Medicated Cervical Ripening: The Entire Process Explained
SEPTEMBER 30, 2021 BY JULIANA PARKER, RNC-OB, C-EFM, CLE
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Cervical Ripening is one of the not spoken often about procedures of labor and delivery. Usually by the time it is being introduced, you are close to your due date with little time to know what to expect. Here is a complete overview of cervical ripening with medication. This article discusses:
WHAT IS CERVICAL RIPENING
Let’s first discuss what cervical ripening actually is. The cervix, before you are 37 weeks, is typically about 4 centimeters thick and does not have an opening. It’s like the gateway or doorway to the uterus. Up examination, your doctor or nurse, at this stage, would call your cervix LONG (for thickness) and CLOSED (no opening).
As you approach your due date, you may begin to have what are called “Braxton Hicks” contractions or false labor contractions. These contractions are not labor, but they do serve a purpose. Frequently, these contractions create a change in your cervix also known as “ripening”.
Your cervix may become thinner and may even open a little. The thinning process of your cervix is called effacement and the opening of your cervix is called dilation. When your cervix becomes thinner and begins to open a little, depending on how much, it is considered to be in the process of ripening or all the way ripened.
Complete cervical ripening is typically when your cervix is has opened (or dilated) to at least 2 centimeters. If your cervix has not ripened completely prior to starting an induction, then it may need a little assistance before the induction process is started.
A ripened cervix prior to induction has a better chance leading to a vaginal birth outcome.
THE MEDICATIONS USED FOR CERVICAL RIPENING
Ripening agents are meant to help your cervix be more prepared and receptive to Pitocin. As well as to meet that 2-centimeter goal. There are two medications that may possibly be used to ripen your cervix.
The first medication is called Cervidil (aka Dinoprostone). This is a little piece of cloth attached to a string. On the cloth there are prostaglantins. Cervidil is inserted vaginally and placed against the cervix and left in place for approximately 12 hours. After 12 hours, the string is pulled out, the cervix is rechecked and decisions are made based on your exam.
Cytotec (aka Misoprostol) is the other medication, also a synthetic prostaglandin, that may be used for cervical ripening. This is a pill (or a partial pill) that is placed either vaginally or is given to you orally. If oral, you allow it to dissolve in your cheek, you don’t swallow it. This partial pill is given every four hours as long as you are not having too many contractions and can be re-administered for up to six doses of needed. But these doses, as mentioned earlier, are spaced out by 4 hours.
THE CERVICAL RIPENING PROCESS
Once either of these medications are administered, you should begin having very mild contractions. Contractions will usually slowly and may remain unnoticed for several hours. Typically, patients begin noticing their contractions about 6 hours into the process (sometimes sooner, sometimes later). These contraction, for many, feel like menstrual cramps.
During this time, rest will be encouraged. You will not be able to eat for 2 hours once the ripening process begins, but most facilities will allow you to eat after 2 hours. Nothing but, just a snack or something. Some facilities will only allow you to have clear liquids.
Your baby will be monitored during ripening. Therefore, your nurse will be observing their heart rate the entire time. Because most ripening appointments occur at night, there is a good chance you will not see your nurse very much. This is so you can rest as this may be the only chance for you to get good rest before your baby is born. Use your call light if you need to reach your nurse, they are there, just hopefully allowing you some sleep.
Be aware that some people go into labor with ripening medications. It is not the most common scenario, but if your contractions become so strong that you are considering an epidural, be sure to let your nurse know.
Don’t feel obligated to wait for them to come check on you. At the same time, you don’t need to notify your nurse that you are simply having contractions. This is expected and your nurse will see this from the monitor feedback. But most definitely notify them if you are growing very uncomfortable with the contractions.
SPECIFICS FOR CERVIDIL
Cervidil should be left in place for a full 12 hours, unless there is a medical reason to pull it out sooner, such as the baby is not tolerating the contractions, your water breaks or you are having too many contractions. Try to advocate for the full 12-hours if a provider tries to pull it out early.
After 12-hours, the Cervidil is removed by pulling on the string. Your cervix will be checked again and your baby’s heart rate is then monitored for an additional 30-minutes. If the baby looks good, then you will be offered an opportunity to shower and eat breakfast prior to starting the Pitocin.
SPECIFICS FOR CYTOTEC
If Cytotec is used, you will be given a new dose every 4-hours, as long as you are not contracting too many times and as long as the baby is tolerating the contractions. You may be offered, in between doses, or upon request, an opportunity to shower and eat.
Take advantage of this before your contractions become stronger.
