This blog attempts to mythbust around induction of labour to empower women to make a decision about whether they want it and, if they do, to enable them to understand their choices during an induced labour.
Is it true that I have to be induced if I go beyond my due date?
Babies are only born on their due date about 4% of the time. 60% of babies are born one week either side of the due date and 90% within two weeks either side of the due date.
In the UK, women who go beyond 41 weeks are offered induction of labour any time after 41 weeks and they are encouraged to have it after 42 weeks. This is due to good evidence showing that outcomes are not as good for mothers and babies after that point (the stillbirth rate rises, as does death shortly after birth, for babies born later). One of the reasons for this is thought to be related to the placenta becoming less effective at nourishing the baby after 40 weeks.
Women being offered induction should be given personalised information on risks for them and their baby and this will depend on their own medical history, how the pregnancy has been and any health concerns; positional problems or size issues (smaller or larger than average) found in their unborn baby. The information they are given should be both in verbal and written formats to ensure the woman has all the information she needs to decide in her own time. She should not be rushed in this decision-making process and should be given time to talk it over with friends and family.
The stillbirth rate is still pretty low in the UK being less than one in 1000 babies between 29 and 40 weeks, one in 1000 at 41 weeks and two in 1000 in babies at 42 and 43 weeks. Therefore, it is important the woman makes the decision based on her own personal circumstances.
What exactly is induction?
Induction is where medical interventions are used to bring on labour. This can be done in a number of ways. It is usually done as an inpatient and the woman should be thoroughly assessed prior to being induced i.e. to find the presenting part of the baby (head down or breech (bottom down), double checking location of the placenta and the cord. The woman should also have regular monitoring during the induction process – not necessarily continuously but regularly with review by healthcare professionals and cardiotocography (CTG*) monitoring.
In the UK, in the year 2016-17, NHS Digital data suggested that ~29.4% of labours were induced. More conservative estimates suggest that about 1 in 5 women have an induced labour. And around 63% or 3 in 5 of those had an uncomplicated vaginal delivery following the induction.
Since induced labours are often more painful than spontaneous labours, women should be made aware of their pain relief options before the induction starts, and should be offered these options promptly, when required during labour. Here is a leaflet produced by Guy’s and St Thomas’ NHS Foundation Trust on pain relief options during labour.
In most cases, induction is started using a hormonal (prostaglandin) tablet, gel or pessary which is inserted into the vagina. This should really be given first thing in the morning as women who have it then report it is a better experience for them. Women then wait for labour to begin. Healthcare professionals encourage them to remain active during this waiting period.
Other options for induction include mechanical induction (where a balloon is inserted into the vagina) and surgical induction (where the sack around the baby is punctured to release the amniotic fluid). These are not routinely recommended for primary induction of labour. Here is an interesting article on whether amniotomy (artificial rupture of the membranes) should be used at all. Occasionally, there are indications for mechanical or surgical induction but these should be very carefully explained by healthcare professionals to the pregnant woman, along with their risks and benefits, and women should be fully involved in the decision-making process.
What are the risks of induction?
As mentioned above, induced labours can be more painful than spontaneous labours. Therefore, it is worth the woman discussing her pain relief choices prior to the induction so that she knows her options once the labour has started.
Furthermore, women who are induced are more likely to have instrumental assisted deliveries (forceps or ventouse/vacuum) than women who have spontaneous labours. Around 15% of women who are induced will have an assisted delivery. Women who have an assisted delivery are more likely to have an episiotomy or vaginal tearing. Here is more information on an assisted delivery.
Of those women that do go into labour following induction, around 22% will have an emergency caesarean section. However, it is not thought that the risk of emergency caesarean section is overly higher in induced women than women who labour spontaneously due to the induction itself – it is thought to relate to the cohort of women that are induced i.e. they are more likely to have other factors causing the likelihood of caesarean section to be raised.
Other than pain the other most common complication is failure of induction at all. If this occurs, the woman should be consulted. She can have further induction attempts or an elective caesarean section or a watchful waiting approach (no intervention but close monitoring).
Rarer but more serious risks include uterine (womb) hyperstimulation (making contractions very aggressive) and even uterine (womb) rupture. If the former occurs medication can be given to slow down the contractions and pain relief given to help the woman cope with the pain. If the latter is suspected, emergency caesarean section is offered.
Are there any other options other than induction?
Yes, there are. You can choose expectant management (i.e. watch and wait) and/or membrane sweeps. Expectant management means that you will continue to be monitored closely by your midwife (twice weekly CTG* monitoring of the baby’s heart beat and twice weekly monitoring of the amount of amniotic fluid surrounding the baby) and you can see what nature intends for the start of your labour. If you choose this option you can change your mind at any point and this is encouraged if there is concern about your or your baby’s health. Again, the advice should be personalised to you. Furthermore, you can have expectant management with membrane sweeps if you would like. Membrane sweeps are shown to make going into labour spontaneously more likely.
What is a membrane sweep?
A membrane sweep is a procedure carried out by a midwife or doctor to encourage spontaneous labour. It is offered to women who have not had a baby before or at their 40-week and 41-week antenatal appointments and for women who have had a previous baby at their 41-week antenatal appointment.
It can be done in various settings such as hospital outpatients, a GP surgery or other location where the midwife practices. You do not have to be admitted to have it. It involves the healthcare professional inserting their fingers into the woman’s vagina and detaching the membrane which encases the baby from the lower part of the uterus (womb). This stimulates hormones (prostaglandins) to be released which encourage spontaneous labour. Here is a leaflet with more information produced by Sandwell and West Birmingham Hospitals.
As the leaflet explains, there are no major complications associated with this procedure but it can be uncomfortable and sometimes causes bleeding. Membrane sweep should not be carried out if a woman has a low-lying placenta.
It is important for women to know that it doesn’t always work. Evidence from a review carried out in 2005 showed that out of 8 women who are treated with a membrane sweep, only one will go into spontaneous labour.
Every woman is different and it is worth chatting through this option with your midwife and making the decision about whether it is worth having that is right for you and your baby.
What kind of factors make induction more or less suitable?
Less suitable: It is not usually recommended for women with breech presenting babies.
More suitable: A woman who has gone beyond 41 weeks of pregnancy, a woman who is large for dates and has diabetes, a woman who has significant high blood pressure, other medical indications which your midwife will discuss with you.
Other: Usually maternal request for early induction is not accepted as a reason for induction. Sometimes a request for induction at or after 40 weeks is accepted by healthcare professionals if a woman has a partner who is in the armed forces and due for a posting abroad in the very near future to ensure she is supported by her partner during her labour.
We hope that this blog helps women to understand that the decision to induce is rarely black and white and that the decision to induce is not without risk. Therefore, we hope this helps women to feel empowered to probe their healthcare professional about their personalised risks and benefits. And if the decision is to go for it, we hope that it empowers women to discuss their pain relief options and to know what to expect.
If you have further queries or comments do post them in the comments below or get in touch @PregnaPouch or PregnaPouch@gmail.com.
The PregnaPouch team
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*CTG = cardiotocography (a way to measure the baby’s heart beat continuously for a period of time, can also be used to monitor uterine contractions)
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