Let's be clear: labour onset is either spontaneous OR induced!

It’s important to be clear that labour is either spontaneous or induced. And to understand what those terms mean.

I once wrote about this in an article. Here’s what I wrote:

“We need to address the term ‘natural induction’.

Is it me, or is the term ‘natural induction’ an oxymoron?

I do realise that the term ‘natural’ is so laden these days as to be almost meaningless, but I hope you will be able to take my point nonetheless.

I am guessing that most people who use this term actually mean what Hall et al (2012) more appropriately term ‘the use of complementary and alternative therapies for induction of labour’, which I accept is quite a mouthful, especially when the conversation is verbal.

But what do we mean?

But the first part of my concern is that using the term ‘natural induction’ rather than ‘induction using holistic therapies’ might make induction itself sound like it could be a natural, normal thing to do.

I would like to argue – quite strongly if I may – that this is not the case and we should do everything we can to ensure that this does not become the case.

Let’s remember that the ideal is to save intervention for when it is truly warranted, and let’s also not lose sight of the fact that, no matter what methods are used, attempting to induce labour is – by definition – going to involve trying to make labour happen before it would have happened ‘naturally’.” (Wickham 2012)

Weighing up the risks

Trying to induce labour before the baby initiates labour itself has downsides, as I described in In Your Own Time. We can end up with babies who are born too early, and with mums and babies who have intervention and unwanted side effects (some of which are long term) brought about by the induction interventions.

Some people argue that holistic methods are less likely to lead to the sorts of problems that the drugs and interventions that are used in hospitals can led to. To some extent, I would agree, although we don’t have good evidence on that. But anything that can induce labour can cause the baby to be born before it is ready. And it’s important to remember that nature is by no means benign. Many pharmaceutical drugs are based on naturally occurring substances, and some herbal and plant-based medicines can have some very unwanted effects.

If induction was genuinely the best way forward, then a woman may decide that the risks of inducing labour – by western medical or more holistic means – are justifiable.

But this isn’t what’s happening. Induction is increasingly being offered to healthy women for questionable reasons or debatable risk factors. And many women and families are turning to holistic induction methods, or medical outpatient interventions such as membrane sweeping not because they want induction, but because they want to avoid inpatient induction.

Here’s an example

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.

Here’s one example of the problem that we have when it comes to the research being done in this area. This is an older article but the point is still relevant. I have highlighted the key phrases.

Aim: The aim of this study was to evaluate two regimens of administration of sustained-release dinoprostone on the need for oxytocin induction of labor.

Material and Methods: We carried out an open prospective study comparing labor, maternal and neonatal outcomes after 12 h of prostaglandin cervical ripening insert versus 24 h of prostaglandin cervical ripening insert in 284 patients (142 ripenings at 12 h [P12 group] and 142 ripenings at 24 h [P24 group]).

Results: The two groups were demographically similar. There was a significant difference in the need for artificial rupture of membranes/oxytocin induction of labor between the groups (49.3% for the P12 group vs 38% for the P24 group, P = 0.03). The delay between the beginning of ripening and delivery was significantly decreased in the P12 group, but the duration of active labor (6.6 h), the dose of oxytocics used (1326 UI), the rate of cesarean section, the rate of uterine hyperstimulation, the rates of hemorrhaging from delivery, the neonatal state and the experience of induction were similar in the two groups.

Conclusion: This study allows us to show for the first time that sustained-release of dinoprostone leads to spontaneous induction of labor without increasing the obstetrical risk in a majority of patients.

Denoual-Ziad C, Aicardi-Nicolas S, Creveuil C et al (2015). Impact of prolonged dinoprostone cervical ripening on the rate of artificial induction of labor: a prospective study of 330 patients. Journal of Obstetrics and Gynaecology Research 41(3): 370-76.

Can you see the problem?

Dinoprostone is a drug which induces labour.

So the sustained release of this drug cannot, in any circumstances, lead to spontaneous labour.

And there’s no such thing as spontaneous induction of labour.

Spontaneous labour and induced labour are completely different things.

It’s not that this particular research study isn’t useful in its own right, by the way. When I speak about induction, I talk a fair bit about the importance of not giving up on women who are having interventions such as induction of labour. I talk about the things that we can do to increase their chances of having a vaginal birth. Within that context I am always happy to see the publication of research which helps us better understand how we can do that.

I am also respectful of the fact that many of the authors of such studies are not writing in their mother tongue.

But, just as I argued that we need to take care when using the term (or oxymoron) ‘natural induction’, I also want to argue that we need to take care not to use the word ‘spontaneous’ in conjunction with the word ‘induction’, or the action of using any drugs in an attempt to start labour.

Saying that a pharmaceutical intervention leads to ‘spontaneous induction of labour’ is inaccurate, and we need to take care not to begin down such a slippery slope.

We need more nuance

I appreciate that it may be of value to consider the use of cervical ripening agents separately from the use of intravenous oxytocin. I also appreciate that outpatient membrane sweeping is different from hospital induction, and that visiting an acupuncturist or other therapist is different from being alone on the antenatal ward for three or four days.

But these are all still methods of inducing labour.

And we shouldn’t be applying the terms ‘spontaneous’ or ‘natural’ in a context where we are using any drugs or interventions – however holistic – in an attempt to bring on labour.

Induction of labour isn’t a bad thing, if this is the result of a decision made by an informed woman who has decided it is right for her and her family within their individual and unique context. And I’m not criticising or condemning any of these methods.

I just want us to call it what it is.

There’s enough confusion out there already.