(updated September 2021)
Induction of labour is the bane of many birthworkers lives (and of many pregnant women’s too). In the area I live in, it is reaching epidemic proportions (about 35% of first time mothers)
Deciding to consent to induction is a complex decision, one that should be fully supported, without pressure or coercion, so that women and their supporters make a truly informed decision. Only it doesn’t happen. Most of the time, women just get taken for a ride.
I need to give a disclaimer : I have no doubt that induction of labour is the right option when a medical situation (say, high blood pressure, or reduced fetal movements) means that doing something is probably more sensible than waiting. Because things are likely to only get worse if we wait. I get it. This isn’t what this post is about. I also have to warn you, if you are pregnant, before you read any further, that this might not feel like a pleasant post to read. I’m going to talk about what induction entails and depict it in a light that I know could be anxiety inducing.
Now that this is out of the way, let’s look at the situations when induction might not always be the most sensible thing to do.
1) Your baby is “late”. Being overdue is probably the top reason for unnecessary induction – and I have already written an extensive post about that.
2) Your baby is “too big” is another very debatable reason. Women tend to grow babies who fit their pelvises. Pelvises aren’t hard, inflexible bony things, in fact they have lots of joints and ligaments (which are made extra flexible by the pregnancy hormone relaxin) and can open to let your baby out. Babies heads mold to fit inside the pelvis. So we can’t predict that the fit, short of doing a constant MRI scan during labour. There simply is no evidence to support the idea that a big baby won’t fit. Similarly, estimated baby’ size towards the end of pregnancy via scan or palpation is notoriously inaccurate. Evidence based birth has reviewed the evidence on big babies, and states that ” Research has consistently shown that the care provider’s perception that a baby is big can be more harmful than an actual big baby by itself“. You can read the full article here.
3) Your placenta is “failing”- again there is no evidence to back this up. In this article, Prof Harold Fox states that ” A review of the available evidence indicates that the placenta does not undergo a true aging change during pregnancy…..The persisting belief in placental aging has been based on a confusion between morphological maturation and differentiation and aging, a failure to appreciate the functional resources of the organ, and an uncritical acceptance of the overly facile concept of “placental insufficiency” as a cause of increased perinatal mortality“. You can read this article here.
4) You are “too old”. First time mothers over 40 get “offered” an early induction of labour. This is mostly due to the risk of stillbirth increases in older mothers. To quote the RCOG scientific impact paper “The incidence of stillbirth at term in women is low. It is higher in women of advanced maternal age. This at 39–40 weeks of gestation equates to 2 in 1000 for women ≥ 40 years of age compared to 1 in 1000 for women < 35 years old.15 Women ≥ 40 years of age having a similar stillbirth risk at 39 weeks of gestation to women in their mid 20s at 41 weeks of gestation, at which stage the consensus is that induction of labour should be offered to prevent late stillbirth.” This means that the risk is stillbirth is still very small. It might not be an acceptable risk for you. But it still makes sense to balance those risks against those of the induction process, so you can make a truly informed decision (you can read a great review of the research on the evidence based birth blog)
The thing that really gets my goat, though, is the lack of discussion on the risks of induction, and on what induction actually entails.
What I see happen on a regular basis, are expectant parents being “booked in” for an induction at whatever random date (it varies between NHS trusts) their local health system has decided is the “right” time. They don’t realise this isn’t compulsory, they don’t realise they have a choice, and more worryingly, they don’t really understand what they are letting themselves in for. What bugs me most is that the lack of open, honest discussions itself goes against clinical guidelines.
NICE states that
“Healthcare professionals should explain the following points to women being offered induction of labour:
- the reasons for induction being offered
- when, where and how induction could be carried out
- the arrangements for support and pain relief (recognising that women are likely to find induced labour more painful than spontaneous labour) (see also 18.104.22.168 and 22.214.171.124)
- the alternative options if the woman chooses not to have induction of labour
- the risks and benefits of induction of labour in specific circumstances and the proposed induction methods
- that induction may not be successful and what the woman’s options would be.”
In practice, yes, perfunctory discussions take place and leaflets are given, and health professionals rarely explain the realities of what induction of labour entails.
Therefore parents consent to go in for induction thinking they’ll have the baby that day. They also do not have a real concept of the risks involving induction of labour (because usually the only discussion that took place covered the risks of not inducing only). Some of the risks are that induction either doesn’t work, or that the baby doesn’t cope with the drug induced contractions-in either case, a caesarean is then the only option.
In my area, the rate of caesarean for first time mothers being induced is 45%. That’s nearly one in two. This stat isn’t usually given during induction discussions. I believe that if this was explained in a more balanced way (the way NICE recommends it above), more parents would probably choose to wait. What happens in practise is that people are told that induction doesn’t increase the chance of having a cesarean. Whilst some debatable publications from the past says so, in practise (I’ve been in this field since 2010), this doesn’t fit with the statistics produced by most UK hospitals. More recent published research like this paper, show what I’ve witnessed time and time again since I’ve worked in the birth field, which is that, for first time mothers, induction of labour roughly puts the chances of having a caesarean at 50% instead of the 30% for the average population).
Induction of labour also carries other risks which are rarely explained such as explained below:
“Although induction at term could prevent rare cases of fetal death,” write Seijmonsbergen‐Schermers in the BJOG, “all induced women will be exposed to potential disadvantages. Women whose labours are induced have a higher risk of postpartum haemorrhage, uterine rupture, hyperstimulation resulting in fetal distress, and perineal injuries (Miller et al. Lancet 2016). Furthermore, more women need pain medication and have limited freedom of movement, a longer labour, and a negative birth experience. There is increasing evidence that suggests negative consequences of synthetic oxytocin administration. This may influence maternal–fetal bonding, the maternal psyche, and neonatal preparation on being born. A large cohort study found higher rates of jaundice, feeding problems, infections, metabolic disorders, and eczema up to 5 years of age among children born after induced labour (Peters et al. 2018).”
