Following up on last week’s inaugural FAQ Friday post, in which I responded to the question, “how is a doula different from a midwife?“, this week I will be addressing a question that was posed to me by a reader: “what is the difference between pain experienced during a natural childbirth and during… an induction?”

A little background to start us off, in case you aren’t familiar with the term “induction”. An induction is when, instead of waiting for labour to begin on its own (or, ‘spontaneously’), measures are undertaken to force the body to go into labour. Usually when we refer to an induction we mean a medical induction, where various steps are taken by medical practitioners in order to cause labour onset.

The word induce is a verb meaning “to bring about or give rise to”. While a medical induction is certainly the most aggressive and surefire way to make labour start, there are many non-medical techniques that women have traditionally used when they want to hurry things along a little. These may include acupuncture, eating certain foods (such as spicy things or pineapple), having sexual intercourse involving both female and male orgasm, or taking homeopathic and/or herbal remedies. Castor oil is also commonly ingested to bring on labour, though many women report unpleasant side effects, so this should only be tried as a last resort (i.e. to avoid a medical induction) and with the blessing of your healthcare practitioner. A medical induction may involve three steps:

• if the cervix is not yet ‘ripe’ (i.e. it is not yet softening, shortening or opening) a synthetic prostaglandin gel is applied to the cervix directly in order to encourage it to soften and dilate (one of the reasons that sex involving male orgasm is helpful is that semen contains prostaglandins)
• once the cervix has dilated a little bit, an amniotomy is performed. This is more commonly known as when a doctor or midwife “breaks your water” (aka AROM – artificial rupture of membranes). This is done using an amnio-hook, which looks a little bit like a crochet hook. The hook is inserted into the opening of the cervix and the bag of waters is punctured.
• sometimes immediately following AROM, but sometimes after a period of waiting (in which labour may start on its own), Pitocin is administered. Pitocin is the brand name for synthetic oxytocin. Oxytocin is the hormone that is secreted during labour, which causes uterine contractions (here is where the female orgasm is handy – our brains also release significant amounts of oxytocin when we have orgasms…also when we kiss, hold hands, sing in chorus…). Pitocin is administered by an IV and the amount is increased gradually until contractions are happening frequently and with enough intensity to cause the cervix to open fully.

As you can probably gather from the above description, a medical induction is a way of simulating the natural processes that typically cause spontaneous labour onset. As with almost any intervention, each stage has some risks or drawbacks, including increased likelihood of a Caesarean section, in the event that the induction fails (a Bishop’s score is a means of assessing the likelihood that an induction will succeed in advance).

One of the biggest drawbacks to inducing labour is what the original question alludes to, that is, increased contraction pain. While every birth is different and some women experience more or less pain than others (indeed, many women experience no pain at all in labour), it can be said in general that an induced labour is significantly more painful than labour that begins on its own and proceeds without augmentation (augmentation is the use of Pitocin in 1st stage labour when it is felt that labour is not progressing rapidly enough).

Why is this? There are a couple of reasons. First, because Pitocin is not your body’s naturally produced oxytocin, but a synthesized form, it affects different people (and their uteri) differently. This makes it difficult to know how much to administer from woman to woman in order to get labour going gradually they way it most often does when it occurs spontaneously. One of the reasons that women who are induced are required to wear continuous electronic foetal monitors is because of this. One monitor shows how strong the contractions are (though not always accurately) and the other shows the baby’s heart rate (again, not always accurately). This is important because babies are affected by the contractions of the uterus and if they are too intense, this can cause foetal distress.

In addition to dosage issues, Pitocin is a substance that is being introduced to the body from outside, rather than being released from within the body as a part of a complete system. Oxytocin is only one of the hormones produced in the body during childbirth. When labour happens on its own the body is responding to prior hormonal secretions (such as melatonin) and subsequently causing others to be released (such as endorphins). When labour begins spontaneously, it usually does so somewhat gradually. The most definite sign of ‘true’ labour is contractions that progress – that is, they become stronger, longer and closer together over time. As they become more intense, longer and more frequent, the body begins to release increasing quantities of endorphins, which allow the woman in labour to cope more easily with the contractions themselves. Endorphins can reach a potency that is significantly stronger than morphine. These hormones (melatonin, oxytocin, endorphins) have a synergistic relationship to one another – that is, they enhance each other’s effectiveness in the body. Because Pitocin is synthesized and administered artificially, the body’s ability to respond with appropriate amounts of endorphins is compromised. It can’t keep up. It is important to note, that the release of endorphins can also be compromised by the release of stress hormones – catecholamines – such as adrenaline. This means that any interruption that causes stress, fear, humiliation, etc. in a woman has a direct impact on her physiologic ability to cope with the sensations of labour. These stress hormones can also interfere with the release of oxytocin, which then may lead to augmentation with Pitocin because contractions are slowing or stalling. For many people, simply being in a hospital is a stressful thing, which may be one reason why statistically speaking, hospital labours tend to be longer and tend to lead to a greater number of interventions, such as augmentation or pain medication, even when they begin naturally.

When you look at naturally occurring contractions on a monitor, they look like hills that have a slow incline, a rounded peak and a slow decline. As labour intensifies, the slopes on either side become more extreme and the peaks get higher. Contractions caused by Pitocin on the other hand, tend not to have very gradual slopes and have much higher peaks, earlier on. They look spiky, rather than hilly. In other words, induced labour hits women much harder, faster, instead of allowing for a gradual ‘easing in’. Add to that the fact that your body’s pain ‘medications’ – endorphins – don’t work as effectively when the system is circumvented, and it’s no wonder that women who have experienced both induced labours and spontaneously occurring labours say that the former are much more painful than the latter.

Do you have a question you’d like me to answer? Maybe you’d like to know more about induction, or maybe your question is on another topic altogether. Anything goes! Leave it in the comments and I’ll be happy to tackle it next week.

photo credit: Fire Engine Red via photopin cc