medically indicated or Elective.

Medically indicated induction: occurs when the health of the mother or the health of the unborn baby is at risk. Your provider may recommend induction when the benefits of delivery outweigh the risks of continuing the pregnancy.

Conditions of the mother may include:

Hypertensive disease of the mother, either chronic hypertension, preeclampsia or eclampsia
Maternal Diabetes, either gestational (pregnancy-related) or preceding pregnancy
Maternal conditions involving problems of the heart, lungs or kidneys.

Conditions of the unborn baby include:

Growth restriction (poor fetal growth)
Low amniotic fluid
Suspected problems (insufficiency) of the placenta
Premature rupture of membranes

Conditions of the pregnancy including:

Your pregnancy has lasted more than 41-42 weeks
You have pre-labor rupture of membranes (PROM)

Elective inductions: occur when labor is induced by choice of the mom, in the setting of a healthy mother and a healthy unborn baby.

Some reasons for Elective induction include:

Distance from the hospital/Inadequate access to transportation in an emergency
Military service/deployment of a partner
Providers’ schedule (rare)
Patient Preference

Recent data support the consideration of elective induction at 39 weeks for 1st time mothers (primigravidas) in order to slightly reduce the chance of a cesarean birth, and to slightly reduce the chance of developing preeclampsia if the pregnancy continues.

Before proceeding with an elective induction you should know:

Elective induction should NOT be performed before 39 completed weeks of pregnancy.
You should not feel pressured to proceed with an elective induction.
An elective induction is ideally performed with a favorable cervix.

What is a Bishop’s score?

A clinical assessment (examination) of the cervix and is the most common method to rate the readiness of the cervix for induction
A 10-point system that standardizes the readiness of the cervix for induction (dilation, effacement, station, consistency, position)

A ‘Bishop’s Score’ < or = 6 (considered unfavorable) > or= 8 (considered favorable)

Starting with an “unfavorable” cervix does not mean that the induction will fail and end in a c/section, but it does mean that the process from induction start to delivery of your baby could be quite prolonged. (Several days)

What can I expect from the induction process?

Labor induction is a process, starting with cervical ripening followed by the stimulation of contractions.

Methods of Induction:

Cervical ripening: used when Bishop’s score is “unfavorable” – Softens, thins and dilates the cervix (mouth of the womb)

Cervical Ripening can be accomplished with synthetic prostaglandins (hormone-like substance) or with mechanical dilation

Prostaglandins: Hormone-like substances (Dinoprostone or Misoprostol) that are given vaginally, orally, or buccally (in the cheek)

What are the risks with this type of induction method?

Tachysystole-contractions that occur too frequently or back to back
Meconium stained amniotic fluid

Prostaglandin cervical ripening is NOT used in patients with a history of c/section as it is linked to Uterine scar rupture.

Mechanical Dilators: provide gentle pressure to dilate the cervix. A double balloon catheter (insert image) is inserted thru the cervix and dilated with saline water.

One balloon is inside the uterus (next to the amniotic sac) and the other balloon is in the vagina.

What are the risks with this type of induction method?

vaginal bleeding
rupture of membranes
maternal discomfort

Once the cervix is “ripened” Uterine contractions can be stimulated with:

Pitocin: a synthetic form of Oxytocin (a hormone) and one of the most commonly used drugs in the US

Pitocin is administered intravenously and is dosed per protocols with the goal to produce regular and strong uterine contractions. In general, continuous fetal monitoring is required when Pitocin is being given and there is an associated restriction of movement with continuous monitoring.

Risks of Pitocin: Tachysystole (uterine contractions that occur too frequently)

Amniotomy: is the artificial rupture of membranes, this is often performed after contractions are regular and cervix is already dilated.

Amniotomy alone is generally not performed unless the cervix is well dilated with goal to increase onset of labor contractions

Risks of amniotomy include:

Prolapse of umbilical cord (rare)
Changes in fetal heart rate due to loss of amniotic fluid and umbilical cord compression
Prolonged rupture of membranes can lead to intrauterine infection (chorioamnionitis)

What is a typical induction like?

In the hospital, an induction always starts with a cervical exam (to guide the induction method) and a non-stress test (an evaluation of baby’s heart rate for the safety of an induction).

The process starts with cervical ripening if necessary. You will be allowed to eat during this phase of a labor induction. Generally, the cervix is reassessed after 12-24 hours or sooner if mom becomes uncomfortable if uterine contractions start in response to the prostaglandins.

If the cervix is considered “favorable” (thinned, softened and opened), cervical ripening is followed by Pitocin, amniotomy (rupture of membranes) or both. It may take an additional 12-24 hours to obtain regular uterine contractions.

What happens if labor induction doesn’t work?

Sometimes labor induction doesn’t work. If you and your baby are doing well and the amniotic sac has not ruptured, your provider may give you the option of going home and trying again in several days.

According to ACOG, if the maternal and fetal status allow, cesarean deliveries for a failed induction of labor can be avoided by allowing longer durations (>24 hours) for early labor, and requiring that Pitocin be given for at least (12-18 hours) after membrane rupture before considering the induction a failure.