Image from thinkbaby.co.uk

Image from thinkbaby.co.uk

How long we cook our baby continues to be an incredibly sensitive subject. The moment we reach 40 weeks there is immense pressure to give nature a little helping hand in one of many different ways to induce labour (more on that later). In fact, 22% births in the UK in 2011-12 were induced. [1]

We have already discussed how cooking times may vary by up to 5 weeks and how our EDD (estimated time of delivery) is calculated, and expected to be, bang on 40 weeks. But that we should have a bit of faith in our bodies at the very least up to 41 weeks if not 42, which is still considered normal term.

So why are we crazy scared that once we hit 40 weeks then we will start “overcooking” baby? Where has this fixation on inducing labour come from?

It really all boils down to risk, and our interpretation of it.

Risks of not having an Induction

After 40 weeks there are risks to the unborn child, such as the placenta deteriorating, and these risks can sometimes mean our bodies don’t keep cooking the baby nicely and in some awful situation in can even result in stillbirth. And it is also true that this risk doubles by 42 weeks. Scary stuff, right? Nobody wants to be in that situation, ever. So, let’s go for that induction as it reduces those risks, or even eliminates them! [2]

Ah, but hang on a minute. Do you understand the difference between relative risk and absolute risk?

This statistic is outlining a relative risk. Yes there is an increase in the risk: it is twice as likely to happen! It is a terrifying thought as you hear “twice as likely” and in our minds we translate this into “there is a massive chance of risk of this happening to me”.

If we look at the absolute risk we can add a bit of perspective. The actual risk of a stillbirth, according to NICE, is 2-3 per 1000 births over 40 weeks, and by 42 weeks that number has gone up to 5-6 per 1000.[3]

Yes, the relative risk has doubled but in real terms this is an increase from 0.3% to 0.6%. These are pretty tiny numbers, especially when you consider that 22% of all labours are started by induction. [1] That is a high percentage of inductions that really doesn’t add up.

Why can we not trust our bodies when even the statistics show we don’t need to be quite so concerned and close monitoring should pick up the few people who fall under the risk? NICE quotes: “…that 469 women would have to be induced to prevent one perinatal death.”[3] So why are so many women being induced when clearly many of them are not at risk at all?

Why are we offered Induction?

Doctors and midwives need a framework. They need to be able to quantify what to expect so they can be alert to possible complications and also teach others how to watch out for them. The guidelines established to help them do their job are published by organisations such as NICE, and they offer a crucial framework to work to. These guidelines are issued to hospitals and many of them embrace them so heartily that what is a guideline of care somewhere along the way becomes a hospital policy.

The NICE guidelines suggest [5] that because of the increase in these risks of stillbirth, induction should be offered to all women from 40 weeks so they can make up their own mind about the risks of waiting for a spontaneous labour. The risk is outlined in easy to understand ways – in relative risk. But absolute risk is often not part of the conversation and is the one that is painting a clearer picture.

Many women make the decision to induce their labours out of fear and misunderstanding about what risk they are exposing themselves to. And Mums-to-be are often so fed up of pregnancy by 40 weeks that many of them are quite happy to undergo an induction just to be more “in control” of their labour and because they feel quite ready to give birth, thank-you very much!

But how often are the risks of induction outlined to pregnant mums? In fact, how often do people opt for an induction without really knowing what it entails, let alone the associated risks?

Risks of Induction

So here are some statistics to help you understand the other side of the story: the risks associated with Induction. Now before I start, I must point out that these risks are not of Stillbirth itself and therefore not a direct comparison. But each scenario must be taken as a whole so lets be sure we understand the full picture for each case.

When you are induced you have to have continual foetal monitoring as it is a very artificial process that the body can’t control and so we have to keep a very close eye on mum and baby to ensure the induction is not too strong. This means mum will have reduced freedom of movement, which goes against all active birth principles of being free to move spontaneously (although you can still have an active birth, many women think that they must lie back on the bed – no, no, NO!).

And you can say goodbye to that water birth.

You are quite likely to need pain relief as your body is not in control of the contractions, and your endorphins – the body’s natural morphine – is unable to keep up with the artificial oxytocin drugs, meaning labour can be very intense and painful, and reduced movement can make this much worse. In fact you are more than twice as likely to have an epidural – 13% have an epidural without induction, 30% have epidural with induction. [1]

And if you have an induction the risk of requiring an assisted delivery (forceps or ventouse) is 19%, as opposed to 13% without induction. Perhaps because you are lying in bed, in great pain and are having to resort to an epidural? And with an assisted delivery, you are highly likely to have an episiotomy (71% ventouse, 88% forceps). [1]

There is much debate about whether there is an increased risk of caesarian after having an epidural. I am not going to comment other than to say some studies say higher some say no difference and I point you in the direction of this reference [6] for a very detailed summary of the discussion. Nevertheless it stands to reason that if you are unable to move or feel your lower body, your chances of having a Caesarian must be higher – but this is JUST MY OPINION and based on logic and common sense rather than any statistics! (Believe me, I looked for stats but, well, there is much debate on this point.)

