Five questions to ask if you’re offered induction of labour

What are the best questions to ask if you’re offered induction of labour?

This is something I get asked a lot. So I have put together this guide to the five best questions that you can ask in order to get more information and make the decisions that are right for you.

I’m also going to tell you what you can learn from the answers you are given.

In case we’ve not met before, my name is Sara. I’m a midwife, speaker, researcher and the author of two books about induction of labour. They are In Your Own Time and Inducing Labour: making informed decisions. I’ve also written a book to help women and families make birth decisions. That’s called What’s Right For Me?

Here’s the important thing. I’m not here to tell you whether to have your labour induced or not. That’s not up to me. (Or your midwife, obstetrician, childbirth educator, doula or hypnobirthing teacher, but we’ll come back to that.) Your decision won’t affect me or any of those people. And, as I am very fond of saying, one size doesn’t fit all. My work is about trying to help you to understand and navigate the evidence so you can make the decisions that are right for you.

Let’s start with what I think is the first question anyone should ask if induction is mentioned.

 

Question 1: Why are you suggesting this? / What’s the indication?

The first thing you need is a clear and specific explanation of why you’re being offered induction of labour. So “why” is the first question to ask.

Midwifery and medical professionals call this “the indication.” Asking “what’s the indication?” will help you find out whether or not there is a clear, single indication. But you don’t have to use the jargon. You could also ask, “Why are you suggesting this?” Or, “Can you tell me exactly why you’re offering me induction?”

You might have to ask this – and the other questions – more than once. Don’t be afraid to do that. It’s your body and your baby, and the decisions you make can affect you and your baby’s health and you family for a long time. So unless you’re in one of those rare situations where it’s really an emergency, it’s really okay to take time to think about them.

And one tip is that, if it’s truly an emergency, you’re not likely to be offered an induction. Induced labour often takes three days to get going. If there’s a genuine emergency, you’ll be offered a caesarean, which is much faster. So if someone offers you an induction and says it’s an emergency, you might want to ask some questions about that.

 

What can you learn from the answer?

There are three common answers to questions about why induction is being offered.

 

“You or your baby have a medical problem.”

The answer you get may be very clear and specific and mention an actual medical problem.

For instance, you might be told, “because you have pre-eclampsia.” Or, “because your baby has a heart condition and we need him to be born so we can do surgery.”

In these situations, it’s still your decision, of course. And yes, there’s a difference between having symptoms of pre-eclampsia and being close to developing eclampsia. So you might want to explore what you’re being told in a bit more depth. You’ll still want to ask the remainder of the questions below, and you can then decide whether or not the benefits of induction outweigh the downsides for you and your family. But where there’s a clear and specific reason that involves an actual medical condition, it’s more likely that induction is genuinely warranted.

This is a useful thing to know. Because there’s an important difference between being offered induction because you or your baby actually HAS a specific named medical condition, and being offered induction because you or your baby is thought to be “at risk” of something. It’s important to determine which is the case for you.

You might be told that you’re being offered induction because you or your baby are “at higher risk.” When you ask what that means, you discover that it’s because you are for example over a certain age, larger than average, or you conceived by IVF.

None of those things are an actual medical condition. So let’s look next at what you might want to consider if you’re told you’re being offered induction because you have one or more risk factors.

 

“You have a risk factor.”

The second possible answer is that you are told something like this:

“We offer induction to everyone who is 41 weeks pregnant.”

“Your BMI is over 35.”

“We offer induction to everyone who has a suspected big baby.”

“Induction is best for women who conceived by IVF or ARTs.”

That list isn’t exhaustive; they are just a few examples.

What this kind of answer tells you is that the offer isn’t tailored to your specific, individual situation. You’re being offered induction because you fall into one or more categories. In many countries, induction is routinely offered on a population basis to anyone who ticks a box or has a ‘risk factor.’

You might still want induction in these circumstances, but it’s important to know that having a risk factor is different to having an actual medical condition. Having an actual, diagnosed medical condition right now is different from being in a group that might be at greater risk of developing a problem. Most of the time, only a small number of those in the group will develop a problem, whereas someone with a medical condition definitely has that condition.

Often, the actual chance of women who are told they are “at risk” having a poor outcome is very low. More on what to ask about the numbers below. In many cases, there’s still a very high chance of everything being just fine. And remember that induction has downsides too and life doesn’t come with a “no risk” option.

This is where you really need to look at the evidence and weigh things up. Sometimes, induction is offered to women with risk factors in the hope of saving a very small number of babies. But there’s not always clear evidence that it does save babies. And hundreds or thousands of women and babies need to have induction in the hope of saving one. Some of them will end up with other problems as a result of the induction and associated interventions, and so it’s a question of weighing up the pros and cons. Often, there isn’t good evidence to support induction for risk factors alone. There are some articles on this on our induction information hub and loads more on the evidence in In Your Own Time. And there’s more on how to ask about the actual numbers below.

 

“Mumble, waffle, jargon, jargon.”

The third common answer to this question is a reply that is unclear, provides little information or is full of jargon. Someone may list several potential problems or risk factors in an unspecific way that leaves you wondering what they just said. Don’t let that put you off asking more questions. A garbled, unclear, or ‘stun you with science’ response may mean that the person you’re speaking with is not really keen on you making your own decision. It might mean that there isn’t a clear indication. If someone has to add three risk factors together to justify their offer but can’t provide you with robust evidence for any of them, be wary.

