First of all let me make it clear that what I’ve put together here are things for you to consider if induction is offered to you. Only you know what’s the right decision for you and your baby. And, let’s be absolutely clear – ‘offered’ is a key word here…. I speak to SO MANY mums who say things like ‘they won’t let me go past X weeks’ or ‘I’m not allowed to go past X weeks’ or ‘my midwife has said I have to have an induction at …’ …. The language around birth and mums perceiving they are in a permission-seeker role & healthcare professionals in a permission-giver role is a topic for a whole other blog post, but know this – whether or not you accept or decline an induction is your decision, no one else’s. Of course you’ll want to get evidence-based info. from your carers and discuss the pros & cons with them, but one size certainly doesn’t fit all. So, use the *BRAIN acronym to help you get the info you need that will enable you to make an informed decision.
Secondly, what I’ve put together here barely scratches the surface of the issues and research surrounding induction. If you’d like to read up in depth I suggest going to Dr Sara Wickham’s website to read her articles. Her book ‘Inducing Labour’ has been updated and is available as an e-book if you need it in a hurry. Another good resource is Dr Rebecca Dekker’s website. There are others, of course but always make sure that the info. you’re reading is evidence-based. What I’ve picked out for you here mainly comes from those two websites. Both of these websites have evidence-based info on induction for specific circumstances too, for example maternal age, that I haven’t gone into here.
Yesterday’s NHS England’s Maternity Statistics make for uncomfortable reading – showing that in the year ending March 2018, 32.6% of women had their labour induced – a massive increase from the 20.7% of ten years ago. The figure from 10 years ago was bloody high, but this increase is really, really concerning – yes, induction is appropriate for some women but not for over a third of them!
If you’re happy accepting an induction and the risks and benefits have been explained fully to you then you don’t need to read this. If you’re a bit unsure, I hope that this blog helps you to focus your thoughts, highlight any gaps in your knowledge and guides you in your discussions with health professionals. What I’ve addressed here are the common issues that come up frequently with the parents I support. I’ve done the wading through info. so you don’t have to and I suggest some things to consider:
Term is 38-42weeks – your baby isn’t ‘late’. Even at42 weeks you’re within the accepted definition of Term.
Your Estimated Due Date (EDD) is just that – estimated. Only 4% of babies arrive on their EDD.
On average a first time mother will go into spontaneous labour at 41+1 that’s on average so some women will go into labour before that point and many will do so after that point.
A 2018 systematic review has looked at the effects of induction prior to post-term on the mum and baby and concluded that induction prior to post-term is associated with few beneficial outcomes and several adverse outcomes.
You need info. about risks to make decisions about what’s best for you. It might also be helpful to ask yourself/discuss with your partner the following:
Why would you consider accepting an induction? What’s worrying you about waiting until your baby & your body are ready? Why is it important to you that your baby arrives sooner rather than later?
Why would you consider waiting? What’s worrying you about accepting an offered induction? Perhaps, if your pregnancy has been uncomplicated so far, you feel a sense of trust that your body will continue functioning normally?
There is no ‘risk free’ option. But worth understanding that the risk of your baby dying (which is the main concern women voice to me) is less than 1% either way– whatever you decide – whether you accept the offered induction or decline it if you and your baby/placenta are well.
Research doesn’t usually ask ‘why’ but focuses on ‘what’ – what happens. For example congenital abnormalities of a baby & placenta are associated with post-term (beyond 42weeks) which may, in part, account for increased risk that’s referred to rather than length of pregnancy. Also research takes a general perspective rather than considering this woman, this baby, this situation. And, of course, the quality of research isn’t always high.
Risks associated with waiting (declining induction
Basically if a woman is induced at 41 weeks her baby is less likely to die during, or soon after birth. Remember the chance of a baby dying is small either way – less than 1% until 42 weeks
At 42 weeks the risk of still birth rises in babies who are not growth-restricted: from 0.4 per 1,000 to 0.6 per 1,000 – 0.6 is 50% higher than 0.4 so it would be true to say that “the risk of stillbirth increases by 50%” which is what many women will be correctly told, or (totally terrifying & coercive) “the risk of your baby dying doubles at 42 weeks” although this can be a bit misleading if she’s just presented with those statements without having the actual numbers behind them explained.
The risk may be higher in some women who have additional risk factors for stillbirth.
Cochrane (global network of health practitioners, researchers etc. making sense of research) state that the “absolute risk is extremely small”
WHO (World Health Org.): “low quality evidence. Weak recommendation”
Other reviews of evidence conclude that it’s “not possible to pinpoint specific gestational age at which an otherwise uncomplicated pregnancy Should be induced”
One theory is that after 42 weeks the placenta starts to deteriorate. There is no evidence to support this.
Here’s a physiological explanation of the development and aging of the placenta to consider, which concludes that: “A review of the available evidence indicates that the placenta does not undergo a true aging change during pregnancy. There is, in fact, no logical reason for believing that the placenta, which is a fetal organ, should age while the other fetal organs do not: the situation in which an individual organ ages within an organism that is not aged is one which does not occur in any biological system.”
Risks associated with induction
It’s difficult to untangle & isolate induction because usually more risk factors come into play (syntocinon, continuous monitoring, epidural) – induction tends to be a package deal.
Risks associated with actual procedure
Women should understand that accepting induction usually means agreeing to other interventions, monitoring & time frames. For many this is fine, but if you’re not entirely comfortable with this level of intervention, it’s worth understanding the pros & cons fully in order to make an informed decision.
Discomfort, distress for mum
Prostaglandins to ripen cervix/breaking waters/syntocinon increases the risk of hyperstimulation which can lead to fetal distress. This is why continuous fetal monitoring is suggested with induction procedures involving syntocinon.
Increased likelihood of assisted birth for first time mums.
Syntocinon produces stronger contractions, without a gentle build up or endorphins. This is why women are 3x more likely to require an epidural.
Epidural – may slow labour down, longer 2ndstage which can lead to fetal distress ……. Increased risk of assisted birth (forceps/ventouse/caesarean)
There are risks associated with instrumental birth & CS for mums & babies.
Alternatives to Induction
The baby controls the “on” button for labour, she signals she’s ready, oxytocin is released, the uterus responds.
Sweeps – do they work? How can we ever know? We can’t for sure.
There’s not really any such thing as a ‘natural’ induction – trying to force the body/baby to do something it’s not ready for is intervention. However, there are varying levels & those methods that are aimed at relaxing the mother & encouraging patience & acceptance may assist her body/baby to initiate labour if physiological changes have already taken place
Doing nothing – waiting until **42 weeks, then discussing
Have scans after **42 weeks to check baby & placenta – this can seem like a huge inconvenience. Why not compare 3 days of trudging to hospital for scans with possibly 3 days going between home & hospital waiting for labour to start, and then you can decide which one you’d prefer.
Got any questions? Get straight in touch.
*BRAIN Acronym for getting info. from caregivers & making decisions:
B – what are the Benefitsof what’s being suggested?
R – what are the Risks?
A – are there any Alternatives?
I – what are your Instinctstelling you?
N – can we do Nothing/have a bit more time?
** Maidstone & Tunbridge Wells now offer induction at 41+6