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. Many people also 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’.
Other reasons for offering induction include that the woman is older than average, that her waters have broken early and/or that she has a health problem or condition. These days, induction is often suggested where someone has a high BMI, or has been told they have gestational diabetes.
There’s a big focus on telling women when they are deemed to be ‘at higher risk.’
Induction is really common now. Some people think it’s oversold. Some are concerned about how a lot of the ‘official’ information is geared to promoting induction. For instance, women and families are often told the pros of induction, but not the downsides. There are pros and cons to everything! Some are given an induction date without even being asked whether this is what they want.
But this is not the whole story. There are many other aspects to the decision that some women need to consider about whether or not to have their labour medically induced.
That’s what this blog post is about. I’m not going to tell you the things that you know or have already been told. I’m here to offer a deeper perspective and cover some of the lesser-known things you might want to consider.
Hello, I’m an induction researcher
In case this is your first visit to my website, maybe I should introduce myself. My name is Sara, hello. I’m a midwife and a researcher who has been studying induction of labour for more than twenty years. That’s me in the pic, speaking about induction and risk in Australia.
I have written two bestselling books about induction of labour. Inducing Labour: making informed decisions talks the reader through the process and the pros and cons of induction. In Your Own Time: how western medicine controls the start of labour and why this needs to stop explains how we got to the current situation and looks more deeply at the evidence and issues in relation to topics such as the due date, suspected big babies, and being deemed to be ‘at higher risk.’
And I’m passionate about helping women and families make the decisions that are right for them.
One quick note, though. I’m not anti-induction. I’ve looked after lots of women whose labours were induced. I want everyone to make the decisions that are right for them. If you’re fully informed and decide you want an induction, that’s brilliant. But lots of women and families aren’t given all the facts, so that’s why I’ve written this blog post. In it, I share some of the evidence, issues and implications that women have told me they were less aware of but which they wish they had been able to take into account when making their decision.
And there are, of course, far more than ten things to know! That’s why I’ve managed to fill two whole books with information that parents may find useful when considering induction. This article is intended to serve as a starting point for discussion and offer links to more info rather than to tell you everything that you might want to take into account when making your decision.
So let’s dive in!
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. These 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. They also come with a range of possible side effects. That 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. That in turn 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. Induction can also take quite a long time. Women are often waiting (usually, but not always, in a hospital ward) for two or three days before labour really gets going. This is frustrating to some women, especially when their loved ones aren’t allowed to stay.
It’s also worth knowing that there are many advantages to spontaneous labour. These are lost when labour is induced, so that’s the first reason why it’s important to look at the pros and cons of both approaches. If you’d like more on this, I wrote a whole chapter on it in In Your Own Time: how western medicine controls the start of labour and why this needs to stop.
2. Some women find induction of labour more painful.
I started to cover this already, 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.
The contractions brought on by an oxytocin drip can also be very strong. There is often less time to get used to these than when labour starts spontaneously. With induction, your body doesn’t get to make the decisions about what hormones you need and when. Those decisions are made by your caregiver and/or dictated by the hospital protocol or guidelines. They may or may not work for you and your body. Which is why induction sometimes fails, as I discuss below.
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 about beforehand. If you decide to have your labour induced, you might want to give some thought to your pain relief decisions. And plan ahead so that you can take things that will help you cope.
More on the process of induction in Inducing Labour: making informed decisions.
3. Induction of labour is a package deal.
I am frequently asked whether women can have a physiological placental birth or decline monitoring and/or vaginal examinations if their labour is induced. The answer is usually no.
But that’s not because anyone wants to prevent a woman from making the decisions that are right for her. It’s because the drugs used to induce labour are powerful substances that block a woman’s own hormones. They 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.
I have written about this in this blog post too if you want a bit more detail.
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. They do this 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, there are downsides. A stretch and sweep can cause discomfort, bleeding and irregular contractions. And it probably won’t do that much. In some of the studies the stretch and sweep intervention only brings labour forward by about 24 hours, and then only in some women.
It’s also important to remember that a stretch and sweep is a form of induction. Find out more about what the research on this intervention can show us here.
5. Natural induction of labour is an oxymoron.
Some people talk about ‘natural induction.’ But there’s no such thing. 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 has a 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. Some holistic therapists offer to help women ‘go into labour’ but try to avoid using the word induction.
I am not saying there is anything wrong with trying these things, but I think it’s important to be clear. Either we are letting the body and the baby do its thing spontaneously, or we are trying to induce labour.
