In modern Western culture, most women know about induction of labour before they even become pregnant. They know that it is suggested when it is felt that it would be safer for the baby to be born than to stay inside its mother, and I suspect many women know that one of the main reasons for recommending induction of labour is because pregnancy has lasted for a certain number of weeks and the baby is perceived to be ‘overdue’. Many women will know a good few other women who will have had their labours medically induced, and so they are likely to know that other reasons are sometimes given for this. These reasons include that the woman is older than average, that her waters have broken early and/or that she has a health problem or condition which is felt to necessitate the bringing on of her labour.
But this is not the whole story, and there are many other aspects to the decision that some women need to consider about whether or not to have their labour medically induced. This blog post offers an updated version of my article on this topic, which reflects the latest update of my bestselling book; Inducing Labour: making informed decisions (Wickham 2018). In this article, I didn’t want to focus on the things that are commonly understood, but instead on some of the evidence, issues and implications that women tell say they were less aware of but which they wish they had been able to take into account when making their decision. There are, of course, way more than ten things to know, but this is intended to serve as a starting point for discussion rather than to be exhaustive.
1. Induced labour isn’t like spontaneous labour.
This might be obvious to some people, but I know from experience that it isn’t to others. Induced labour is very different from labour that starts spontaneously. Individual women’s experiences vary, of course, but there are a number of key and interwoven areas of difference that are fairly universal. First, a woman having her labour induced is given artificial hormones, which can create more pain more quickly than would occur in spontaneous labour. Synthetic hormones don’t trigger the release of a woman’s own natural pain-relieving substances as her own hormones would if she were in spontaneous labour, and they come with a range of possible side effects, which means a woman whose labour is being induced needs to be monitored more closely. The increased monitoring can lead to the woman being less able to move around, which can increase her pain and stress, and this can quickly lead to a woman feeling that things have spiralled out of her control. Not everybody finds this a problem, but it is something to be aware of.
2. Some women find induced labour more painful.
I started to cover this already in point 1, but there is a bit more to know about this in relation to possible sources of pain. The contractions caused by the cervical ripening methods that are the first stage of medical induction can become really sharp really quickly, but without having any measurable effect. Some women feel that this has a negative effect on women’s experiences, and it is easy to become tired and/or disillusioned more quickly than if they were in spontaneous early labour. Oxytocin-induced contractions can also be very strong, and there is often less time to get used to these than when labour starts spontaneously. In addition, the increased number of vaginal examinations and other interventions (such as the insertion of cannulas) can create additional pain or discomfort. Again, not everyone finds this a problem, but it’s worth knowing beforehand. If you decide to have your labour induced, you might want to give some thought to your pain relief decisions.
3. It’s a package deal.
I have written about this quite a bit elsewhere on my website so I won’t repeat myself too much here, but the fact that I get asked so frequently whether women can have a physiological placental birth or decline monitoring and/or vaginal examinations if their labour is induced makes me think that this is not a commonly understood fact. It is not that anyone wants to prevent a woman from making the decisions that are right for her. It is that the drugs used to induce labour are powerful substances that block a woman’s own hormones and that can sometimes cause side effects in the woman or baby. It is the effect of these drugs that needs to be measured, monitored and compensated for in induced labour. If a woman is concerned that aspects of induction are not what she wants, then it might be better for her to consider whether induction is really necessary or right for her in the first place.
4. Stretching and sweeping isn’t benign.
Nowadays, many areas have introduced a policy of offering women a ‘stretch and sweep’ at a certain point in pregnancy in the hope that this will reduce the number of women who go on to have full-blown medical induction. Even if we ignore the assumption that all of the woman who are offered induction will consent to having it, a stretch and sweep can cause discomfort, bleeding and irregular contractions, and in some of the studies the stretch and sweep intervention only brings labour forward by about 24 hours. The authors of the Cochrane review on this concluded that: ‘Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women’s discomfort and other adverse effects’ (Boulvain et al 2005: 2).
5. Natural induction is an oxymoron.
This is another issue that I have written about elsewhere on my website, but the gist is easy to summarise. Either we are awaiting spontaneous labour, or we are trying to interfere and bring it on earlier than it would otherwise have occurred. Sometimes there is good reason to try to bring labour on, but if a woman takes castor oil or asks her midwife to do a daily stretch and sweep or picks any one of the range of things that are purported to bring on labour, then she is aiming to induce her labour with non-medical means. I am not saying there is anything wrong with that, but I think that, particularly because we exist in a culture which continually devalues patience and women’s bodily processes, it is important to be clear about what our intention is.
