Written by midwife Julie Watson (UB Academy)
There are lots of famous quotes about labour and birth but few related to the impact induction can have on that process. Many moons ago when I thought I knew so much about labour and birth (but in reality I had so much more to experience and learn), i read how Mary Cronk compared labour and its amazing intricacies to a synchronised swimming team; in-tune and utterly wonderful. She said that induction of labour is like throwing one of those swimmers in the pool and hoping the others jump in.
Can you believe that today in every maternity unit across the country, 1 in every 3 women are beginning their labour as a result of an induction? Only 52% of women’s labours start spontaneously, with the proportion of births where labour was induced increasing from 20.4 per cent in 2007-08 to 32.6 per cent in 2017-18, if this trajectory continues our future mothers could be faced with navigating choices driven by a 44% induction rate.
Now some may say we are so very fortunate to have advanced medicine, skilled expertise and our NHS readily available to all, and having worked in the NHS all of my working life I would absolutely agree, however what is not always evident is the impact modern medicine has had or is having, what I have witnessed is these new advances being overused and encouraged because they are available rather than because they are necessary.
The unfortunate stark reality for pregnant mums is that they are under the impression that they cannot labour and birth without assistance and intervention and who can blame them when the national caesarean section rate hovers at around 30% and the induction rate is 32%, this can only lead to fear and anxiety which in turn inhibits the body’s natural ability to produce oxytocin, which affects the labour process and so we have a cycle which almost makes the induction process inevitable. In fact, many women know all about induction even before the point of conception! Unfortunately, in all areas of medicine, but particularly within maternity services the right balance has yet to be found when considering appropriate and necessary use of intervention, blanket policies and guidelines have led to a ‘one size fits all’ approach to something that should be a magical and individual experience. This approach is not a 21stcentury or even a 20th century dilemma, as far back as the 1860s there has been a feeling that new approaches in medicine were causing their own issues for the people receiving it. During a lecture to the Massachusetts Medical Society, Oliver Wendell Holmes Senior stated “If the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.’
As an experienced midwife I have seen how the culture within maternity services can directly impact the way in which women are informed, encouraged and supported. This can be anything from subtle behaviours of the leaders within the team, direct policies and guidelines that are described as unbendable by healthcare professionals, the use of language during important care discussions, I firmly believe that as healthcare professionals we have a duty to inform couples of their choices in an unbiased way and then we must allow them time to consider all their options and then finally support them with what they feel is right for them. But for healthcare professionals to take and maintain this approach is challenging, time constraints, litigation, peer pressure are all real when you are working in a busy maternity unit, but midwives are the ‘guardians of normality’ we are ‘with woman’ and so for that reason we must be the tall poppies willing to speak up and ensure we are advocates.
Induction is a necessary intervention for some women, it can be a positive experience and in some very rare cases it can be lifesaving but to see that over 70% of mums who are induced as a result of ‘post-dates’ just makes me question why so many women’s bodies are deemed to be unable to go into labour of their own accord? As a society we watch in awe as mothers conceive and grow another human, week after week their baby develops and thrives, all entirely normal and as expected until one day the woman wakes and for some reason her pregnancy is now seen as ‘risky’, her body no longer knows what to do despite the previous weeks and months of doing a pretty bloody awesome job and she is faced with discussions related to stillbirth or placental insufficiency. For some the pressure and fear is overwhelming and consent is given to ensure they keep their baby safe. A recent piece of research by Rydahl et al, 2019 looked at a cohort of Danish women, focusing on what happened before the timing of induction of labour was moved from the existing threshold of 42 weeks to 41+3 weeks, the conclusion was there was no difference in stillbirth rates or lower Apgar scores, in fact what it highlighted was that those women who had been offered and accepted the earlier induction date experienced far more elements of intervention and it showed an increase in the number of uterine ruptures moving from 2.6 per 1000 to 4.2 per 1000.
There is also over a decade of data which has been methodically collected showing that stillbirth rates and perinatal mortality rates are lower for women choosing to birth after 42 weeks than those who birth between 37 and 42 weeks. These pieces of research are important for couples to know if they are faced with deciding if an induction feels right for them. Any concern that is highlighted as a reason for induction must be counterbalanced by the risk induction itself brings, induction must be seen as a package, you start at step 1 and there are certain and expected steps to take along the way, each one of these steps will bring their own risks and all should be explained before a couple can make a decision.
