Induction

  • General
  • Induction for Older Mothers?
  • Research on induction
  • Links to other sources of information

For more on “natural”, or non-pharmacological, induction methods, see our page on complementary therapies and midwifery, and Sweeping the Membranes.

Induction – General

I am newly qualified, working in a hospital setting. In our unit women having induction of labour are usually initially assessed by consultant or sometimes registrar. If plan is to use prostin gel then reassessment after 6 hours is usually done by midwife, to decide either more gel or if ARM (artificial rupture of membranes) is possible. This assessment of cervix and giving of gel was not something we did as students so is all very new to me – in fact have only done it once and there was clearly very little change in cervix since last assessment so I administered the gel. (I had senior midwife standing by in case I was unsure).

Anyway my question is: Presuming the woman is showing no signs of going into labour, at what point would you consider that ARM was preferable to more gel? Is there anything to be gained/harmed from giving gel if cervix is soft and ARM is possible?(Not meaning the known dangers and side efects generally but specific to the giving of gel in this situation). Since I am also inexperienced in doing ARM’s (only did one in three years of being a student) I realise that my opinion of if ARM is possible may not be the same as someone more experienced.

Andrea
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Policies will vary from unit to unit and you would be wise to practice according to your unit policy. You will find guidelines on the Royal College of Obstetricians and Gynaecologists website (www.rcog.org.uk) – See Good Medical Practice: Induction of Labour

You will need to find out what your unit considers to be an ‘unfavourable cervix’ using a Bishop’s Score and the different policies regarding dosage for primigravidae and multigravidae. Unnecessary use of prostaglandin when a cervix doesn’t require it has caused hyperstimulation of the utuerus.

Ruth
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My daughter’s babe is now 1 week post-term. Originally, she wanted to birth at home, but now feels that she would like the ‘safety’ of hospital. Babe is active, the right size and all is well. There are no indications that either is in jeopardy, but an automatic date was made for induction next Wednesday. Once we were outside the hospital, the flood gates opened and she DOES NOT want to be induced.

If I had known her feelings at the time, I could have advocated for her. But, where does she stand if she says no? I am so newly qualified, and not working for this hospital, I do not feel confident at starting an argument, but do any of you have some good, research based ammunition to fire if push comes to shove? My feeling is that she and the baby are in good health and the infant will turn up when she is ready, and I would suggest that she have some proof of foetal compromise before being started on what will probably be the start of the ‘cascade’. She so wants a natural birth.

Elaine
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Well, she certainly can’t be forced to accept induction. She has been offered induction, and it’s up to her whether she takes it at this point or not. She should certainly not even have to justify declining it or changing her mind.

You don’t need to give a reason for declining to have your body messed around with – you don’t need to be talked into it. It’s reasonable to apologise for the inconvenience caused by changing an appointment, but there is no reason to apologise for declining the induction per se.

I would imagine that, if your daughter goes along with induction at 41 weeks and things don’t go absolutely perfectly, then she might always wonder what would have happened if she’d waited a bit longer for spontaneous labour.

41 weeks sounds very early to offer induction nowadays – I got the impression that few people were even offered induction before 10 days postdates, and most women I speak to seem to wait until 42 weeks. What are the guidelines in the hospitals that midwives on the list work for?

So, how to get out of it? Here are some suggestions – and apologies in advance to the midwives if these would make your jobs difficult!

1. Simply phone up the office now, and say that you have decided that you do not want to be induced at 41 weeks, and will let them know when you would like to make another antenatal appointment to discuss alternative options. Or say that you will be happy to come in for a bit of monitoring at 41 weeks to assess baby’s condition, but will not be induced unless there is a sound reason to do so.

2. For the less bolshy: phone up and leave a message (don’t get into a discussion) saying that unfortunately you won’t be able to make the date set for induction, and will be in touch later to make another date for the next week.

3. Even less bolshy: just phone up on the day and say that you’re not coming in, but will be in touch, etc.. Maybe your car’s broken down, or your long-lost cousin has just turned up, or whatever – maybe you feel a few twinges and want to wait to see what happens.

4. Might be easier if your daughter asks her partner, or you, to do the phoning for her. It’s always possible to be polite, but to explain that you just don’t want to discuss this at the moment.
5. For the really cowardly…. just don’t turn up! They’re hardly going to come and drag you in… just say you forgot! OK, OK, I know the midwives will hate this one!

Angela H.
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A lady with her first pregnancy had got to 42 weeks. An induction date had been ‘offered ‘ for 42 weeks She had planned a home birth, and didn’t communicate to her community midwife that she didn’t want an induction. A well meaning friend(planned birth supporter) had brought her to the maternity unit to have a CTG trace, thinking they would be able to use this to persuade the consultant team that all was well. The community midwife was unaware of this visit to the unit. The induction was booked for the following day. The friend, a midwife, hadn’t been aware of the following. Had this lady spoken to her midwife about what she wanted, an appointment would have been made for a ‘bio physical’ profile. She would then be given the option to use the information gained from this to decide how she would like to go on. No one can MAKE you do anything. Unfortunately the friend had come with a challenging attitude towards the midwives/obstetricians, and I feel may have blighted the attitude of the team towards him.

