Induced Labour – Why and how?

Before you consent to induction it is worth knowing what the procedures involve and exactly what you are consenting to.  Also remember to ask:

Why is this being suggested? 
What are the Benefits?
What are the Risks
Are there any Alternatives?
What does your Intuition tell you?
Is there time to do Nothing, to watchfully wait for a while?

The BRAIN set of questions is a great one for any intervention and is a useful, non confrontative tool for using with your carers.   Asking the How, Why, BRAIN questions first might be useful if you have forgotten all the info in this article.  Don’t forget to ask everyone to leave so you can discuss what you think with your birth partners.

Below is a standard induction process, bear in mind that in certain situations, for example ruptured membranes,  some steps may be skipped as moving straight to a drip might be more effective in those situations.

Membrane/cervical sweep

If your pregnancy has lasted longer than 41 weeks many hospitals have a policy of first “offering” a membrane sweep (sometimes also called a cervical sweep) to be carried out by your midwife at home or in your GP’s surgery. It involves the mother being asked to lie down as though for a vaginal examination. The midwife then performs a vaginal examination, inserting a finger into the cervix to part the bag of waters containing the baby from the cervix. This has been shown to increase the numbers of women going into labour “normally” within 48 hours. Certainly if you are one of those that goes into labour after this procedure then labour will be treated as “normal” and you can continue with homebirth, midwifery led and waterbirth plans.

Does membrane sweeping hurt?

Many women describe it as no more than uncomfortable but some describe it as very painful. Some women experience some bleeding after a sweep. It is probable that sweeps are painful when the cervix is not very ripe. You could tell your midwife in advance of agreeing to this procedure that you only give consent to her doing it if it doesn’t hurt and that if it does hurt she must stop at once. Taking your partner, your doula , a relative or friend with you might help as it is hard to assert yourself when lying down with legs astride on an examination table.

What happens if I accept induction?

If you decide to accept induction you will be asked to come to hospital, often in the evening on a set date where you will be admitted onto the antenatal ward – not usually the labour ward itself unless you are high risk (twins, previous caesarean or other medical conditions).

After going through all your details and doing a vaginal examination to assess how ripe your cervix is, the doctor or midwife will put prostaglandin tablets or gel into your vagina. Prostaglandins work by ripening the cervix and stimulating the womb to start contracting. A woman’s body normally produces these of its own accord at the beginning of labour. The theory is that by stimulating the body to do what it does anyway a more “normal” labour can be triggered.

There is a risk of overstimulating the womb using prostaglandins, there is also a risk of causing rupture of the womb, it is small but it is there and in a tiny number of women it can be catastrophic. It is important therefore that the doses of prostaglandin take place at measured intervals and that any contraction activity is monitored carefully if labour starts.

The more unripe the cervix is, the more doses of prostaglandin you are likely to need and the longer the whole process is likely to take. The assessment of your cervix at the beginning of the induction process is important, the doctor will give it a score, called the Bishop’s Score. If your “Bishop’s Score” is 8 or less the cervix is considered unripe. The NICE guidelines say that in this instance the induction should not be continued unless there is an urgent medical reason to do so, however many hospitals will continue with routine induction without discussing the score with you.

Induction after previous caesarean

If you have had a previous caesarean then induction using prostaglandins is dangerous and not recommended by NICE or many health care professionals. The evidence is quite categoric on this and if it is being suggested to you do get support and a second opinion.  There is no evidence that being overdue in a pregnancy after a caesarean is more risky than any other overdue scenario.  See the VBAC section for more information and support.

What happens next?

Sometimes when prostaglandin tablets or gel are used, women experience what feel like contractions but no real dilation (opening) of the cervix happens. These are known as “Prostin pains” and can be deeply disappointing and painful. Some women go into a slow, stop-start labour which is very tiring and eventually a drip is recommended to speed things up. Some women go into a very

straightforward labour. It is very hard to predict what will happen apart from by how ready the body is to labour anyway. It is worth looking at whether there are any factors that might make you more likely to go “overdue” – see alternatives and self help below.

If no contractions have happened after several doses of prostaglandin then what usually happens is that a doctor will break the waters (often called Artificial Rupture of the Membranes or ARM) and a drip (needle attached to fine tubing) is put into your hand. This drip contains an artificial version of the hormone, oxytocin, which women normally produce in labour and which makes the womb contract.

What effect does the syntocinon drip have?

This produces contractions in most women. However many women describe these contractions as very painful and they can go from being in no pain to quite intense pain very quickly which can be much more difficult to deal with. Added to this, most hospitals will want to carry out continuous electronic foetal monitoring – this involves two straps around the mother’s abdomen, one listening to the baby’s hearbeat and one which records the strength and timing of contractions. It is felt to be a good idea as it is important to be able to know what strength of contraction is being produced and how the baby is responding to this. However, it can be difficult to use the monitor in an upright position, still more difficult to rock and sway and pace about which is how many women deal with contractions. Faced with painful contractions and no mobility, many women then opt for epidural pain relief.

