How to decide if induction is for you. (pt 1)

Induction. What does it bring up for you?

Have you been offered it?

Are you wondering whether to go ahead or not?

Do you know what it involves and if there are any risks involved?

This is part one of a series on induction this week we will look at the differences between spontaneous labour and induction of labour. Next week we will look at the common reasons induction is offered and the risks and benefits of waiting or accepting induction. Further blogs will look at how to create an induction birth plan and finally natural induction.

The beginning

Induction was introduced as part of medicalising childbirth. There was no supporting evidence for bringing it in to the options for birth. Although there are several reasons for being offered induction there is not a huge amount of research that has been done weighing up the risks of induction over the risks of waiting for spontaneous labour. However, for some medical reasons induction may be the safest option.

Different hospitals will have different protocols when it comes to when and why induction is offered and this is often done to mitigate the risks of legal action taken against it, rather than thinking of the risks to the individual.

For this reason you may feel that you are being told you will have an induction or feel that you are being pushed that way and it can be difficult to get information or to decline.

If you find you are being offered an induction you will need to make sure you are offered the correct information and have the time to discuss with your partner, to look at a variety of information, ask questions and be supported in the decision you make.

What does spontaneous Labour look like?

What starts labour?

It’s largely unknown exactly what starts off labour but common scientific understanding is that it is started off by the baby via a hormone signal to the mother once they are ready for life earthside.

During the final weeks of pregnancy progesterone and a complex mix of other hormones increases which helps to allow the cervix to thin, open and move to allow the baby to be born.

Oxytocin receptors are created on the wall of the uterus so it can respond to the oxytocin and contract.

During these last weeks the baby lays down extra fat for energy to get through labour and to be able to start feeding. Their brains develop so they can breathe, regulate their temperature, feed and sleep. They also receive antibodies from the mother to help guard against infection. During this time their lungs mature so they are able to breathe once they are born.

Contractions begin fairly small to give the body the opportunity to build up the level of the pain killing opiates the body naturally produces, to allow the baby to move into a good position for birth and to allow the mother to find a safe space to labour.

Oxytocin is the hormone that initiates contractions and helps keep the mother calm and increases bonding instinct at birth. Oxytocin is regulated by feedback from the baby, the uterus and the outside environment (and why it is important that women give birth in a calm, low light environment)

The amniotic fluid plays an important role by providing cushioning from the contractions so the baby is not overly stressed and the oxygen supply via the umbilical is not compromised.

As labour progresses a surge of adrenalin is produced by the mother to help with the final pushing stage and for the mother to be able to protect her baby once it is born. This is also known as ‘transition’. It is around this point the waters break and there is a surge of hormones that allow the mother to breastfeed and bond with her baby. The perineum is gently stretched to allow the baby’s head to come out and to reduce the instances of tearing. Once the head is born there is often a pause to allow the baby to turn to get their shoulders out. The surge of hormones allows the mother to feel euphoric and empowered after birth.

Induced Labour

Very different to spontaneous labour as the complex mix of hormones is not produced by the body, so there are three steps to induction:

  1. Ripening the cervix
  2. Breaking the waters
  3. Creating contractions

1) Step 1 – Ripening the cervix.

First, the cervix is assessed to see if it is favourable. The assessment is based on the Bishop Score with the higher the score the more favourable to induction. Although not very accurate it is helpful in working out the next step in the process.

The Bishops score looks at the thickness of the cervix, how open it is, how low in the vagina, how soft it is and the position it is in.

Ripening the cervix is done to allow it to open and to allow breaking of the waters.

Although a complex mix of hormones ripens the cervix in spontaneous labour induction focuses just on prostaglandins – either by trying to encourage the body’s production or by using synthetic prostaglandin.

Membrane sweep or a ‘stretch and sweep’ is often offered before induction is even mentioned but it is useful to know this is not a necessary part of the end of pregnancy and is the first step of induction.

A midwife will perform a vaginal exam and will use her fingers to sweep around the cervix and try to separate the amniotic sac from the cervix.

Risks
It is not gentle and a lot of discomfort is needed to stimulate prostaglandin release. Side effects can be pain, bleeding and irregular contractions.

Amniotic sac can accidentally be broken

 Can cause prolonged pre-labour and painful contractions that can last for days before getting in to established labour.  Which can be exhausting and frustration and often leads on to further interventions.