Your daughter has already refered to the safety of the maternity unit birth. Keep the options open to her. Visit the place for birthing in the unit, and let her be reassured by the positive outcome of a bio physical assesment, and then maybe she will feel confident and safe enough to give birth whenever and wherever. I do realise that there will be gasps of disbelief that it could be as easy as that. You have to be confident in women and their bodies to be a strong midwife. Being her mother you could find that hard, find yourself some good support. I’m sure all will go well and look forward to your birth report!

Lesley
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Just say NO!

You don’t need any ‘amunition’ to justify the decision – just lots of support!

Lynn
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Tell your friend to get moving with the “natural induction” big time, nipple stim, clary sage, sex….you know the stuff. Tell your friend to listen to her instincts……does she think the babe is okay…? Then she could wait…….? Get a massage…..aromatheraphy……..it worked as induction for me…and it couldn’t hurt even if she has to be induced. Accupuncture….?

Kelly
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For more on “natural”, or non-pharmacological, induction methods, see our page on complementary therapies and midwifery.

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Maybe this baby wants to a bit bigger before being born? None of the stuff I’m going to say is particularly scientifically-based but I’m speaking as Mum/midwife to Leif who birthed at home Xmas Eve (in Australia).

By her dates (she never had a scan at all) she gave birth at around term plus 14 days. I was getting mw edgy as she was particularly oedematous in her legs but I needed to quell my anxieties and to keep looking to trusting the mysteries of the birthing process. Apart from the oedema, Leif was well and the baby was well. The Australian midwife was relaxed as well and apparently swelling is a much more common sight with the sub-tropical heat (though I didn’t see it in the The Philippines).

Leif was desperate to avoid hospital- and keen to give birth at home before Xmas. She and her partner Beh tried lots of sex and orgasms. She’d been having raspberry leaf tea. Evening primrose oil was suggested as a supplement as Leif had had some cervical Rx in the past. At Leif’s request I tried a membrane sweep around the tenth day.

Leif then went to a naturopath. He suggested she cut down on any mucus-forming foods (this was for reducing oedema) and he did some of the usual acupunture points. No signs of activity she went back for a second time and he gave her more acupuncture and Golden Seal Tincture with instructions on use. I had never come across this herbal substance for labour- I had heard of the Blue and Black Cohosh but as with everything I do recognise that they are forms of intervention in another guise.

It felt like I needed to leave the situation and I went off away to help change the home energies and Leif went into labour that night about midnight, the day of the hospital appointment to discuss induction (but not necessarily to agree to it!). I returned as midwife and attended Leif at home where she birthed Linus in the afternoon. Leif took some Golden Seal during the “back” labour when her ctrxs slowed down and I was a bit suprised of what seemed to be a dramatic effect of augmentation (reasearch or ideas about this would be interesting to hear about).

Kerrianne
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Induction for Older Mothers?

My friend is 42, having her first baby and has been hale and healthy throughout – babe too. Her EDD is today, but she rang last night to say that she is being induced on Sunday.

The obstetric registrar told them that: “Because you are over 40 and this is your first baby, you have a 1 in 8 chance of your placenta giving up the ghost. One day your baby’s heart beat is there and the next ……. so, to be on the safe side, our policy is to admit you two days after your EDD and start you off”.

I, for one, am totally incensed by this statement. Can any of you out there back this statement up with evidence? I would be a little more prepared to swallow this outrageous blackmail if it is backed by reliable research. Of course, my friend is going for induction on Sunday – what would YOU do if someone told you that you had a 1 in 8 chance of your baby dying? I am so upset for her as she had planned an active, upright labour with hopefully, no drugs. Now, all I can see is the whole dreadful cascade of events following this so called essential, “life-saving” induction.

Brenda
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My suggestion would be to ask your friend to insist that her obstetrician confirms the source of that spurious claim.

Lorna
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I am also shocked by that statement; certainly at the hostpital where I am training I have seen women over 40 (primips, with uneventful pregnancies of course) go over the EDD just the same as the under-40’s, our consultants do not ‘push’ them towards an induction 2 days after the EDD.

Jo
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That is a very specific, and very scary, claim; I think this consultant should put up or shut up.

Would it be possible to write to him saying that a mother believes he told her that this was the case, and that you would be very interested to know of the research that he has based his advice on, as this is a matter of great importance and interest to all midwives and many women?

It will presumably be too late for your friend, but really, I think this sort of statement is too serious not to be followed up. Either it is rubbish and he is frightening women for no reason, or it has some basis in fact and therefore some of us are underestimating the risks of post-dates pregnancy.

Angela Horn.
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Or the mother may have misunderstood what the doc said to her…..and again, a note to the doc would be useful to clarify, and he needs to know that something in the way he says things is not getting through correctly.

Heather Neil
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Research on induction

Induced labour:doctoral thesis portrayed in a Finnish paper

A recent doctoral thesis of an obstetrician Mika Nuutila.

