Inductions of labour - the boogie monster of obstetrics
One of the great misconceptions, and a constant source of tension in women's maternity care, is the notion that an induction of labour is necessarily a bad thing. In fact, it is fair to say that in some quarters women are actively discouraged from considering an induction of labour, regardless of the reasons that induction might be recommended. This is unfortunate as it only seems to add to the anxiety and trepidation that women may feel when the subject of induction is raised and often creates barriers to engagement with obstetric care.
So what are the concerns surrounding induction of labour and to what extent can they be alleviated? In my own experience two principle concerns are commonly voiced to me by women:
1) If I have an induction of labour it will hurt more or be a more intense experience; and
2) If I have an induction of labour I am more likely to end up with either a caesarean section or an instrumental delivery.
Both are entirely valid considerations and my own view is that there are a multitude of variables that need to be considered in addressing these concerns adequately.
A critical variable is the why. Why is an induction being performed? Is there a medical consideration or has the decision been made for non-medical reasons? The distinction is important as it undoubtedly affects the psychology underpinning induction of labour which then feeds into the woman's experience.
When medical considerations arise, whether they be concerns for the woman's health or that of her unborn baby, a layer of anxiety necessarily enters the picture. Will I be alright? Will my baby be alright? These anxieties then feed into the intensity of the woman's experience - by their very nature, medical concerns potentially undermine the prospect of a relaxed mental frame of mind (insofar as any woman feels completely relaxed about the prospect of labour).
Furthermore, given that most medical considerations are reflective of the intra-uterine environment and foetal well-being, there is an unavoidable increase in the risk of further interventions, including caesarean sections and instrumental deliveries. But these reflect the underlying pathology affecting the pregnancy and not the induction process itself. In other words, where a medical concern is present, whether a woman labours spontaneously or is induced does not greatly alter her chances of further obstetric interventions. She is already at increased risk of requiring such steps. The point of an induction in these circumstances is to manage the developing risk associated with the medical issue that is complicating the pregnancy with the aim of striking a balance between in-utero foetal development/maturity vs harm to the pregnancy from the complicating factor.
What then of so called elective inductions - those performed in the absence of overt medical concerns? Here the true controversy arises and advocates on both sides of the equation can point to evidence supporting their diametrically opposed positions: 'caesarean section rates are increased' vs 'caesarean section rates are decreased'; 'instrumental rates are increased' vs 'instrumental rates are decreased'...and the list goes on. Indeed, for women seeking to be fully informed, the inconsistency in the available evidence and the variability in how that evidence is interpreted and presented must be quite frustrating.
Presenting a review of the literature is not the purpose of this blog. Rather, I wanted to offer up my own observations and thoughts as they pertain to elective (meaning non medical) inductions. Of course, most of these thoughts pertain equally to medically indicated inductions.
Firstly, not enough credit is given to the sense of control and agency afforded women who opt to determine the timing of delivery. For many women this is an important motivation driving a request for elective induction of labour and, if we believe in woman centred care, it seems self evident that such choices be offered and supported.
What of the induction process itself? How the induction is managed and approached, including the education leading into the process, makes all the difference.
I have read and heard of women being told that the drugs used for induction of labour are intended to create a quicker than normal labour with stronger and more frequent contractions. Such statements are divorced from good clinical practice and the correct intent of the induction process. Inducing labour is about stimulating labour that is as close in contraction intensity as natural labour. It is not about creating some sort of super labour - I tell my own patients that my goal is not to turn them into some sort of labouring machine . The key to achieving such an induction is careful management with attention to how the woman, and her uterus, are responding. Questions that should be addressed include:
"What is this woman's native contraction pattern?"
For most women it will be 3-4 contractions every 10 minutes - though some will naturally tend towards 5 and others only 2 contractions. The key is carefully assessing the intensity and duration of contractions to determine if the achieved rhythm seems right for that patient. It is not about imposing a cookie cutter approach to her labour.
"Are the contractions achieving the desired result?"
Clinically of course I am referring to appropriate progress of labour.....measured by a combination of cervical dilation and descent and rotation of the foetal head. This is assessed with timely examinations in labour and careful attention to the importance of obtaining all of the clinically significant information that such examinations should reveal Unfortunately it is too often the case that clinicians, medical and midwifery, perform perfunctory assessments that are lacking in all of the relevant findings. This only acts as a disservice to their patients as it renders the clinician incapable of managing the labour optimally.
What the clinician does with this information is the point of the matter. If labour is progressing, great. Of not, then determination of the why is the goal. What should not happen, but all too often does, is that the clinician simply increases the medications driving labour. This is both lazy clinical practice and a significant contributor to poor induction outcomes and experiences.
So then, if a well managed induction of labour simply brings on a natural labour pattern, is the experience largely the same as spontaneous labour? Well, there are of course differences and these need to be acknowledged and discussed with the woman as part of her pre-induction education. The critical differences are:
the anticipation of the event - knowing when things will happen is very different to the 'surprise' of spontaneous labour;
being attached to IV lines (used to administer the labour drug); and
being attached to a CTG (continuous foetal heart rate monitor).
These necessary elements of an induction do impact to some extent upon the experience and mobility in labour - a woman certainly will struggle to pace around the room. Though it has to be said that, with appropriate support, good mobility in labour can be achieved (these days, CTG sensors are available in wireless configurations and IV lines can readily be placed on wheeled supports). Indeed, elements such as the birthing ball and even water immersion are often readily available to women undergoing inductions of labour.
What of interventions? Well, as I implied earlier in this blog, a well managed induction of labour does not increase the risk of other obstetric interventions. This has been well established in the medical literature - indeed, there is even a trend towards a reduction in caesarean section rates as compared to expectant management at term. One important point to acknowledge is that nursery admissions may be slightly increased, however, overall perinatal mortality and morbidity (ie. baby outcomes) are improved. (ref)
Ultimately, when it comes to inductions of labour, education, a collaborative approach to decision making and good clinical management of the induction process determine the experience that a woman has when undergoing an induction of labour.