Induction: help or hindrance?

Like most medical tools, inductions have a valuable role to play when there is a medical need. Like most medical tools they are used too often, too quickly and with minimal regard for the complications they pose to mother and child.

The NICE guidelines, on which this post is based, state in the introduction that inductions are less efficient and more painful than spontaneous labour requiring more intervention including pain relief such as epidurals and assisted deliveries.  It says inductions are common and usually occur during the daytime when hospitals are already busy.  This tells you that inductions are being over used and have a detrimental effect on the experience of birth for mothers and babies at a time when the ability of staff to care for women with increased needs is reduced.  So, we are off to a good start.

The guidelines then suggest that from 38 weeks women are educated about inductions and offered them between 41-42 weeks of pregnancy.  The problem with this is that many Trusts have a policy of booking in women for inductions at this time rather than just discussing it with them.

Before launching into the details of inductions I want to cover a few important details.

What is an induction?

Inducing labour is the process of forcing the body to go into labour when it is not ready.  No one knows exactly what triggers labour but it is thought likely to be a hormone or enzyme released by the baby.  Different methods are available and suit different women.  Some methods aim to open and thin the cervix, others aim to stimulating surges.

The most common way of trying to get labour started is not considered a method of induction but rather ‘augmentation’.  A membrane sweep is when a midwife or doctor runs their fingers around the inside of the cervix separating the membranes from the cervix.  The idea is to stimulate the cervix into action.  For many women it is ‘offered’ as a ‘routine’ procedure at their 38 or 40 week appointment.  Sweeps can be repeated and are not thought to cause any distress to the baby.  Women may find them uncomfortable, sometimes painful and they can cause bleeding.

Artificial Rupture of Membranes (ARM) is when something that looks like a crochet hook (called an amniotic hook) is pushed up through the cervix (this is only available when the cervix has already opened a little) and snags the membranes holding the amniotic fluid.  The aim is that by releasing the fluid (‘breaking the waters’) the baby’s head will descent onto the cervix and this will stimulate labour.  Though the releasing of the membranes does not hurt, getting the hook, and therefore most of the care providers hand to the cervix can be uncomfortable.

Prostoglandin (PGE2)   comes in the form of gel or tablet and aims to ‘ripen’ the cervix (thin and open it) which in turn will stimulate labour.  There are strict limits on how much can be used and how often it can be re-applied.

Syntocinon is delivered via a drip and designed to mimic the body’s own hormone oxytocin that is required to start labour.

When are inductions necessary?

If the mother is ‘overdue’, i.e. has gone beyond 42 weeks gestation.  The fear is that the placenta will start to deteriorate becoming less efficient and putting the baby at risk.  This only happens to some women (2-3 per 1000) so if you want more time, ask for regular monitoring before going straight for an induction.  The NICE guidelines state “In all cases, there is a clear need for the provision of information to allow women being considered for induction of labour to make a fully informed choice.”

If membranes release and labour has not started within 24 hours.  The fear is that an infection could occur posing a risk to mother and baby.  An induction is one of several options.  Minimise the risk of infection – no vaginal examinations (VEs) or anything entering the vagina as this is the most likely way of getting an infection.  Suggest regular monitoring to check for signs of infection or foetal distress.  Lastly consider requesting antibiotics to buy more time for labour to start naturally though weigh the effect of antibiotics carefully against the effect of induction.

Pre-eclampsia is when the placenta functions badly reducing oxygen and nutrients to the baby.  It makes the mother feel ill and if untreated can develop into eclampsia, a rare life threatening illness.   Regular monitoring and in some cases treatment can help but the only cure to pre-eclampsia is to birth the baby.  Induction is recommended if labour has not started spontaneously between 39-40 weeks.

Diabetes has an adverse effect on babies, often making them large but weak.  In some cases inductions are recommended because it is thought the baby would fare better outside the womb.

If the baby has died in the womb there will already be close medical supervision.  There may be pressure to induce labour but the guidelines say the indication for induction in this scenario is if there are signs that the membranes have released, signs of an infection or bleeding.  In these instances induction is preferred over ‘expectant mangement’.

When are inductions not necessary?

Because the mother is bored of feeling pregnant.

Because a healthcare professional thinks the baby is ‘big for dates’ – many people believe a woman’s body will only grow what she can cope with and there is no such thing as a baby too big to be birthed naturally.  Any suggestion that babies are too big, or too small for dates should be taken with a pinch of salt if all other indications are that the pregnancy is going well.  The methods of assessing size have a questionable evidence base and it should be remembered that babies are as individual as their mothers and do not conform to medical charts that are often outdated if they were ever accurate in the first place.

