Can I have a natural placental birth after induction? (with apologies to Sir Edmund…)

5581007563_260038813aI am sometimes surprised at how often I get asked whether, if a woman has her labour medically induced, she can still birth her placenta naturally.  My reply to this question usually involves my saying that I am not sure that any part of a labour that follows a full-blown medical induction could accurately be described as natural and that, while I would never want to deny a woman choice, there is a really good reason not to suddenly remove synthetic oxytocin once it has been started.  I have written this post to offer a (hopefully searchable) explanation of why I take this position for women and midwives who are looking for information on this, and perhaps to provide a forum for debate if anyone disagrees.  (Caveat: if a woman goes into labour after one dose of prostaglandin or having her membranes ruptured, then things might be a bit different, but here I am assuming we mean induction that includes the use of synthetic oxytocin).

Before I answer this question in full, though, I would like to be clear that I am a big fan of natural placental birth.  In fact, I co-wrote the book(let).  I have attended hundreds of women who have birthed their placentas naturally and would consider my own comfort zone to be really quite wide in this area,.  But induction of labour interferes with normal physiology to the degree that I would also consider it inadvisable to suddenly stop an oxytocin drip after a woman had been receiving this for several hours, especially if she had not yet birthed her placenta.

The reason for this is simple: oxytocin is needed to birth the placenta and to keep the uterus in good shape once it has done so, but synthetic oxytocin (as found in the drip used to induce or accelerate labour) inhibits the woman’s ability to produce her own natural oxytocin.

Symphonies and mountain climbing

I have every faith in a woman’s ability to release appropriate amounts of her own oxytocin if she is in natural labour (although, if you are not already aware that oxytocin flows better if women are disturbed as little as possible, I would invite you to read up on this too).  But let’s not underestimate how amazing this journey is, and what massively complex and powerful things a woman’s body does to birth a baby.  The hormones involved in labour could be likened to a physiological symphony that develops its rhythm and builds to a crescendo over the course of the journey.  During the last bars of the ‘labour’ movement of this symphony, pulses of oxytocin help the placenta to separate and birth and enable the now empty uterus to begin to return to a more normal size, which helps reduce bleeding from the placental site.

But this is if labour progresses naturally, and in an induced labour, the presence of synthetic oxytocin inhibits the woman’s ability to produce her own oxytocin.  Under these conditions, expecting any woman to suddenly be able to produce enough natural oxytocin to facilitate the birth of the placenta AND the vital postnatal clamping down of her uterus from a standstill is a bit like parachuting someone out of a helicopter to a point halfway up Mount Everest and then expecting them to be able to sprint straight to the top without a chance to warm up or get used to the freezing cold oxygen-depleted air.  But (and admittedly this analogy isn’t perfect, but I think it will suffice for our purposes) what if you had also given your imaginary mountain runner unlimited oxygen and a nice big chunk of dark chocolate every ten minutes from when they woke up that morning until they piled out of the helicopter, but then suddenly took away the supply of both just as they started to run?  What odds would you give them on reaching the top now?

Induction as a package deal

I know.  It’s not always helpful when people make unrealistic comparisons, and I apologise if this sounds harsh, but I think it is important to recognize that induction of labour entails a serious level of intervention which might be best thought of as a ‘package deal’.  Although there are some choices which can be made along the way, some of the core elements of it (including repeated vaginal examinations, ongoing fetal monitoring and medical management of elements of labour, such as the birth of the placenta) are an intrinsic and, sorry, fairly necessary part of that package.  Even to those of us who spend our lives stretching the fabric and journeying the boundaries.  It is not that we’ve stopped trusting women’s bodies.  It is that we trust the physiology of minimally-disturbed labour, and the drugs used to induce labour are potent substances which interfere with the ability of women’s bodies to ‘do their thing’.  Therefore, where labour is artificially induced, the effects of these drugs need to be monitored and sometimes compensated for.

I really empathise with those women who feel they have no choice about having an induction but wish they did, but I think it is important that women who are considering induction of labour understand the rationale behind the package nature of the deal, as my experience tells me that this is not always explained well.  Perhaps my experience isn’t the norm, but I am asked this question so often that I am concerned that the differences between spontaneous and induced labour are not well enough understood. With something like one in five women in the UK (and even more in the US) having their labours induced, I would say this needs to be rectified, because if we are not ensuring that women understand the differences well enough, then how on earth can their choices be informed ones?