Monitored labours seem to be more likely to end in emergency caesarean. Using and assessing the output from fetal heart monitors is not an exact science and some doctors may be better than others at assessing whether a certain pattern of heartbeat is a real problem or not. If there is a suggestion that baby’s heartbeat is reacting badly to the induction then the Royal College of Obstetricians suggest that the doctor takes a sample of the baby’s blood by inserting a small needle into one of the veins in the baby’s head. True fetal distress means that the baby is short of oxygen and only a blood test can measure this accurately. It is unlikely to cause the baby a lot of pain to have this done but if the baby is still very high up in the pelvis or awkwardly positioned it might not be possible to get a sample.

How can I help myself in an induced labour?

Firstly by considering very carefully whether there is a good reason for it and if it is just “routine” thinking through whether you want to accept it at all. As with all labours, having someone with you who can ask questions and support you as effectively as possible is important. This may be the baby’s father, however you may also like to think about an independent midwife, a doula, a female friend or relative.

Some hospitals send the father/birth partner home if the first dose of prostaglandins is done in the evening and doesn’t produce contractions. You might want to think about what impact that will have on both of you and to negotiate with your hospital over this. A few women choose to go home having had prostaglandins and a little monitoring, to await contractions. Some hospitals will support this but others would want you to sign a disclaimer form to say that you are aware you are doing this against their advice.

If you are just hanging around between doses of prostaglandins, and its usually 6 hours between doses, then asking for a side room so you can get some sleep might be an important factor for you. Trying to labour when you are already many hours short of sleep is like trying to run a marathon uphill with a backpack on, it can by done by some but why make it more difficult than it needs to be? You may be offered drugs to help you sleep, it may be important to you to check out what effects these might have on you and your baby before, during and after the birth.

Staying mobile to deal with contractions can be very important in helping women to cope with labour pain, discussing with your carers how they can help you to achieve this before your accept induction might be a good idea. Some hospitals have “telemetry” monitoring which does not attach you to long leads. Look at the other “self help” options in the straightforward labour pages and discuss with your carers how many of these are feasible or available to you.

Many hospitals will still be happy for you to use a water pool if you go into labour after induction using just the prostaglandin tablets, some won’t. As they control the use of the pool it is hard to negotiate on this one once in induced labour but is worth finding out about before you give any consent to induction.

Alternatives

Faced with the prospect of induction many women look for natural alternatives. There is a school of thought that says that if your body or baby isn’t ready anyway then you risk starting something that may be a stop/start or very slow labour – a baby lying back to back who is induced by any means can produce a very hard, slow, backache labour. It might be worth thinking about why your baby is overdue or if you are even overdue at all and just watching and waiting?

Get the baby in a good position – see the article “Bottoms Up” on optimal foetal positioning. Posterior (back to back) babies are well known for going overdue and for being more difficult to birth so sorting out the position is probably a very good idea before considering any type of induction. Many osteopaths and chiropractors believe that persistant posterior babies may be caused by a pelvis that is misaligned and this could be corrected safely even in late pregnancy

If you are genuinely overdue and feel you have to do something there is not a lot of evidence that any of the much touted “natural” induction methods work but sometimes women feel better for doing something and some of them can be quite relaxing.

SEX – there that got your attention didn’t it? Male sperm contains prostaglandin which if you remember, is the stuff that is in the induction drug. So getting some via a more natural route, ie sex, might be a good idea and get labour going of its own accord. Orgasm and nipple stimulation make women produce oxytocin, often called the Love Hormone, it is the other main hormone involved in labour. The combination of the two might set labour off in a woman whose body is almost ready to labour anyway. There is no solid research to recommend it but you might have fun doing your own research.

Complementary Therapies: there is little evidence to base a recommendation on but don’t let that put you off, quite often it is just that the research is hard to do and there’s no money to be made from it. Many, many women swear by acupuncture, reflexology, homeopathy or aromatherapy. It is vital to only consult a qualified therapist who is registered with the appropriate governing body and experienced in working with pregnant women

See also Raspberry Leaf Tea article..

Curry: the theory behind this one is that if you have a hot enough curry to make your bowels gripe that this pulsating action will stimulate the cervix (the large intestine lies close to the cervix). Its a theory but you may not fancy having a dose of Delhi Belly and then having to summon up the energy to give birth.

Castor Oil: midwives used to use this before induction drugs were invented. Its similar to the curry idea , only more drastic because it can cause violent diarrhoea and vomiting in women and , in extreme cases, can lead to dehydration for the mum to be and distress in the baby.