Labor is a painful process. One or two women out there might argue this, but we think it’s safe to say that labor is painful across the board. As far as induction, we would hope that you are not being induced without your consent. No medical procedure, including an induction of labor, can take place without a patient’s consent.

There are multiple reasons for inducing labor. Sometimes the patient requests induction. A family member may be coming from out of town, or the patient may be suffering extreme discomfort. Physicians may recom­mend that a patient be induced for medical reasons, such as preeclampsia (rise in blood pressure, protein in the urine, and edema), decreased amni­otic fluid (oligohydramnios), intrauterine growth restriction, twins, and gestational diabetes.

Just as there are multiple indications for labor induction, there are also multiple means by which to induce. Your physician or provider will deter­mine which method is best by using a system called the Bishop’s score. This score helps predict how likely your cervix is to dilate with an induc­tion. The word ripe is used to indicate that the cervix is ready to dilate. In other words, it will be more receptive to dilation when induced. The scoring system takes into account the following factors:

- Cervical dilation. The opening of the cervix is measured in cen­timeters, ranging from 0 (closed) to 10.

- Cervical effacement. This term describes the thinning and short­ening of the cervix. A cervix less receptive to induction is long and thick, whereas a ripened cervix is thinner. Cervical effacement is described in terms of percentage. A normal, long cervix is approxi­mately 4 centimeters in length. If it is 50 percent effaced, it’s approx­imately 2 centimeters in length; 100 percent effacement means the cervix is as thin as paper.

- Station of the fetal head. The station measures the location of the tip of the fetal skull in relation to the bony prominences of the ma­ternal pelvis called the ischial spines. Zero station occurs when the fetal head is at the level of the spines. When the fetal head is crowning and visible at the perineum, the station is +5 station. A -5 station, on the other hand, means that the fetal head is floating in amniotic fluid and is not engaged in the pelvis. This fetal position is called ballotable. So, the lower the station, the more ripe the cervix.

- Position of the cervix in the vagina. When the cervix points toward the back of the vagina, it’s in a posterior position. When it points to the front of the vagina, it’s called anterior, and when it points to the opening of the vagina, it’s midline. Midline and ante­rior cervixes are considered ripe. The cervix will move more toward the vaginal opening when it is ready for labor.

- Cervical consistency. Normally a cervix feels like the tip of your nose. If the cervix is soft, like the texture of your cheek, it is consid­ered ripened and ready for induction.

Each portion of the Bishop’s score can receive a 0, 1, 2, or 3. A cumula­tive score of 8 or more is likely to support a successful induction.4 If the Bishop’s score is low, indicating that the cervix is not as susceptible to dilation, a medication will be used to ripen it Vaginal pills or gels may be used, as well as medications on a string that can be inserted into the vagina. Typically, these methods do not initiate painful contractions and are well tolerated. Once the cervix changes in dilation, position, or consistency, Pitocin (brand name of oxytocin) will be administered. In many cases, if the cervix is already considered ripe, induction will start immediately with intravenous oxytocin. Some­times, breaking the bag of water, which is technically called artificial rupture of membranes, is used in combination with Pitocin. Occasionally a labor becomes dysfunctional, meaning that contractions are irregular and the cervix is not dilating. In this case, labor is “augmented” with Pitocin in order to obtain “functional labor,” meaning that contractions will cause the cervix to dilate and ultimately result in the safe delivery of the infant.

Many women think that contractions induced by Pitocin are more painful than those of regular labor. This must be the gist of why so many women think that an induction hurts more than going into labor naturally. Is this merely a misguided perception or do contractions brought on by Pitocin really hurt more than natural contractions? The Pitocin used intra­venously during labor and delivery is biologically identical to the Pitocin—called oxytocin—made by your pituitary gland. Contractions stimulated through intravenous Pitocin may possibly affect the uterus in a different manner than natural labor, though this has not been proven.

If a patient experiences dysfunctional labor, we may augment her labor with Pitocin, which will result in a functional labor. As the labor begins to progress normally, the pain also begins. The Pitocin itself does not cause pain; it increases the frequency and power of con­tractions, thereby increasing discomfort.

Another reason for the perception that induction results in more pain has to do with the stages of labor. Labor includes two phases: a latent phase and an active phase. The latent phase occurs at the very beginning of labor and can last anywhere from twenty-four to forty-eight hours for a first pregnancy. It is signaled by contractions that are irregular but persistent and a cervix that is dilated anywhere from 1 to 4 centimeters. The active phase of labor starts when the cervix is dilated to at least 4 centimeters and regular contractions occur at least every five minutes.

Usually women who go into labor naturally are told to come to the hospital when their contractions are five minutes apart and they have dif­ficulty talking during them. When contractions occur at this interval, the patient is likely to be in active labor. When a patient is induced, she may be “stuck” in the latent phase, which means being in the hospital for a longer period of time while the medication is beginning to work on the uterus and cervix. If not induced, a patient is at home during this period, in the comfort of her own bed and able to move around and eat or drink. Conversely, the induced patient is in the hospital, typically in bed and hooked up to a fetal monitor. Perhaps this difference is one reason why induction is perceived as being more painful.

Furthermore, once labor becomes active and functional, meaning the cervix is dilating and the contractions are consistent, it becomes painful. So whether active labor occurs by the natural secretion of your own Pitocin, or the injection of Pitocin intravenously, as in an induction, it hurts.

All of these factors likely contribute to the perception that induction “hurts” more than spontaneous labor. As a male obstetrician, Shawn can honestly say that he has never experienced labor, but we have both witnessed labor in thousands of cases, and be it natural or induced, it hurts.