” Doctoral thesis shows: after all induced labour/birth is not more troublesome than a spontaneous labour/birth ”

” Stubbornly existing stories that describe induced labour/birth as tremendously more painfull and longer are being proven untrue in the recent doctoral thesis done by obstetrician M.Nuutila. Study that was carried out in the University of Helsinki Hospital of opinions of 270 women/birthers shows that women did not really find any differences in painfullness or in other “troublesomeness” between spontaneous and induced labour/birth.

Every 10th woman who had experienced induced labour found it negative. The reasons for the negative attitude were pain, previous unpleasant experiences and general idolizing attitude towards natural childbirth.

Third of the women in the study also felt that they did not get enough information about the possibility of induction and the ways it is carried out during their prenatal care.Also the different alternatives that may have to be used during labour were not discussed enough prenatally.

The pregnant women (the high risk) that had to visit the maternity clinic of the University Hospital felt that they got enough information about the possibility of induction, but not all pregnant women are seen by the hospital doctors. Women would also want more say in the mode of birth.

Obstetrician Nuutila works in the University of Helsinki Hospital.His thesis is the first study in Finland of induced labour that interviews the birthers/women themselves. In Finland every 5th birth is induced – and in the University Hospitals that care for the high risk women the number is even higher. The most common reasons for induction of labour are PIH, hepatogestose, placental insufficiency and post term pregnancy. Post term pregnancy is according to Nuutila equal to over 42 gestational weeks. Extremely many pregnant women would want to get rid of the “troublesome belly” as soon as 40 gestational weeks are full.

Only very seldom a labour is induced for other reasons than medical ones. Such can be a very important job related trip of the father-to-be. If the labour is to be induced while the cervix is not yet mature the prostaglandin hormones are used to encourage the ripening. In the study of OB Nuutila the ripening was done using the new prostaglandin called misoprostoli. The substance is new only in the obstetrical use: it has long been used in the ulcer-therapy. In ulcer-therapy its effect to the ripening of the cervix was originally found. “The same tablet that the ulcer patients swallow is now put to the vagina of the pregnant woman. The medicine is very effective, so one must be very carefull. One major benefit of misoprostoli is that it is very cost-effective compared to the other prostaglandin-hormone medicine/methods developed for this purpose”, says Nuutila.
So far nobody has been able to tell when the induction can be done successfully. In the study of Nuutila it was found, that in the cervical mucus a insulin-type growth factor could be isolated that should show well the ripeness/maturity of the cervix. With the help of this growth-factor the right timing of induction can be found quite successfully. If the labour does not start after trial/s of induction the whole procedure has been for nothing since there are then no other alternatives than a cesarian section ” Marjut Lindberg/Helsingin Sanomat 24.9.99

The attitude of the article is quite frightening but even if it does not present the study in its original “tone” it nevertheless shows well the present official view to the childbirth in Finland that emphasize the cost-effectiveness and the imagined troublesomeness that women are thought to experience during their pregnancy: that the birth should be “quickly done and get over with”.

Johanna
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Your email took my breath away and the temptation to scream at the screen was enormous. I don’t believe this study – is there any possibility you could get an English translation? I suggest that you contact Marsden Wagner who, at a recent international midwifery conference organised by Midwifery Today, delivered a vigorous critique of misoprostoli which he described as a barbaric drug and said that it is so viciously powerful that there have been many cases in the USA of ruptured uteri. I think you need to invite him to speak in Finland. If you would like to send me your address I will send you an AIMS journal onActive Management of Labour, a procedure which I suspect is vigorously used in Finland.
Best wishes, Beverley Lawrence Beech.
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Dear Beverley,
I participated in the Midwifery Today conference in London (we also met briefly both there and in Helsinki at the seminary you were lecturing in summer) and listened M.Wagner’s lecture on misoprostol. The cytotec-trend is certainly approaching Finland (as I have understood it, mostly as an abortificant) but at the same time I am also hearing here a lot of critical discussions about its use and for example in the small hospital I work in the dangers and the history of how it has come to be used was recently talked (we use the “traditional” medical methods). I reacted to this OB’s way of talking about misoprostol, but was reacting even more to the way the thesis was portrayed in the media. As I said the childbirth is rarely in the news. I am going to try to get hold of this thesis to check how the research was done and were the results as described in the paper: I got really motivated to try to see through medical studies from the inspirational lectures on midwifery research in The Evidence-Based Midwifery conference!
Johanna
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Links to other sources of information:

Sweeping the Membranes – a drug-free intervention which can help to induce labour.

complementary therapies and “natural” induction methods – our own archive page, with further links.

Overdue – but still want a home birth? Induction and alternatives to it, from the Home Birth Reference Site – also relevant for people planning hospital birth.
(www.homebirth.org.uk)

Misoprostol – several articles from AIMS (Association for Improvements in the Maternity Services) (www.aims.org.uk)

Active Management of Labour – from AIMS (www.aims.org.uk)

Royal College of Obstetricians and Gynaecologists – guidelines on induction of labour (www.rcog.org.uk/guidelines/eb_guidelines.htm)

US Midwife Archive pages:
Postdates pregnancy
Pharmacological induction of labour
Natural induction methods
(www.gentlebirth.org/archives)

Many thanks to Sunrise Jade for help with compiling this archive.

AH updated 12 October 2001

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