After all, when it comes to postdates induction, even the Cochrane database states that ” the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction).”
One thing that isn’t explained in the NICE bullet points above, is how long induction can take. Yes, parents are told it can take days, but the discussion isn’t complete enough in my opinion.
I often talk about continuums, or gauss curves, to explain how different we all are, and how variable our individual responses to certain situations can be. When asked about induction, I explain that for the majority of people it usually take 2 to 3 days, but that some people respond incredibly fast to induction, and that some may take up to 5 days (or more!).
In my experience, parents are rarely told, for example, that because the ward might be busy, they might get admitted in the induction ward, only to get bumped off due to other more urgent cases jumping the queue. The record I have seen is 5 days. Yes you read that right. 5 days of restless hospital nights before the process even gets started. Exhausted before labour even begins. Nice.
I have seen instances of women’s inductions being stopped half way through because the delivery unit was suddenly full.
At the other end of the spectrum, I’ve also heard parents who responded to the induction faster than expectant, having the scary experience of birthing they baby on the ward with nobody supporting them.
Don’t get me started on the Bishop’s score (an assessment based on how low, soft and open her cervix is), which is done prior to induction, in order to assess readiness for labour, and also to choose the best drug option for cervical ripening. Only the results of the assessment aren’t unusually shared with the woman. Yet, in order for the woman to make an informed decision about her care (and even if the caregivers have little flexibility about options based on the results of the assessment, because an unfavourable cervix is usually followed by induction taking place anyway), surely some discussion should take place between the caregiver and the woman about the result of this assessment?
I just don’t get it.
Admitting that induction is started straight away, very few parents realise that the first line of induction, artificial prostaglandin, is usually something (especially if the woman is a first time mother and her cervix is “unfavourable”) that can take a loooooong time. 24h of propess (a kind of tampon like prostaglandin pessary), followed by up to 3 times application of prostin (a prostaglandin gel) 6h apart. We’re already 42h in the process and labour may not even have started yet. Assuming this has worked enough to soften and slightly open the cervix, then waters are artificially broken, and a drip of synthetic oxytocin drip is used to start contractions. It isn’t unusual after that for it to take another full 24h to reach full dilation of the cervix.
During this time, again this is my personal experience, many first time mothers find the contractions caused by syntocinon (the synthetic oxytocin) more painful to cope with. Natural oxytocin comes in peaks and throughs with breaks in between whilst your own natural painkillers (endorphins) rise accordingly. With syntocinon you get a constant high hormone level in your bloodstream and often no break in pain between the contractions. And there is no build up of natural endorphins because the artificial oxytocin doesn’t cross the blood brain barrier.
Because induced labour is more painful, more induced women end up with an epidural. This means that they are lying on their back, with no gravity, and a slack pelvic floor (no sensation means no muscle tone), which makes it harder for their baby to be in a good position for birth. Having an epidural double the chances of needing instruments or a caesarean to help the baby being born.
So we are often looking at process that can take up to 3 whole days. Or more. And which in half of the time ends up with a caesarean anyway.
So sometimes, I wish women where really given the option to opt for a caesarean instead of induction, or at least be told that they can say “enough” at any point and choose a caesarean instead.
So when faced with the prospect of induction, how to do navigate the maze of options to decide whether to say yes or wait?
Here are a few things you might want to think about before consenting to induction of labour.
- Whether the risks involved continuing the pregnancy are greater than the risks involved in induction (risk is a very personal concept and you need to be fully informed to make such a decision).
- That you are committing to getting this baby out once you start the induction process. Once you start you cannot back out, and a caesarean is recommended if the induction does not succeed or if the baby becomes distressed
- That the induction itself creates risks that require further monitoring and interventions (in particular, the use of constant fetal heart monitoring is recommended rather than using a hand held ultrasound for intermittent monitoring).
- That induction reduces your birth place options (no home or birth centre) and your ability to move around in labour.
- That induction, as an intervention, significantly reduces your chances of having a straightforward vaginal birth.
If you want to read more, Dr Rachel Reed has written an extensive article on the topic of the risks of induction, which includes all literature links
Sara Wickham has written an excellent article about induction too, called ten things I wish every woman knew about induction of labour.
Above all, remember that medical guidelines are based on an average of the population, so the same blanket policies are applied across the board, regardless of individual circumstances. You aren’t the population. You are an individual with your own personal individual history and risks, and your own personal preferences and risk perception.
You deserve individualised care and true open discussions to make the right decision for you.
Update September 2021.
Two new aspects that one now needs to take into consideration:
Since March 2020, partner’s access has been restricted. So I have supported women who went through several days of induction alone, without their partner or my support, and their partner was only allowed to join then when the last past of labour when they transferred to the delivery unit.
Staffing issues which where already a problem prior to March 2020 have gotten worse, and therefore women get admitted to the induction ward, but often left there to wait for some days before the induction starts, or the induction process gets stopped half way through due to lack of space in the delivery unit. This has become such an issue that someone just published a paper about it.
You might want to factor in these aspects in your decision making about whether to consent to induction of labour or not.
Some families have choosen to take matters into their own hands and induce the labour themselves using castor oil. If this is something you would like to explore, I wrote a blog post that reviews the evidence about castor oil as a method of inducing labour.