I’m not saying this because I want to stop anyone trying bumpy car rides or having acupuncture. You do you. And I love acupuncture. But I think it’s important to be clear that all the different means of induction – which include western medicine, Traditional Chinese Medicine, home remedies, holistic therapy – are still induction. The alternative to medical induction isn’t necessarily to choose another form of induction. Though it can be, for some. But the alternative to induction can also be to wait and let your body and baby do their thing. It’s easy to forget this in a culture which over focuses on time and continually devalues patience and women’s bodily processes. More on the over focus on time in In Your Own Time.
This is another issue that I have written about elsewhere if you’d like to know more.
6. Induction of labour is NOT the law!
I was absolutely appalled to hear, part-way through writing an earlier version of my inducing labour book, what one woman had been told.
‘We have to induce you twenty four hours after rupture of membranes. It’s the law’.
The woman agreed to induction when she was told this. She went on to have what she felt was a very traumatic birth experience.
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.
There’s a bit more on rights in my book ‘What’s Right For Me?’ There are also fab organisations around the world that help women to understand their rights. I recommend that anyone who is pregnant seeks out good local sources of information.
7. It’s not ‘just a trickle’ (or a whiff)…
I am always really concerned when I hear midwives, doctors and birth workers using language which downplays the interventions that they are recommending or discussing. I particularly dislike the terms ‘trickle’ and ‘whiff’ when used in relation to intravenous oxytocin (syntocinon).
“It’s just a trickle,” they’ll say.
That sounds very soft and innocent, doesn’t it?
But that’s always not how it feels to your body or baby.
Now, syntocinon is an amazing medication. As a midwife, I am grateful for it and have seen it literally save lives.
But anything that is sometimes lifesaving is, by definition, very powerful. Syntocinon is a very powerful and very overused drug which needs to be respected as such. It can cause the baby to not cope as well with labour. In fact, in some areas the practice is to keep increasing the amount of syntocinon that women receive until the baby reacts and shows that it isn’t coping well any more. It is only turned down then as it is considered that the optimal level has been found. In this situation, the ‘optimal level’ is the maximum dose that can be given before the baby displays signs of stress. This in itself shows you what syntocinon can do to babies’ wellbeing.
But even where this is not done and the syntocinon is only increased until contractions are effective at making a woman’s cervix dilate, it is still a powerful drug that needs to be given respect.
If you weigh up the pros and cons of syntocinon and decide that it is right for you, then great. That’s informed decision making. But its effects should not be minimised by professionals using language that downplays those effects.
More on the pros and cons of syntocinon in Inducing Labour: making informed decisions.
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 Inducing Labour: making informed decisions, we now know that some women don’t respond as well to the drugs used as others because of genetic factors. There are also several other reasons why induction might not work. A key one is that the woman or baby weren’t ready for labour. If they were ready, labour would have begun on its own! That’s a really key thing to consider when deciding whether or not induction is right for you. And it’s not a black or white decision, either. Maybe it’s not right today or this week, but you might want to reconsider the decision in a couple of days, in week or two, or if a genuine problem develops.
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 both Inducing Labour and In Your Own Time, 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 women’s labours.
The simple answer to this is, well it’s complicated.
Sorry about that.
But there is an advantage to knowing that it’s complicated. When you encounter someone who tries to make it sound as if it’s a simple decision, you’ll know to ask some questions.
Here’s an example. 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 were added together that it was possible to see a small difference. And there was still a big question mark about whether induction really made a difference because the quality of the research wasn’t that 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.
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), women who have a higher BMI, women who have been told they have gestational diabetes, and women who conceived by IVF. Some other groups are affected too, but it depends a bit on where you are in the world.
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 … there’s a big but.
That doesn’t mean that induction of labour will improve outcomes. In fact, we don’t have robust evidence demonstrating that it does.
It’s nice to think that it would. It’s nice to think that we can control things, and prevent tragedies. That’s why the offer of induction is so compelling. But sadly, in many of these situations, there’s no evidence that it will help.
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. But this can cause complications, restrict movement, and lead to more intervention.
Older women are also more likely to have other health challenges, which is sometimes called co-morbidity. That means that it is hard to tell whether these problems and/or their age are the cause of poor outcomes.
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.
This issue is such a big one that I devoted an entire chapter of In Your Own Time to it.
What’s the take home message?
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. Some are really happy with their experience, and others much 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.
That’s why I write so much about induction.
If you’d like to find out more so that you can get informed and make the decisions that are right for you, please look at my books.
Inducing Labour: making informed decisions talks the reader through the process and the pros and cons of induction.
In Your Own Time: how western medicine controls the start of labour and why this needs to stop explains how we got to the current situation and looks more deeply at the evidence and issues in relation to topics such as the due date, suspected big babies, and being deemed to be ‘at higher risk.’
I wish you well in your decision making.
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, or you can keep up with my research postings via my free updates and monthly Birth Information Update.