However, overall, you are twice as likely to need a Caesarian if you are induced. In absolute terms this means 23% of induced labours end in a Caesarian, compared with 11% of spontaneous births – quite a significantly higher percentage than the risk of Stillbirth if you don’t induce! [1]

Of course, Stillbirth and Caesarian are radically different outcomes here – as I said before you can’t compare like for like, but a very high number of people are opting for induction and taking the high risks associated with it, and many more than need to be are ending up with a caesarian to avoid what is, in absolute terms, a very tiny risk of Stillbirth.

Educate yourself

So the scaremongering about your body not working has turned into scaremongering about an induction. Sorry about that. But putting across a balanced view is very difficult in short midwife appointments and I am just presenting the statistics as they are – you should make up your own mind.

Women (and their partners) need to arm themselves with their own knowledge, and educate themselves about their care and treatment to ensure they have the best understanding possible for their own situation.

Induction is not awful. It can be life-saving, essential and just what a mum and baby need. There are many medical reasons why it is necessary and good. It doesn’t always result in a dreadful labour and birth, and can actually take many different forms (more about that later).

But in Birthzang’s opinion, Induction of labour is undertaken far too often and too quickly after 40 weeks considering the risks of what it is aiming to avoid, and is often done for non-medical medical reasons – going over 40 weeks gestation is not a medical reason!

What to do when considering an Induction

If you are over 40 weeks in your pregnancy and thinking about induction there is much you can do to help you make the best decision for you and your baby.

  1. Talk to your midwife about your specific situation and whether the offer of induction is just routine, or whether there is a specific medical reason why you should consider it.
  2. Discuss whether you or your baby are in a specific or imminent danger. If an induction is really urgent, why are so many people booked in and then turned away due to lack of space? Not THAT urgent then.
  3. What percentage of inductions in your chosen hospital result in further interventions, such as epidural, assisted delivery and caesarian.
  4. Ask for those statistics because every hospital has them.
  5. Ask for a copy of your hospital’s Policy for Induction. (You may be able to download it from the website.) It will outline their exact procedure for induction and all the different stages it takes (each hospital has slight variations).
  6. Download and read NICE’s (shorter) guidelines to Induction [4].
  7. Ask what the alternatives are to induction, such as close daily monitoring.
  8. Remember it is not “refusing” an induction, merely “not consenting” to it.
  9. If you still feel uncomfortable, or feel like you just don’t have enough information, get a second opinion.
  10. Make sure you understand what the process of Induction is.

Above all, be an active participant in this discussion. Be an active participant in your labour and birth. Assess the risks for yourself and have faith that your oven has its own thermostat and that bread will pop out of the oven just cooked to perfection!

Active Birth classes help you to tune in to your body and teach you practical and emotional methods to cope with labour and birth, whatever shape it takes. Whether it is a completely natural water birth at home, or a hospital-led labour with pain relief and interventions, you can always use active birth principles to ensure you have a positive birth experience.

Learn more about Birthzang’s Active Birth Workshops at www.birthzang.co.uk/activebirth.

References

[1] Statistics from Hospital Episode Statistics from 2011-2012, I mainly used the spreadsheet of raw data.
http://www.hscic.gov.uk/article/2021/Website-Search?productid=10061&q=birth&sort=Relevance&size=10&page=1&area=both#top

[2] The Cochrane Review, in fact quotes: “A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.” http://www.ncbi.nlm.nih.gov/pubmed/17054226

[3] NICE Full Guidelines for Induction of labour.
http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf

[4] There is also a shorter version of the NICE guidelines to Induction: http://www.nice.org.uk/nicemedia/live/12012/41256/41256.pdf

[5] NICE actually says, “Although the risks of fetal compromise and stillbirth rise steeply after 42 weeks, this rise is from a low baseline. Consequently, only a comparatively small proportion of that population is at particular risk. Because there is no way to precisely identify those pregnancies, delivery currently has to be recommended to all such women. If there were better methods of predicting complications in an individual pregnancy, induction of labour could be more precisely directed towards those at particular risk.” See

[6] “Does epidural analgesia increase rate of cesarean section?” by Michael C. Klein, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1481670/