Induction of labour would be appropriate where there is clear risk to the mum or her baby should the pregnancy continue, conditions such as pre-eclampsia, obstetric cholestasis, diabetes and other conditions will lead to induction being discussed as an option. The process of induction is not going to be outlined here, it is something that should be discussed at the unit you are planning to birth at, this is so you have the correct information for you and we are not guilty of giving a ‘blanket approach’ response.
Underwood Baby Academy are committed to the couples we support, our primary focus is you and ensuring you have the positive birth you deserve, so what we can outline here is what you can do to make your induction experience positive.
The first thing to focus on is your brain, not your actual brain but the pneumonic BRAINS. This will keep you focused on what you want to achieve, Benefits, Risks, Alternatives, Instinct, Nothing and Smile 😊 Your midwife and obstetrician will be able to give you the risks and benefits related to the induction process specifically for you and your pregnancy, there is always an alternative, even if that alternative is to do nothing, your instinct is your guiding friend, don’t ignore it. A decision that is born out of great information, with time and consideration will ensure you enter the process feeling confident which will enhance the physiological process of birth. Decisions are taken with you involved; they are not done to you.
This moves us on to the gathering of information, the first step is to understand why induction is seen as the preferred option for you and your baby, its ok to ask ‘why do you feel induction is the safest option for me and my baby?’ There are a range of reasons why this might be the case and each of these reasons will have evidence to support induction as an appropriate choice. Occasionally a woman will only be given the reasons the induction is appropriate but to make an informed decision you need to know the consequences of moving forward with the induction so you can balance the decision with all the information. There are a range of resources about induction, Sara Wickham’s book on Induction, the AIMS website, the National Institute of Clinical Excellence, as well as your healthcare professionals working within your maternity unit of choice. The other group of professionals to consider is the Independent Midwives who have a wealth of information and are not entwined in the culture that can sometimes affect our NHS maternity services.
The next thing to move onto is that the maternity unit will be keen to give you a date for induction, for post dates this would be on or around 41+3, it will be dropped into a conversation along the lines of ‘I will pop you in the induction diary’ and before you know it you’ve got a date. Now if you’ve read our blog on due dates you will know the stress and anxiety these bring so why would we now give ourselves another date to focus on and stress about when we know all that will bring is adrenalin and before you know it induction is necessary because our body has been inhibited. Never forget that if there was a risk to you or your baby that needed immediate intervention, we are truly blessed with a maternity system that would accommodate that. Take each day as a new day and return to the information and decision-making process as you need to.
Earlier in this blog I spoke about seeing induction as a package, but that does not mean that if you consent to starting the process you have to accept all the steps that are to follow, every step must be explained and discussed, you are in control and you can stop the process at any point. For many women just to know that they have the option to stop at any point will bring a quiet confidence and a calmness, which in turn will ensure the process is positive.
We know that oxytocin is the star player when thinking about the physiological process of birth, the more we have the better. Our birth environment, our birth partner, our feelings during labour are important whether we have started our labour spontaneously or if we have been induced. Do not forget what you had envisaged for your birth environment at the point inductions starts, it is still your birth, do not hand over the responsibility of it to your midwife or obstetrician as you give consent. Your birth partner touching you, kissing you, massaging you will help to build not only your oxytocin, it will also build your endorphins, these are your natural pain-relieving hormone. Although you will not produce them in the same way when you are induced the more you can encourage them with physical touch the less likely you are to decide on medical pain relief as an option.
In all maternity units across the country there will be a clearly defined plan for all women who are induced, ask what your units plan is, discuss the plan, consider how the plan feels for you and your baby. Do you understand it all? Are you happy to consent to the plan? If there is anything within that standard plan that you are unsure about or unhappy with, please do not leave those discussions until you are in the midst of your labour, you can never be too early to discuss your wants and wishes with your healthcare team and they will want to support you but they can only do that if they know what is important to you.
So to wrap this up inducing labour is to make your body and baby do something before they are ready, so consider the information carefully, be part of the decision making process and whatever your decision ensure you understand how you’ve made it and why you’ve made it. Never forget your labour and birth is yours to own, to influence and to enjoy.