Because a healthcare provider has an arbitrary timescale like the weekend.

Because it is 40 weeks.  ‘Normal’ gestation runs to 42 weeks – and the accuracy of that date needs to be considered carefully as in when is 42 weeks and does your baby need more time even if others don’t?

Because it is routine in this hospital. I have heard many stories of women being booked in for an induction at 41 weeks during the 38 week antenatal appointment which sets completely the wrong mental attitude and negates the concept of informed choice.

Because baby is breech.  Most doctors and midwives are so de-skilled in breech births that they prefer caesarean-sections.  Even without this threat, an induction is removing the last possible chance of the baby righting itself in its own good time before birth.

Because there is placenta previa (low lying placenta).  Again, this is considered an obstetric risk and many healthcare providers will advise a caesarean-section because of the risk that there will be a cord prolapse.  This is when the cord enters the vagina ahead of the baby so that when the baby is birthed, the pressure of the baby’s head against the cord in the birth path cuts off the cord’s supply of oxygen to the baby thus risking damaging the baby.

Complications of inductions

The guidelines state “Although the risks of fetal compromise and still birth rise steeply after 42 weeks, this rise is from a low baseline.  Consequently, only a comparatively small proportion of that population is at particular risk.  Because there is no way to precisely identify those pregnancies, delivery currently has to be recommended to all such women.” There is no way of knowing which pregnancies need more time and which will cause problems if labour is not induced but what the guidelines do not have enough evidence to say is that everyone would be better being offered regular monitoring to ensure babies are not compromised rather than inducing most labours and compromising them through a complicated birth they are not ready for– which the majority of medics do not appear to acknowledge as a problem.

It is also worth dwelling on the concept of ‘risk’ as it is not, in this instance, universal.  The ‘risk’ as perceived by a mother may be different to the ‘risk’ as perceived by a healthcare provider, they have different pressures effecting their decision.  This is why ‘informed choice’ is so important, and so rare.  Being told there is a 99.5% chance your baby will be fine if you don’t induce is different to being told ‘your baby may die’.  (I have heard of this phrase being used in different situations on repeated occasions so don’t kid yourself there aren’t care providers out there with a very warped sense of what ‘care’ is.)

Risks to mother

• ‘Cascade of intervention’ results in a difficult experience for mother and baby resulting in an instrumental or surgical birth.  For example, an induction leads to fast, strong, painful contractions that the mother is not ready for so requires pain relief, an epidural slows and lengthens labour and increases the chances of an assisted birth, the baby was not ready to be born anyway and remains high in the pelvis so an assisted delivery is not possible so a caesarean-section is required leaving mother in pain for weeks to come and baby suffering the effects of the experience including having difficulty feeding and sleeping setting the new family off to a painful, unhappy and sleep-deprived start.
• Increased risk of continuous electronic fetal monitoring (efm) thus restricting  mother’s movement which is her method of getting the baby into a good position for birth, especially important if the baby was high in the pelvis when the induction was done and her best method of coping with the increased pain of an induction.
• An induction can increase the risk of uterine hyperstimulation causing extreme pain to the mother as well as an increased risk if this follows a previous caesarean-section of a second caesarean-section and uterine rupture.
• Post-partum haemorrhage due to the intense surges and the blocking of the hormones that would naturally prevent haemorrhage from additional drugs used during the labour.
• Increased risk of caesarean-section, put at 20% for first time mothers by a 2010 study (Ehrenthal et al.)

Risks to baby

• Risk of uterine hyperstimulation which is the much stronger contractions caused by a drug-induced labour literally squashing baby which can cause distress and therefore, increases the risk of caesarean-section.
• Risk of cord prolapse if the membranes release and the baby’s head is not engaged (down in the pelvis) the cord can slip down the birth path before the baby’s head and then get squashed during birth cutting off the vital oxygen supply to the baby.
• Increased risk of abnormal fetal heart rate, shoulder dystocia, lower apgar score and other problems from, amongst other things, the intense contractions brought on strongly and quickly by drugs that would have been slower and gentler in normal labour
• Increased risk of requirements for intensive care after birth because the baby was not ready to be born with the associated problems of mother / baby seperation effecting bonding and feeding.
• Increased risk of assisted delivery including forceps or vacuum extraction because baby was unlikely to have been in a good position for birth when labour was started before baby was ready.  Increased use of epidurals raises this possibility and the need for assisted deliveries.
• Increased risk of cesarean-section because of all the above factors (‘cascade of intervention’).
• Increased risks to the baby of prematurity because baby wasn’t ready to be born the lungs may not be fully matured leading to breathing difficulties, the brain may not be ready, feeding may be harder, temperature regulation and many other tiny nuances of nature that are undetectable from outside the womb. These will all lead to postnatal complications some of which may require more medical intervention.

