Women's experiences of cervical ripening

What do women think about cervical ripening?

The volume of medical research on induction swamps the very few studies that seek to ask women about their experiences of this process.

So I was delighted to see the publication of a study which did just that.

Sheila Brown and Christine Furber explored women’s experiences of cervical ripening on antenatal wards.

They did not set up any kind of intervention; they simply interviewed some of the women who had experienced ‘usual care’ during induction for so-called ‘prolonged pregnancy’.

What did we learn?

I can’t say I was delighted to read the results, though.

But I also can’t say I was surprised by them.

Overall, as the authors’ summary shows, the women reported negative experiences of inpatient cervical ripening, and these negative experiences appeared to relate to their senses of being undermined (Brown and Furber 2015).

The seven woman who were interviewed in depth had four key areas of concern. I doubt that these will be a surprise to those working in the areas where these women are cared for either. But it’s important that we research this. And even more important that we share and discuss this kind of information. Women deciding whether or not to undergo induction of labour can then be better informed before they make this decision.

The areas of concern were:

1. Having support and comfort from significant others undermined

Discontent with being separated from partners and significant others resonated with almost all of the participants. Isolation from significant others appeared to be exacerbated at night, even though ward staff, and other women, were present on the ward:

… and I could hear all the other women around me all moaning … crying … doing the same thing … everyone’s all in pain at the same time, but you’re on your own … and them literally having their heads [the staff] popped around the corner, every, like once an hour … wasn’t nice really. But at the same time you just think, well, this is all you can have … you can’t have any more. [Participant 1 (P1)] (Brown and Furber 2015).

2. Understanding of the procedure undermined

The main issue appeared to be a lack of awareness that partners would not be allowed to remain with women on the ward during for the duration of the procedure:

…it wasn’t quite what I, what we were expecting. I mean we didn’t realise until we got there that he wasn’t allowed to stay with me the whole time. [P1]

The potential for the procedure of cervical ripening to extend over a few days was also not made clear to women:

I wasn’t really told that, you know, it could take three days for you to actually go into labour. [P4] (Brown and Furber 2015).

3.The women’s perception of their own physiological sensations was undermined

The approach to assessing whether there had been progression beyond cervical ripening seemed to be guided by rigid criteria. Midwives appeared to disregard women’s own perceptions and descriptions of their physiological sensations. In other words it appeared, from participant accounts, that no matter what symptoms and sensations individual women described, external assessments by caregivers prevailed:

To be honest I felt like everything was a paper exercise, because I wasn’t fitting into the right boxes, you know the boxes couldn’t be ticked properly. Then I was just kind of left to it basically, until everything was, sort of, lined up on the chart properly for me to go through to the next stage. [P1] (Brown and Furber 2015).

4. The women’s sense of freedom was undermined

All participants reported that they were encouraged by caregivers to mobilise during the time they spent on the antenatal ward. Participants’ feelings of freedom to mobilise appeared to be compromised within the ward environment; their sense of freedom to mobilise appeared to be facilitated by leaving the ward environment:

I think I spent more time out of the ward that I did in the ward, “cause I just wanted to be walking and walking.” [P7]

Leaving the ward during the night appeared to be problematic:

…I tried walking around at night time, “cause I was so bored once, and then like no one’s around. So then you’re a bit like, “Ohhhh, I’ll just go back” … “cause if no one was around and if you fell or anything, you know. [P5] (Brown and Furber 2015).

It is also worth noting that some of these women spent a considerable amount of time on the antenatal ward before they moved to the labour ward. The woman who was on the antenatal ward for the shortest length of time, 12 hours, was having her fourth baby. The two women having their second babies spent 13 and 52 hours on the antenatal ward, and the four women having their first babies spent

Sara Wickham’s bestselling book explains the process of induction of labour and shares information from research studies, debates and women’s, midwives’ and doctors’ experiences to help women and families become more informed and make the decision that is right for them.

19, 19, 25 and 72 hours there. Although the number of women in this study is too small to be the basis of any generalisable numerical results, I would say from experience that these time spans are not unusual. When women write or speak to me about their experiences of induction of labour, this is one of the things that they particularly mention not having been told about.

The authors of this study offer a useful discussion about the implications of their findings, which are complex. Some of the women felt safer on the ward even though they felt restricted by the policies there. The possibilities of offering outpatient (sic) cervical ripening and providing areas where partners can stay have been suggested, although the former is often seen as less than ideal from a safety perspective. I would like to humbly offer – amidst my thanks to the authors for a really useful study – another possibility, particularly as these women were not experiencing particular health or pregnancy-related problems but were having their labours induced simply because they had reached a certain point beyond their ‘due date’. Rather than only thinking about how we can make cervical ripening more palatable, it might be that women may wish to consider whether induction is right for them at that point, or whether they might prefer to wait a bit longer for labour to start spontaneously. Especially as the first couple of days of the induction process are likely to be spent sitting, often without loved ones, on the antenatal ward.

Brown SJ and Furber CM (2015). Women’s experiences of cervical ripening as inpatients on an antenatal ward. Sexual & Reproductive Healthcare, doi:10.1016/j.srhc.2015.06.003