Understanding induction of labour

by | Jul 16, 2021 | News

Make an informed decision about induction

Induction of labour has become so commonplace in Australian hospitals that almost half of all first time mothers are being induced.

National records reveal 45.3% of first time mothers had an induced labour in 2018, up from 31% in 2004, and at least one in three of all births followed an induced labour.

While induction of labour may be medically necessary in some rare circumstances, these high and increasing figures suggest induction is happening not always out of need, but by choice – or coercion, in the Australian maternity system.

And it raises the question, who is making these decisions, and why?

What is an induction?

Induction is the process of artificially stimulating the uterus and cervix in an attempt to get labour to begin.

The process of induction generally involves three main steps, being:

1) Preparing the cervix: Artificial prostaglandins in the form of a gel, pessary or tape may be applied to the cervix in an attempt to soften it. These prostaglandins can cause hyperstimulation of the uterus and result in fetal distress, so hospitals will usually recommend continuous monitoring of the baby, which may restrict the mother’s movement and prevent access to water immersion or upright positioning as natural comfort measures. It can also cause ‘prostin pains’ and irregular contractions. Another method commonly used is the balloon catheter (Foley’s or Cook), which can be described as a water balloon, inserted into the cervix and filled with water to apply pressure to the cervix to encourage it to open.

2) Breaking the waters: An amnihook may be inserted to perform an artificial rupture of membranes, or forcefully break the waters. This may strengthen the induced contractions by causing the baby’s head to press harder against the cervix. Breaking of the waters and any insertions such as vaginal exams may increase the risk of infection or damage to the internal tissues.

3) Causing contractions: In a natural, physiological birth, the labour process releases oxytocin (the love hormone) from the brain, into the bloodstream. Natural oxytocin helps labour progress by regulating contractions of the uterus, and providing natural comfort measures by contributing to the altered state of consciousness or ‘birth high’ associated with undisturbed labour and physiological birth. In an induced labour, artificial oxytocin such as syntocinon (Aus) or pitocin (US) is given intravenously. This synthetic form is unable to cross the maternal blood-brain barrier and only works on the uterus, creating strong and more painful contractions of increased pattern and intensity.

As a result, women are unable to slowly build up natural endorphins and oxytocin, which increases anxiety, pain and hemorrhage risk. The strong contractions can cause distress to the baby, particularly if they’re not yet optimally positioned for birth, resulting in a deceleration in foetal heart rate, and increased need for c-section.

But it doesn’t end there……

Midwife, speaker and research Dr Rachel Reed, author of Midwife Thinking, states physiological placental birth is not safe following a medical induction, because an induced mother doesn’t experience a natural oxytocin rush at high enough levels to make the uterus contract efficiently and close of the vessels from the placental site wound. “Basically, medicine has taken over, and must finish the job.”

Why is induction so common?

One recent study led by esteemed Professor of Midwifery at Western Sydney University, Hannah Dahlen, found at least 15 per cent of healthy mothers were induced with no medical reason. Alarmingly, multiple studies have found the decision to perform these inductions is usually that of the care provider, with women not being routinely engaged in the decision making process, and their expectations and preferences going largely unmet.

Hospital policies and the processes of outdated obstetric-led models of care often don’t align with the latest evidence-based practice or human rights in childbirth.

As a result, birth plans and preferences may be overridden as obstetricians and hospital midwives are pressured to comply with workplace policy. This can include: routine induction at 39 weeks, pre-term inductions for ‘large baby’ or ‘small baby’ diagnosis, time limits on how long labour can continue without intervention, mandatory c-sections for breech presentation, disallowing access to water for labour or birth, forcing labouring people into a reclined position, and many more.

Mothers have even reported their inductions have been scheduled around public holidays, weekends and care provider vacations, purely for the convenience of their care-provider.

People always have the right to decline these recommendations, but many mothers are not aware they have the right to informed consent and that the recommended maternity care is her decision, or they’re fearful of disagreeing with care providers they perceive to be experts of their field.