6. It is NOT the law!
I was absolutely appalled to hear, part-way through writing an earlier version of this book, that one woman had been told: ‘We have to induce you twenty four hours after rupture of membranes. It’s the law’. The woman had agreed to induction and went on to have what she felt was a very traumatic birth. In most countries, including the UK, there are no laws which state what a pregnant woman must or must not do, and any practitioner saying such a thing should be reported to their professional body.
7. It’s not ‘just a trickle’ (or a whiff)…
I am always really concerned when I hear midwives and doctors using language which downplays the interventions that they are recommending, and I particularly dislike the terms ‘trickle’ and ‘whiff’ when used in relation to intravenous oxytocin (syntocinon). This drug is sometimes lifesaving and sometimes overused and it is a very powerful drug which needs to be respected as such. It can cause the baby to not cope as well with labour, and in fact in some areas the practice is to keep increasing the amount of syntocinon that women receive until the baby reacts, and only then turn it down as it is considered that the appropriate level has been found. But even where this is not done and the syntocinon is only increased until contractions are effective, it is a drug that needs to be given respect. Its potential effects should not be minimised by professionals, whether intentionally or otherwise.
8. Women don’t fail. Inductions and systems do.
This one pretty much speaks for itself. Induction doesn’t always work, and this is not the fault of the woman. As I discuss in my book, we now know that some women don’t respond as well to the drugs used as others because of genetic factors, and there are multiple reasons why induction might not work, including that it is carried out before the woman or baby were ready for labour. I wish I could reassure all women who have had an induction that was unsuccessful that there was nothing wrong with them or their bodies. This is another case where some of the language used in the maternity services really needs to be reconsidered.
9. The risks are later, lower and sometimes less preventable than people think.
In my book, I look at a number of studies and data sets that look at the risk of stillbirth and whether the chance of this can be reduced by inducing lots of women’s labours. And the answer is, well it’s complicated. In some situations, like post-term pregnancy, the increase in risk doesn’t happen as early as some people believe, and it is also lower than women are often told. In fact, the outcomes experienced by women who awaited spontaneous labour and by women whose labour was induced were so similar that none of the individual studies which compared induction with non-induction were able to show a benefit to induction in their findings. It is only when all of the results for all of the studies are added together that it is possible to see a small difference, and even then we have a big question mark because the quality of the research isn’t always high. As I will explain further in the next point, we don’t always have good evidence that sad events like stillbirth are preventable by increased intervention, such as induction of labour.
10. The risks for older women, women with suspected large babies and women who conceived via IVF aren’t as clear cut as is often suggested either.
My final point relates to the women who are told that they are at greater risk of having a baby with a problem, and that they should hav their labour induced because of this. This currently includes women who are older, women who are thought to have a large baby (even though we aren’t very good at estimating fetal weight, even with ultrasound) and women who conceived by IVF. This is complicated, too. Let’s look at older women as an example. Some studies show a correlation between increased maternal age and an increase in certain types of complications, including stillbirth, but that doesn’t mean that induction of labour will improve outcomes, and we don’t have robust evidence demonstrating that it does. There are also downsides to induction, so the decision needs to be weighed up carefully by the person who it will most affect. Women who are older or deemed to be ‘at higher risk’ are often offered monitoring and intervention in abundance, and this can cause complications and lead to more intervention. Older women are also more likely to have other health challenges (sometimes called co-morbidity) and it is hard to tell whether these problems and/or their age are the cause of any problems. The studies that have looked at this have not always separated these issues out, and the only papers that have done so looked at women who gave birth some years ago, and who may not be comparable to women today. So there is a real lack of good data in this area, and unfortunately the studies that are being carried out to look further at this are tending to induce even younger women even earlier in pregnancy, so their results may not be of much use to women either.
Women who are offered induction of labour need to weigh up lots of things in order to determine which path is right for them. We need to wholeheartedly support women who want their labour to be induced, and to wholeheartedly support women who don’t. Women report variable experiences of induction of labour afterwards; some are really happy with their experience, and others less so. But the overarching thing that I hear from new mothers on the topic of induction is that many women wish they had had more information, and that’s why I have re-shared this article as well as updated my book on this topic. In the book, I explain the process of induction, explore some of the things you might want to ask about if you are considering induction and look in more depth at the research that is available on this topic. You can find out more here.
Boulvain M, Stan CM, Irion O. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2
Wickham S (2012). When is induction not induction? Essentially MIDIRS 3(9): 50-51.
Wickham S (2018). Inducing Labour: making informed decisions. Birthmoon Creations.
If you’re a midwife or birth worker who would like to learn more about this area and discuss the issues with like-minded people, I’d love to welcome you to one of my online courses, including post-term-pregnancy: exploring evidence, inspiring confidence or you can keep up with my research postings via my free updates and monthly Birth Information Update.