Prior to each dose of Cytotec being administered, a cervical exam is required. If at any point, you are 2 centimeters or more, no more Cytotec will be given and Pitocin will be started.
WHICH CERVICAL RIPENING MEDICATION WILL BE USED?
Cytotec is much less expensive than Cervidil, so most hospitals are using Cytotec these days. Either one can be effective. There are times when it seems that Cervidil doesn’t work well and other times when it seems Cervidil is putting everyone into labor. The same goes with Cytotec.
But ultimately, if you have a high-risk condition involving your baby, such as intrauterine growth restriction or low amniotic fluid, where there is a higher risk of fetal distress, Cervidil will ways be used because it can be pulled out and the process stopped.
Cytotec contractions can only be stopped by using another medication, an injection, or by it wearing off with time. Therefore, this is not used when the baby’s oxygen supply could be compromised in any way.
The decision of whether to use Cytotec or Cervidil is often discussed with your provider during your prenatal visits or at the hospital. If you do not have a clear understanding of the process, you should request to speak with your doctor as you should feel comfortable signing an informed consent form. This form means you have been informed about the procedure, have had all of your questions answered and are ready to proceed.
WHAT IF CERVICAL RIPENING DOESN’T WORK?
If the first round of cervical ripening does not work, you may repeat cervical ripening. Yes, this is called serial cervical ripening. For example, if you start with 12-hours of Cervidil and there has been no change, you may be offered Cytotec, or vice versa. Therefore, be prepared that your pre-baby hospital stay may be a couple of days before Pitocin is even started.
Ultimately if there is no change with multiple attempts of cervical ripening, Pitocin can still be started and attempted. Also, if your cervix is open just a little, it allows other possible options such as manual ripening (this will be discussed in another post) or breaking your water.
WHAT SHOULD I DO DURING CERVICAL RIPENING?
During this process, most people are fairly comfortable. I encourage you to rest. You will be connected to fetal heart rate monitors. If your hospital has wireless monitoring, this will allow you more freedom, but if your hospital has only wired monitoring then your movement will be limited. Youc an still move, but the distance you may go will be restricted. Furthermore, your nurse will have to unplug you to use the bathroom.
Bring projects, books, movies, etc. to entertain you. Some good ideas are puzzles, knitting, a laptop and a firestick, a good book, magazines, baby announcement envelopes, or thank you notes. You will most likely have quite a bit of time to work on things, so enjoy this last moment of uninterrupted project time before baby arrives. However, resting is what I encourage the most. You will need rest prior to your true labor and your baby’s arrival!
UNEXPECTED SCENARIOS
Please be aware that if you are scheduled for or planning to schedule an induction, there are a few things you should know.
1. There are medical reasons to induce and there are elective inductions. If you are planning on an elective induction, you have to be at least 39 weeks pregnant to be induced.
2. Scheduling is requested by your doctor but is scheduled by the hospital. Your doctor makes the request, but ultimately, the hospital has final say based on schedule availability.
3. Arrival times are not guaranteed. If the hospital is full of laboring mamas, or has a high acuity, (aka there are a lot of patients requiring one-to-one care), your induction can and will be placed on a temporary hold. Inductions are only started when the unit environment is safe for you and your baby. Therefore, do not be surprised if you receive a phone call 1 or 2 hours prior to your arrival time informing you not to come in. And PLEASE don’t get angry at the person calling. This is a safety issue. You will be brought in as soon as the unit is safe for you and your baby. Remember, emergencies can happen in labor and delivery, you don’t want an emergency involving your baby to be met with a staffing shortage.
4. Arrival times vary and can be late at night. Regardless of whether your induction time is 7am or 1am, please be timely. If you do not arrive on time, and the unit becomes busy, you may be sent back home. Once you are there and, in a room, you are considered a laboring patient. Other laboring patients could then possibly be sent elsewhere, but your spot is safe.
5. Just a reminder that ripening will make you contract. You may request a mild sleeping pill and Tylenol to help you rest during the ripening contractions. I promise, you will wake up if contractions become strong. The contractions may break through the Tylenol. If it has been 6 hours since your Tylenol, you may request more. However, if your contractions become so strong that you are considering an epidural, notify your nurse, it is possible you have gone into labor.
6. During your induction process, you will only be allowed to have clear liquids, so be sure to have a light snack prior to arrival. Partners pack snacks and be sure not to skip meals! You will need your energy too!
CONCLUSION
Cervical ripening can be very helpful in a successful induction process. Talk to your doctor about cervical ripening if you are being induced. To learn more about cervical ripening and inductions, be sure to sign up for my Childbirth Master Class. You will learn about all labor inventions and will be more prepared for labor than you ever imagined!
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