It might be that the person offering induction may be afraid of physiological labour, or of waiting for women to birth in their own time. (It’s more common than you might think.) They may genuinely think this is ‘for the best’, or just prefer to control when labour happens.

If you are given a list of complications or risk factors, ask lots of questions about what these complications are. Ask the questions below as well. There’s more about this in my blog post on induction for gestational diabetes. Look at the section in that blog post called “Risks and recommendations.” Even if you’ve not been told you have gestational diabetes, the principles are the same.

Don’t be impressed by jargon. If an intelligent person has a justifiable suggestion, they should be able to explain and discuss it with you in a reasonable manner. If that’s not happening, be alert.

This brings me to my next tip.

 

Question 2: What’s the evidence?

Once you’ve discovered exactly why induction is being recommended in your situation, ask what the evidence says. This is another of the key questions to ask if you’re offered induction. Ask if there is evidence of benefit of induction. Often there is not. And, if someone tells you that there is evidence of benefit, ask them to provide you with the evidence or a reference, so that you can look at it for yourself.

One thing that’s important to know is that not all induction studies are good studies. Some were poorly conducted and/or were biased in their approach. This is especially true of some of those which claim to show that induction reduces the chance of caesarean section. Some studies are now quite old. It’s possible the participants weren’t similar to you. For instance they might not have given birth in the setting/country that you’re in. This kind of evidence may not necessarily apply to you.

This is a complex area and I can’t give all the detail here (which is one reason I write books for those who want more in depth information). But some of the more controversial studies to listen out for include The Canadian Post-Term Trial, the ARRIVE Trial, and the SWEPIS study. The last one is sometimes described as a Swedish study which was stopped because some babies died. Yes, they did, which is very sad. But that doesn’t mean they would have been saved by induction, or that a lack of induction was the problem. The media headlines and those who quote this study have been criticised by other researchers. That’s because there were some issues with the trial. Data from a half-finished study isn’t robust enough to let us draw conclusions and make recommendations. Again, if you’d like more detail, have a look at my other induction blog posts or grab one of my books.

 

What can you tell from someone’s reply to this question?

Well, you’re looking for a reply that is clear, honest and that acknowledges that no research study is perfect. If you feel that the person is trying to convince you that they are absolutely right and there’s no room for debate, be alert. If they try to stun you with science and numbers, they may not really be wanting you to make your own decisions. Good practitioners will be happy to share the evidence with you and discuss the pros and cons in an open way that focuses on what’s right for you.

 

Question 3: What’s the absolute risk?

If you are told that there is a specific reason for induction, especially if that is a risk factor, ask for some numbers.

Some professionals will tell you the relative risk of something happening but not the absolute risk. So they might say, “your baby is twice as likely to die if you do X rather than Y.” But what they don’t tell you is that the risk of Y is one in 4000 and the risk of X is one in 2000. In other words, the unwanted outcome is very, very unlikely no matter what you do.

And, as we’ll get to in the next tip, intervention carries downsides as well as advantages.

It’s always a good idea to ask for the absolute risk of a problem occurring, no matter what health decision you’re making. As with the last tip, you may also want to ask for the evidence or a reference so you can look at it yourself.

Also as with the last tip, you should be able to tell a lot from their response. All of the things I’ve mentioned about this above apply here as well. How open and honest are they in their response? Is there acknowledgement that there’s not always one clear ‘correct’ way that’s right for everyone?

 

Question 4: What are the downsides?

You should also ask about the downsides of induction.

I recommend asking this question even if you feel you already have this information. If you’ve been to my website before, you may already know that induction has downsides. (If not, there’s lots more info on that here. I recommend that families ask this question even if they already know what the downsides are.

That’s because asking this question is an excellent way of finding out if the person you are speaking to is being open and transparent about the pros and cons of the different options. Anyone who is being respectful should honestly and openly tell you the things in this article. They should also mention the negative consequences of induction for you and your baby.

If they don’t tell you these things, or they gloss over them, treat it as a red flag. You need the full picture. And you deserve caregivers who will give you that.

 

Question 5: How, when, where, what and who?

Find out about the process of induction, the pros and cons, the evidence for the most common reasons and the information you need to decide if it’s right for you.

Don’t be afraid to keep asking until you have enough information. If you want to be prepared before you have this conversation, there is also lots of info on the practical reality of induction in Inducing Labour: making informed decisions.

Many women are dissatisfied with their experience of induction. This is one of the key issues that comes up in the studies that ask women about their experience. One of the main reasons for this is that they had not been given adequate information about what would happen. They were not told, for instance, that induction can sometimes take three or four days to get going. They were not told that the early contractions can be quite painful, even though they may not be doing much. Women aren’t always told that their partner, family, friends or doula can’t be with them except during visiting times. These hours are quite restricted in some places. In others, they aren’t. The induction experience varies a lot; it’s a postcode lottery.

So ask as many questions as you need to in order to get a sense of what it would be like in your area. Then, you will be much better placed to weigh this up with all the other information you’ve gathered and decide whether induction is right for you and your baby.

 

So those are my five best questions to ask if you’re offered induction. I hope that these questions will help you consider and explore your options. There’s lots more induction information on this website. Make a cup of tea and have a look around!

If you’d like more in-depth information or to learn more about the evidence, you might enjoy In Your Own Time and/or Inducing Labour: making informed decisions. My book What’s Right For Me? also contains lots of information about birth-related decision making.

 

 

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