Induction of Labour
Induction of labour is the process by which labour is started completely artifically, and should only ever be considered due to a medical condition in either Mother or Baby.
Some common reasons an induction may be offered to you, could be, ‘large’ baby, ‘small’ baby, low amniotic fluid (fluid around the baby), decreased fetal movements, uncontrolled gestational Diabetes or insulin dependant GD, ruptured membranes, known or other health concern with mother or baby. Remembering ultrasound in late pregnancy has been proven to have limitations regarding estimating fetal weight. Studies suggest that often the fetal weight is over estimated.
RANZCOG (Royal Australian + New Zealand College of Obstetrics and Gynacology) reccommend that women who are 41-42 weeks pregnant consider an induction at this time for being ‘overdue’.
The latest data states that induction rates in the public health service is 24% versus 30.7% in Private obstetrics here in Australia.
However, it is important to note that labour was induced in 45% of selected* women in 2018 having their first baby in Australia according to the Australian Institute of health and welfare statistics.
*Selected women include those having their first baby, aged between 20 and 34 years, whose baby’s gestational age at birth was between 37 and 41 completed weeks, whose baby was a singleton and whose baby’s presentation was vertex (head first).
The WHO (World health organisation) states that induction of labour world wide is averaged out at approx 10% of the population. The highest countries being Asia and Latin American countries at approx 35.5% of pregnancies being induced.
It is important that we know why we are having the induction, and understand fully that although in most cases we are trying to avoid a risk of some sorts, we are also creating risks of another nature. There will always be pros and cons, but ensuring your pros outweigh the cons is important.
THE PROCESS
The process of how an induction is undertaken, depends upon the ‘ripeness’ of the woman’s body (cervix).
There may be one or a combination of the following to help induce labour. We can skip step one and two for instance if we already have ruptured membranes. Or maybe after step1 the woman’s body will start labouring without the help of step 2 & 3. Most inductions do however go through the whole process.
Step 1- Balloon catheter or prostaglandin gel. Both of these procedures/medication tries to stimulate the cervix and starting the labour process off. The balloon is a catheter that applies pressure to the cervix to physically force open the cervix. The prostaglandin medication can be done in a couple of different ways, the medication sits at the cervix (inserted via care provider and vaginal examination) and imitates the hormone we believe we release to soften and open the cervix. Sometimes this process/medication needs to be repeated.
Step 2- Artificial rupture of membranes. Once the cervix is soft and open enough (normally around 2cm) from a previous measure, then the membranes (waters) around the baby can be broken. This is done by your care provider doing a vaginal examination and inserting a small instrument into the vagina to ‘pop’ or ‘break’ the waters.
Step 3- Once the membranes have been ruptured, then the artificial hormone, syntocinon (Australia), can be commenced via an IV. This medication is continuous until your baby is born and for 4 hours after birth.
Induction requires us to stay in hospital for the duration of the induction (normally). Most inductions take a couple of days preparing until you meet your baby. Fetal monitoring via CTG is recommended when performing one of the above steps, and then once labour is commenced or step 3 takes place.
QUESTIONS TO ASK
It is important to know why you are being offered an induction, and to understand the risks involved with ‘staying pregnant’ or intervening with an induction. Make sure you ask your care provider these important questions, and any others that are specific to you-
Why are you wanting me to have an induction?
What are the risks involved with induction?
What risks are involved if I do not have an induction?
Is there any other way to keep me/our baby safe without induction?
It is also so important that you listen to your intuition, ask for a second opinion if you feel necessary, or simply just ask for a few minutes (or 24 hours depending on the situation) to discuss between the two of you, to gain clarity and prepare for your situation.
KNOWN PRO’s & CON’s
Some known factors of Induction of labour you might want to consider-
If there is use of synthetic hormones (either step 1 or 3), over stimulation of the uterus can occur, which may cause distress for mother and baby, (reference) either by decreasing the oxygen availability to your baby causing distress, and increasing the risk of uterine rupture.
Induction is often considered more painful than spontaneous labour (read here). There is belief that this is due to the artificial birth hormone not working the same way our own natural birth hormones would, therefore effecting our mindset, perception and physical aspects of labour.
Induction can lead to increased intervention such as increased use of pain relief medication and or instrumental delivery. (reference). Have a read about the cascade of intervention here to see how every decision you will make, will have some risk of consequence. The key is understanding what those risks are and which intervention, if any is required, to help you create the birth you want.
According to a study done in the USA in 2018, The ARRIVE trial, there is no increased risk of caesarean section with ‘elective’ induction of labour at 39 weeks compared to expectant management. This trial does have some concerns, the major one being it was only a small proportion of the population that fitted the study criteria and agreed to be involved.
*EDIT to add latest research*
A recent study released in 2021, has found that IOL (induction of labour) for non-medical reasons was associated with higher birth interventions, particularly in primiparous (first time) women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.Check out this study for more information.
It is so important that you, along with your care provider explore all your options and make the right decision for you.
For example in this evidence, the perinatal death rate of babies in term (37-41 weeks gestation) is 1.5 in 1000 births (or 0.15%), while for babies born after 42 weeks this risk increases to 2.2 per 1000 births (or 0.22%). For some families this increased risk of stillbirth will be considered too great and they will opt for an induction, while others will view the increased risks of induction intervention greater, and will opt for remaining pregnant for a little while longer (obviously, this is only relevant if dates are the only complicating factor'). Everyone is different.
WHAT TO DO
If, along with our care provider, we decide that induction of labour is the best course of action, the least risk for us or our baby, then it is important to prepare our mind and body in the best way possible.
We know oxytocin is a key hormone in birth. We can, and need to promote this hormone even more so when facing an induction. Think love, warm, dark, safe, private. If you haven’t been to Calmbirth or similar and have no idea what I am talking about, quickly get yourself to a class or google how to promote oxytocin! Keeping our head in a positive, relaxed state is going to help your body work with the natural process of labour, even though it is being artificially started. Once you are in active labour, or the syntocinon infusion has started, try to remain active and upright, using all the same tools that you’ve gained and learned throughout pregnancy.
It would be recommended that you would accept active 3rd stage management of the placenta following any intervention, however requests such as delayed cord clamping, immediate and uninterrupted skin to skin & breastfeeding should not be impacted by your induction directly.