Are there good reasons to induce labour?

Are there good reasons to induce labour?

That’s a question often posted when I talk or write about labour induction.

It’s an understandable question. I have spent more than twenty years writing about how induction isn’t always beneficial.

I’ve often pointed out that, sometimes, induction is offered or recommended for less-than-good reasons. Convenience, fear or a lack of trust in the female body, for example.

And many of those who work in birth-related areas see many unnecessary inductions. They also see the negative consequences that can sometimes result. So I understand why people ask.

But the truth is that there are some very good reasons to offer to induce someone’s labour.

I’m going to explain that in this blog post.

 

Good reasons for induction of labour

So my first example of a very good reason to induce labour is a medical condition such as pre-eclampsia. Yes, there are degrees of this, as with many medical conditions. And, like many other situations, timing is key. So it depends a bit. But I know women who developed pre-eclampsia and other conditions who would likely not be with us today if not for their labour being induced. A medical condition that is affecting a woman’s health is a brilliant reason to offer induction.

Another great reason to offer induction happens where the baby has a health problem or condition that will certainly get worse if they stay in the womb for longer. Or where they need treatment or surgery that is only available in a limited situation, place or timeframe. The exact conditions vary, of course. But I also know babies (some of whom are now adults) who would not be with us if not for induction.

It’s a question of weighing up benefits against risks. Do you or your baby need access to a surgical team who are only available this week? Then the benefits of an induction (or maybe an elective caesarean, as induction often takes days) may well outweigh the downsides. This should go without saying but, if it’s your body, then you’re the one who gets to weigh everything up and decide what’s right for you.

 

Why holistic assessment is important

I know of situations in which a woman has decided that induction is right for her circumstances after a midwife or doctor has holistically assessed her individual situation and discussed the issues and possible outcomes in an open, unbiased way. A holistic assessment involves taking into account things that require midwifery or medical knowledge, skills and experience, as well as what the woman knows, thinks, feels, needs and wants. A midwife can, for instance, determine the position of the baby, feel whether and how well the presenting part is fitting into the pelvis and will understand the factors that might be affecting that. They can also help the woman/family to think through the different possibilities that might result from different decisions.

For example, Sally was nearing 42 weeks of pregnancy and was trying to decide what to do. She didn’t want induction simply because she was nearing 42 weeks. Both she and her midwife felt that the baby was on the large side, although both knew that this wasn’t an indication on its own either. Determining the size of the baby also isn’t an exact science, as I discuss in In Your Own Time.

But Sally’s baby’s head was only slightly engaged and not deep in the pelvis. The baby wasn’t in an optimal position (despite the efforts of a doula, rebozo and optimal positioning techniques) and in what we call a ‘military position.’ Sally and her midwife discussed these factors and many others. They discussed how, if Sally awaited spontaneous labour, there was a chance that the size and position of the baby might mean that a caesarean became the only option. Sally really wanted a vaginal birth. She knew about the many benefits to the baby of experiencing labour, and the fact that this is also beneficial if the woman has more babies in the future. They talked through different scenarios and Sally decided that the right path for her was to have an induction, in the hope that bringing on contractions at this stage might help the baby get into a better position and be the key to a vaginal birth rather than an emergency caesarean in a few days’ time.

The important caveat is that someone else might make a totally different decision with the same information. One size doesn’t fit all. You might place a different value on the various outcomes. But this is just an example to illustrate the point. If you’re being offered induction and are unsure, ask whether induction is being offered because of a theoretical risk factor (which I’ll discuss further below) or because of your individual actual situation.

 

There are genuine indications

So yes. There are genuine indications for induction of labour, and two things are important in determining this.

The first is a genuine indication, which takes into account a woman’s individual clinical picture, and not just a risk factor.

The second is a woman/family who has received good information, weighed up the pros and cons of each option and decided it’s right for them.

As I wrote in In Your Own Time, the problem isn’t induction per se. Induction can be incredibly helpful and sometimes life-saving when it’s used appropriately.

The problem is that it is overused.

Some people go too far the other way, though. I have heard some birth workers saying that there is never a justifiable reason for induction, and that’s not the case. Many inductions are unnecessary, yes. But it’s not true that ‘all babies will come out if we leave it to nature.’ And I am all for trying alternative things. I teach these at my workshops! But nothing works one hundred per cent of the time.

So if a friend, family member or birth worker tells you induction (or medically managed third stage or any other intervention) is never useful, I humbly suggest you run a mile. Then find someone more balanced and informed. Because (almost) everything has a time and place.

 

Questionable reasons for recommending induction of labour

The problem is that many of the reasons that underpin current recommendations or offers of induction are questionable.

Some of these reasons aren’t evidence-based.

Some reasons for offering induction of labour are technically supported by a bit of research. Sometimes two or three bits of research, even. But only if you have a wide tolerance for possible bias and ignore the bigger picture.

Here are some of the reasons that I consider questionable. And by ‘questionable,’ I mean that they are really worth thinking about and looking into, because the evidence doesn’t always stack up. There’s more information on all of these in In Your Own Time, so this is just a summary.

  • Induction for estimated birth weight.
  • Induction for maternal shape, age, race or mode of conception.
  • Induction for lack of care provider trust in the female body.
  • Induction for care provider fear of litigation.
  • Induction for care provider or facility convenience.
  • Induction “because it’s the guideline/recommendation.”
  • Induction for a marginal difference in the risk of one outcome without consideration of medium- and long-term effects, social and mental health consequences and other possible downsides.

In Your Own Time was written to help parents and professionals better understand the issues and the evidence relating to the current induction epidemic. Looks at the evidence relating to due dates, ‘post-term’, older and larger women, suspected big babies, maternal race and more.

In some of these situations, some data show that there’s a slightly increased chance of stillbirth in those groups compared to some other groups. But it’s complicated. Sometimes, different studies show different things. The difference can be tiny. Most importantly, we often don’t have any robust studies showing that inducing labour will reduce the risk. But we DO have studies showing that induction has short, medium and long-term health consequences, leads to more intervention, can cause distress and trauma and a whole load of other things that aren’t ideal. So there’s more to it than just recommending induction for anyone who is deemed to be “at higher risk.”

 

Is induction justified?

But let’s return to the question that I set out to answer.

Are there good reasons to induce labour?

Absolutely.

And there’s nothing wrong with induction when it’s appropriate, justified and done after someone has made an informed decision that it’s right for them.

It’s just that this isn’t always what’s happening.

 

If you’d like to know more, there’s tons more info in my book or here on my resources pageWe also offer a monthly newsletter and online courses for midwives and birth folk who would like to stay on top of the evidence and improve their confidence at analysing and communicating the evidence in this and related areas.