Did they also tell you…

You can go home if your induction is a vaginal PGE2 tablet or gel, you do not have to hang around the hospital waiting to see if anything happens.

Not having an induction is an acceptable option, care providers should offer regular monitoring which is assessing the quantity of amniotic fluid and the health of the placenta and baby.

You should have more,  not less, access to natural forms of pain relief with an induction (which often creates more pain more quickly leaving women less able to cope than in a natural labour) including free movement, water, continuous support etc. Any form of monitoring that could restrict this should be intermittent – better still the healthcare provider should change their form of monitoring that does not hinder the mother.

Alternatives to Inductions

The NICE guidelines say ‘the available evidence does not support’ the following: herbal supplements, acupuncture, homoeopathy, castor oil, hot baths, enemas and sexual intercourse.  The key words here are ‘available evidence’, it does not say how much research has looked into these areas or whether any research has taken into consideration the holistic approach to a mother’s mind and body when starting labour.  Plenty of people will anecdotally report the success of these so-called alternative methods and just because there is no financial incentive to do the research does not mean it should be written off by mothers with instinct and faith in themselves and nature on their side.  Consider one, some or all of the following – if nothing else, getting through this list will buy you time.  (Based on advice from HypnoBirthing).

Do nothing.  Wait.  Patiently. Relax and enjoy the peace.

Hot /spicy food – moving the digestive muscles stirs up the birthing muscles.

Castor oil / enema – clearing the bowels ensures there is nothing to stop the descent of the baby’s head and can release prostaglandins, the hormone that softens the cervix.

Sex – ‘hugs before drugs’ is the HypnoBirthing mantra.  Semen contains prostaglandin, the hormone that softens the cervix.  Sex releases the hormone oxytocin which can start surges and will certainly relax mind and body which can release any mental issues blocking the start of labour.  Remember: what got baby in will get baby out.  In a private, intimate space relax and feel the love.

Walk / bathe / relax – keep active and relaxed, both are beneficial for mind and body to get labour started.

Fear release – anyone doing HypnoBirthing will have taken on board the power of the mind at this amazing time in a woman’s life.  A fear release exercise will ensure there are no lingering fears or emotions that could be holding your body back from going into labour.  Visualise your birthing body opening and relaxing.  Michel Odent recommends a class of champagne – and a second just after birth to help the placenta on its way based on the same approach of relaxation – though coming at it from a slightly different angle!

Acupressure, acupuncture, reflexology – where people have been specially trained to help induce labour these therapies can be incredibly successful, and some people use them through labour also with excellent results.

Homoeopathy - there are special homoeopathic kits for childbirth which include remedies for starting labour.

What options are available to women?

The word ‘choice’ is mentioned 17 times in the full NICE guidelines.  Every effort should be made to inform and work with parents who should make their own choices and be supported in that choice – whatever it is.  The guidelines say “If a woman chooses not to have induction of labour, her decision should be respected.  Healthcare professionals should discuss the woman’s care with her from then on.  From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring…”. At the end of the guidelines there is a long list of requests for more research which covers most key areas of induction.  As with so many aspects of birth not enough is known about the full impact of intervention and the guidelines are based on an organisations assessment of the existing evidence.  This suggests that things are not as clear cut as healthcare providers may present them to be.  Induction is a series of choices, not one individual act and women can choose none, some or all of those choices.  I consider informed choice to be the presentation of this information to a woman in a manner she can comprehend and the support to allow her to assess this information in line with her own feelings and beliefs.  Unfortunately this is not always the case and it is up to each woman and her birth partner to achieve this for themselves and – sadly- defend their choice if it runs counter to that of an un-supportive care provider.

If you are at logger heads with your healthcare provider you can ask for a second opinion.  You can also change healthcare providers; have you checked to see if there is another hospital near by with a different policy or even a midwifery-led unit that would care for you?  You could also consider employing an independent midwife.  If you have fallen out with your care provider over this issue it is unlikely either of you will have a good birth experience, you will be branded ‘difficult’ as will they in your mind.  Maintaining cordial relations is a two way street that benefits you both, but you can walk if it is really not going your way.

Check your dates are accurate.

Check you are informed of the reasons why you may want an induction.

Check you are informed of the risks for you and your baby of an induction.

Consider agreeing to regular monitoring to see if the baby (or you) have a medical indication that an induction is necessary. (Could be a good compromise if you have a difficult care provider).

Consider doing nothing.

Consider natural hints to your body.

Consider a membrane sweep.

Consider the lowest dose of the least invasive drug.