 

Want to read more about induction?  My book, “inducing labour: making informed decisions”, which was written for women but is frequently enjoyed by midwives and birth folk too!, is now available in a version for kindle (or other ebook readers) or as a real-life paperback book 😀

15 comments for “Can I have a natural placental birth after induction? (with apologies to Sir Edmund…)

  1. Dhyana Heller
    November 11, 2013 at 11:58 am

    Hi, I am midwife of 33 years in PA. May I post your posts on my timeline giving you the credit? Thank you Dhyana Heller CPM, LM

    • November 11, 2013 at 4:32 pm

      Edit: since I wrote this reply to Dhyana, I have now got a facebook page – it’s at http://www.facebook.com/saramidwife

      Hello Dhyana, I am not on facebook, but I think there is a button which you can click to share my posts which gives a link that people can click to visit my site and read them in full? I am really happy with people sharing via that, but (as explained further on the articles page) please do not copy and paste articles from my site onto other sites, thank you. Glad you’re finding it useful 🙂

  2. November 11, 2013 at 2:32 pm

    Thanks Sara I enjoyed reading this post (and I liked the mountaineer analogy!). In my experience so many women are not given nearly enough information regarding what ‘being induced’ actually means, and what impact this will have on her birth experience.

    • November 11, 2013 at 4:33 pm

      Me too! Glad you enjoyed the post!

  3. Heather
    November 21, 2013 at 10:15 am

    Excellent article! May I add that it’s not just that many women aren’t being given full information regarding medical induction, many don’t research on their own and just expect for their medical caregivers to just spontaneously spout everything, too. Women need to do their research about giving birth, not accepting injections for their baby like vitamin K and the Hepatitis B vaccination, delayed cord clamping and why it’s imperative to not clamp or cut the cord until after it’s done pulsating, and even on why not to circumcise their sons. Women need to be proactive in their own care and the care of their baby, and only if they search out their own answers will they really know what to expect and how to protect their little one. This article is a good start!

  4. November 21, 2013 at 12:12 pm

    This makes total sense to me. Induction is a package, just as having an epidural is. Individual women may decide to take on that whole package, feeling in their heart and head that it it worth it in their unique circumstances. Knowing what the whole package involves is key to making that truly informed decision before the process is set in motion.

    • April 13, 2015 at 8:48 am

      Thanks, Dot. It’s always good to know one isn’t alone in having such thoughts! 🙂

  5. Alice Tuson
    February 21, 2014 at 6:03 pm

    Very well captured. I like the mountain analogy too. Thank you.

  6. Jane Stojanovic
    April 12, 2015 at 3:20 am

    Couldn’t agree more – well said, I too am a fan of physiological placental birth and have a lot of experience with it, and am totally concerned about the amount of inductions being done andd the paucity of information given to women.

    • April 13, 2015 at 8:38 am

      Thanks, Jane; we really do need to get more information out there! 🙂

  7. Lesley Bland
    April 13, 2015 at 6:13 am

    Another fabulous insight into why we need to be educating women about all aspects of childbirth. I’m currently writing an essay about how to improve women’s knowledge and understanding of IOL before they arrive at the hospital expecting a dream birth and a beautiful baby in their arms in next few hours. I despair when they arrive and announce how they are looking forward to this being their baby’s birthday. Most of them still have no idea how long it could take and even what they can expect from the process. My suggestion is a DVD that they can be given either at 38 week appointment or when IOL is discussed due to factors which may result in iol. This means that the community midwife does not need to rush through it in already tight appointment times but that the woman can take it home watch it as many times as she needs can share with family and havd time to question midwives about anything she is not sure about. Informed choice is vital and the DVD should ensure pros and cons of both iol and expectant management are covered. Hopefully when she returns for her next appointment or when she arrives at hospital she is more aware of what to expect. And who knows some of them may decide to wait and see and decline iol?!

    • April 13, 2015 at 8:39 am

      Thank you, Lesley 🙂 I think lots of different kinds of media with information would be great!

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