Effectiveness

It’s hard to tell the effectiveness because we don’t know which women would have gone into spontaneous labour regardless. 1 in 8 women are likely to go into labour after a sweep.


Pharmaceutical

If a sweep does not work the next step is applying prostaglandin near the cervix. It is important that you are given the patient information sheet for the prostaglandin used so you can check for any side effects and risks.

It either comes as a gel or pessary and needs to be given in hospital because you and your baby will need to be monitored closely.

You will have your blood pressure, breathing rate and contractions tested over a 4-hour period.

Your baby’s heart rate will be monitored via CTG for 30 minutes and then 4hours after prostaglandin is given.

Your cervix will be reassessed 6 hours after gel and 12 hours after the pessary. If no change another dose is given. If your cervix is open the next step is to break your waters.

Risks

Sharp pain around the cervix and uncomfortable uterine cramps are common after prostaglandin.

Less common  – nausea, vomiting, diarrhoea and fever.

Very rarely – hyperstimulation of the uterus – this excessive contractions which can be dangerous for mother and baby. The progesterone will be washed out but if the contractions do not slow then caesarean is necessary.

Mechanical

This is often recommended for women at risk of hyperstimulation of the uterus or if prostaglandin has not worked.

An inflatable balloon is inserted deflated and placed in the lower part of the uterus inbetween the cervix and the amniotic sac. It is then inflated with saline solution. Traction is applied by taping the tube of the balloon to your leg. It is designed to create pressure on the cervix to encourage prostaglandin release. It also stretches the cervix which may encourage oxytocin release and stimulate contractions. The cervix will be reassessed after 12 hours.

Risks

Discomfort and cramping although less than pharmaceutical prostaglandin.

Occasionally may break the amniotic sac and may also push baby out of the pelvis which can make breaking the waters more risky as it may cause the umbilical cord to come out before your baby. It may also encourage your baby to move into a less favourable position.

Step 2 – Breaking the waters

A large amnihook, which is like a very big crochet hook is inserted vaginally and used to tear open the amniotic sac. The midwife will use her fingers to make the hole bigger so the fluid is released. There are no nerves in the amniotic sac so this is not painful! For some women labour will start after the waters have been broken, so it is useful to wait before proceeding to step 3.

Risks

 Uncomfortable because of the amnihook being moved around in the vagina and cervix.

Possible bleeding of cervix.

Occasionally the baby’s head will be scratched.

There is an increased risk of infection particularly if lots of vaginal examinations are given.

Step 3 – Inducing contractions

Remember how spontaneous labour involved a complex mix of hormones? Well induction relies on just a synthetic oxytocin, called syntocinon. It acts in the same way on the oxytocin receptors of the uterus. However it is administered by a IV drip so cannot be regulated by the baby, uterus, mothers emotions or the environment.

It also can’t pass through to the mothers brain so you don’t receive any of the calming or bonding benefits (this is why an induction plan is useful so you can plan for creating these circumstances – we will look at an induction plan in part 3 of this series)

It can, however, pass through to your baby’s brain which may alter the baby’s oxytocin system and bonding behaviours such as eye contact and suckling at the breast.

Syntocinon is started slowly as every woman reacts differently to it and the rate is increased every half hour until the uterus is contracting 3 or 4 times in 10 minutes. Once the contraction pattern is established some women can continue without further synoticinon.

Pain from induced contractions is different as it skips early labour and the production of the natural pain-killing opiates.

Unlike spontaneous labour where the contractions change, slow down, reduce in intensity  or even stop to allow the mother and baby to rest or change position, syntocinon is used to keep the contractions strong and regular therefore pain relief might be necessary where it may have not been in spontaneous labour.

Risks

You will have an IV canula and CTG monitor attached so may well hinder how much you can move in labour and may prevent a water birth. Although it is possible to get non-wired  and waterproof CTG monitoring equipment, so it is well worth asking. Also ensure that the IV is inserted in the wrist and in your non-dominant hand so you have a good range of movement.

You may need to have more vaginal examines to determine progress.

Occasionally this fails, it may well be that the oxytocin receptors in the uterus have not had time to develop so contractions can’t be activated. Caesarean will be recommended in this case.

Many women have successful and positive inductions, but conversely many don’t. I feel it is important to know as much about them as possible so you can make an informed decision.

In the next part we will look more closely at the reasons for being offered an induction and examine the risks and benefits of induction versus waiting for spontaneous labour.

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