I am sometimes surprised at how often I get asked whether, if a woman has her labour medically induced, she can still birth her placenta naturally. My reply to this question usually involves my saying that I am not sure that any part of a labour that follows a full-blown medical induction could accurately be described as natural and that, while I would never want to deny a woman choice, there is a really good reason not to suddenly remove synthetic oxytocin once it has been started. I have written this post to offer a (hopefully searchable) explanation of why I take this position for women and midwives who are looking for information on this, and perhaps to provide a forum for debate if anyone disagrees. (Caveat: if a woman goes into labour after one dose of prostaglandin or having her membranes ruptured, then things might be a bit different, but here I am assuming we mean induction that includes the use of synthetic oxytocin).
Before I answer this question in full, though, I would like to be clear that I am a big fan of natural placental birth. In fact, I co-wrote the book(let). I have attended hundreds of women who have birthed their placentas naturally and would consider my own comfort zone to be really quite wide in this area,. But induction of labour interferes with normal physiology to the degree that I would also consider it inadvisable to suddenly stop an oxytocin drip after a woman had been receiving this for several hours, especially if she had not yet birthed her placenta.
The reason for this is simple: oxytocin is needed to birth the placenta and to keep the uterus in good shape once it has done so, but synthetic oxytocin (as found in the drip used to induce or accelerate labour) inhibits the woman’s ability to produce her own natural oxytocin.
Symphonies and mountain climbing
I have every faith in a woman’s ability to release appropriate amounts of her own oxytocin if she is in natural labour (although, if you are not already aware that oxytocin flows better if women are disturbed as little as possible, I would invite you to read up on this too). But let’s not underestimate how amazing this journey is, and what massively complex and powerful things a woman’s body does to birth a baby. The hormones involved in labour could be likened to a physiological symphony that develops its rhythm and builds to a crescendo over the course of the journey. During the last bars of the ‘labour’ movement of this symphony, pulses of oxytocin help the placenta to separate and birth and enable the now empty uterus to begin to return to a more normal size, which helps reduce bleeding from the placental site.
But this is if labour progresses naturally, and in an induced labour, the presence of synthetic oxytocin inhibits the woman’s ability to produce her own oxytocin. Under these conditions, expecting any woman to suddenly be able to produce enough natural oxytocin to facilitate the birth of the placenta AND the vital postnatal clamping down of her uterus from a standstill is a bit like parachuting someone out of a helicopter to a point halfway up Mount Everest and then expecting them to be able to sprint straight to the top without a chance to warm up or get used to the freezing cold oxygen-depleted air. But (and admittedly this analogy isn’t perfect, but I think it will suffice for our purposes) what if you had also given your imaginary mountain runner unlimited oxygen and a nice big chunk of dark chocolate every ten minutes from when they woke up that morning until they piled out of the helicopter, but then suddenly took away the supply of both just as they started to run? What odds would you give them on reaching the top now?
Induction as a package deal
I know. It’s not always helpful when people make unrealistic comparisons, and I apologise if this sounds harsh, but I think it is important to recognize that induction of labour entails a serious level of intervention which might be best thought of as a ‘package deal’. Although there are some choices which can be made along the way, some of the core elements of it (including repeated vaginal examinations, ongoing fetal monitoring and medical management of elements of labour, such as the birth of the placenta) are an intrinsic and, sorry, fairly necessary part of that package. Even to those of us who spend our lives stretching the fabric and journeying the boundaries. It is not that we’ve stopped trusting women’s bodies. It is that we trust the physiology of minimally-disturbed labour, and the drugs used to induce labour are potent substances which interfere with the ability of women’s bodies to ‘do their thing’. Therefore, where labour is artificially induced, the effects of these drugs need to be monitored and sometimes compensated for.
I really empathise with those women who feel they have no choice about having an induction but wish they did, but I think it is important that women who are considering induction of labour understand the rationale behind the package nature of the deal, as my experience tells me that this is not always explained well. Perhaps my experience isn’t the norm, but I am asked this question so often that I am concerned that the differences between spontaneous and induced labour are not well enough understood. With something like one in five women in the UK (and even more in the US) having their labours induced, I would say this needs to be rectified, because if we are not ensuring that women understand the differences well enough, then how on earth can their choices be informed ones?
Want to read more about induction? My book, “inducing labour: making informed decisions”, which was written for women but is frequently enjoyed by midwives and birth folk too!, is now available in a version for kindle (or other ebook readers) or as a real-life paperback book 😀