My husband came home last night saying his work colleague, who had been on hypnobirthing classes, in central London, said that “hypnobirthing was shit” after having an epidural. Instinctively my first questions was “was she induced?” and you know what, it turns out she was. I don’t know the reasons for induction, but I do know he told me that the baby was strong and fine throughout labour. So I am guessing that she is one of the many women who are now getting to 41+ and being pressured into an induction.
So today I’m going to talk openly about induction, some of you may have read an old blog of mine which looks at the dubious methodology used to calculate due dates in the UK, but it was a while ago now and I see more and more women being unnecessarily induced so the time is ripe for a new one.
Now my job is to reduce fear, so normally I would talk about what goes right, but today I’m going to talk about the risks, as it seems that some obstetricians may be pressuring mums into induction with the threat that they are significantly increasing the risk or still birth or neonatal death if they go over 42 weeks. Statistically it’s not wrong to say that there is a 50% increase of your baby dying and this sounds frightening but it’s important to understand what this means, and I’m going to explain this in the blog. I’ve got friends and colleagues that may baulk at the word threaten, but I’m using this work because it’s what mums are hearing. Even if it’s not meant as a threat by the clinician it is most definitely being interpreted that way, mums are being frightened into having inductions, and we know that fear is not the right place to begin labour from a psychological perspective.
In a survey we recently ran, almost all mothers said that their biggest concern was something happening to the baby, so of course when they are told that going overdue could mean death, the red light goes on in their head, but what I don’t understand is why the majority of mums think that it would be safer and better for a baby to be born by induction, if they have had a normal, low risk pregnancy and everything is monitored as being well.
So today I’m going to take the opportunity to turn it inside out – I’m going to reframe induction and talk about the risk of your baby being born alive if you choose not to be induced, if you go over your dates. According to research, the risk of your baby being born alive and well at 43 weeks is 997.88 in 1000 or 97.8% compared to 98.3% at 40 weeks.
Your baby being born healthy depends on a low risk pregnancy, good placental function and levels of amniotic fluid and a spontaneous natural labour. Make no bones about it, NICE agrees that a spontaneous labour has better outcomes physically and psychologically for mother if she is low risk and the baby is well, and that fewer inductions are also a lower strain on maternity units. This is all measureable and the National Institute of Clinical Excellence writes about the choices being offered to women, note the word offered.
“That Healthcare professionals should explain the following points to women being offered induction of labour:
• the reasons for induction being offered
• when, where and how induction could be carried out
• the arrangements for support and pain relief (recognising that women are likely to find induced labour more painful than spontaneous labour)
• the alternative options if the woman chooses not to have induction of labour
• the risks and benefits of induction of labour in specific circumstances and the proposed induction methods
• that induction may not be successful and what the woman’s options would be.
The guidelines also say that
“Healthcare professionals offering induction of labour should:
• allow the woman time to discuss the information with her partner before coming to a decision
• encourage the woman to look at a variety of sources of information
• invite the woman to ask questions, and encourage her to think about her options
• support the woman in whatever decision she makes.”
The guidelines look at various studies, a study in Scotland in 2005 showed that women with spontaneous labour were significantly more likely to be satisfied with their labour than the induction group. To summarise this research, the evidence statement in the NICE guidelines shows that
“evidence from four UK surveys suggested that up to 40% of women felt they were not given adequate information relating to issues about induction of labour, and induction by drug was disliked by 80% of women; overall maternal satisfaction was low”.
If you read between the lines in the guidelines, the risk associated with prolonged pregnancy and stillbirth and neonatal death are linked to babies that have special circumstances. The problem facing clinicians is that at present they are unable to identify which babies are more at risk or not. NICE quidelines interpret the available research as implying that “ that 469 women would have to be induced to prevent one perinatal death”. It quite openly states that,
“Studies should be undertaken to compare effectiveness, safety, maternal satisfaction and compliance of different expectant management protocols,” because “Although the risks of fetal compromise and stillbirth rise steeply after 42 weeks, this rise is from a low baseline. “
“Consequently, only a comparatively small proportion of that population is at particular risk. Because there is no way to precisely identify those pregnancies, delivery currently has to be recommended to all such women. If there were better methods of predicting complications in an individual pregnancy, induction of labour could be more precisely directed towards those at particular risk.”
The low baseline they talk of can been seen in the figures of this study published in the BMJ in 1999, which shows that at 40 weeks the number of still births was 1.61 per 1,000 births at 43 weeks that figure was 2.12 per 1,000 – still very low.
I also commonly hear of babies being induced because they are measuring large for their dates however again NICE guidelines state that “ a baby should not be induced in the absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age.”
So what are the risks of induction?
The main risks associated with induction are uterine hyperstimulation, failed induction, and with breaking of waters, cord prolapse.
However, women should be aware that induction is also an artificial way of beginning labour often, when the body is not quite ready, we know from research when the babies lungs are fully mature that it releases a hormone that triggers labour. Even now we don’t fully understand how this intricate and incredible exchange of hormones happens between mother and baby, and if possible it should be left undisturbed to allow oxytocin to flow and the body to create its own natural rhythm, endorphins and natural anaesthetic.
By disrupting the normal process of birth with the use of artificial hormones, the theory that underpins hypnobirthing becomes to a large extent redundant, and the emphasis shifts to a pain management paradigm, so techniques using hypnosis are still absolutely effective, but with a different approach and focus on the application of dissociation, distraction and visualization rather than the view that women should not feel pain during labour. I’m not saying you can’t have a good birth while being induced, but it is often harder.
The reason why inductions can be associated with a higher rate of intervention is because they are more painful and often women end up with artificial pain relief, such as pethadine, epidurals and assisted deliveries.
I’m mindful of the fact that I’m not a Dr or a midwife, so I just interpret the evidence that’s out there the same way I would if I were in the scenario.
I’ve written this to hopefully encourage other mums to think twice, to look at the research and make an informed choice. Realise that this is a big decision, that there are risks associated with induction. If you want a hypnobirth, or a normal birth you need may wish to take this into account.
NICE Guidelines on Induction
To Induce or not to induce
10 Month Babies – Guardian
Overdue and homebirth on Homebirth UK. With some stories attached.