The risks of unnecessary induction

When medical interventions occur in labour and birth without consent or informed decision making, the potential for birth trauma is dramatically increased. 

One in three mothers in Australia experience birth trauma, which increases the risk of ongoing mental health challenges. Currently one in seven mothers and one in 10 dads experience depression after the birth of their child.

Hannah Dahlen’s study also found induction increased the rate of other interventions and risks, compared to those who went into labour naturally, including:

    • Reduced rate of spontaneous vaginal birth – 42.7% v 62.3%
    • Increased rate of instrumental birth – 28% vs 23.9%
    • Increased rate of emergency C-section – 29.3% vs 13.8%
    • Increased use of epidural – 71% vs 41.3%
    • Increased use of episiotomy – 41.2% vs 30.5%
    • Increased incidence of postpartum haemorrhage – 2.4% vs 1.5%
    • Increased need for vaginal repair – 89.3% vs 84.3%
    • Incidences of neonatal birth trauma, resuscitation and respiratory disorders were also higher, as were admissions to hospital for infections up to the age of 16, suggesting induction may have an affect on the health and immune development of babies.

    By consenting to an induction, mothers are automatically considered ‘high risk’ and treated as such, including continuous monitoring of mother and baby, which means most likely being confined to a bed, and not having the option of waterbirth.

    The increased intensity and timing of contractions also means most people who are induced end up requesting pain relief medication, even if it wasn’t in their birth plan.

    When synthetic oxytocin is used in induction, the uterine muscles never totally relax in between surges, increasing stress on both the mother and baby, which increases the risks of complications.

    All of these elements can combine to derail what would have otherwise been a low-risk birth, and dramatically increase the chances of needing a c-section, and being a traumatic experience for the mother, birth partner and baby.

    What are the medical reasons for induction? 

    Hannah Dahlen’s study shows us that inductions are routinely happening for no medical reason – particularly among first time mothers.

    However, inductions may be recommended for medical reasons if the health of the baby or mother is declining, or would be compromised if the pregnancy continued. It is essential for parents to consider the risks of having an induction versus not inducing, along with consideration of personal values, beliefs and culture.

    The medical reasons that may trigger care providers to recommend induction include:

      • Post-term pregnancy: Approaching two weeks beyond the 40-week ‘due date’, and labor hasn’t started naturally. Although it’s likely induction will be recommended even before this. It’s important to remember the normal term of pregnancy is 37 – 42 weeks.
      • Prelabor rupture of membranes: Water has broken, but contractions haven’t begun within 24-72 hours, depending on the provider’s policies.
      • Chorioamnionitis: Infection of the uterus.
      • Fetal growth restriction or large for gestational age: The estimated weight of the baby is less than the 10th percentile or more than 90th percentile for their gestation.
      • Oligohydramnios or Polyhydramnios: There’s not enough, or too much,  amniotic fluid surrounding the baby.
      • Gestational diabetes: The mother has diabetes that develops during pregnancy, which may increase the risk of baby being larger.
      • High blood pressure: A pregnancy complication characterised by high blood pressure and signs of damage to another organ system such as in preeclampsia, high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy such chronic high blood pressure, or high blood pressure that develops after 20 weeks of pregnancy – gestational hypertension.
      • Placental abruption: Where the placenta peels away from the inner wall of the uterus before birth.
      • Certain medical conditions: Which can include everything from epilepsy and kidney disease to having a high BMI.
      • Foetal distress: Diagnosed after detecting changes to baby’s heart rate – often during labour following the administration of certain medications – including those used to induce or augment labour.

      Foetal distress is a hot topic among birth workers in this situation. It is a common reason for recommending induction, however, foetal distress is also a known side effect of induction drugs. If the baby is distressed, it’s most likely the mother is too, which can make informed-decision making even harder.

      Having a birth partner or doula to support and advocate for the birthing person in these stressful situations can help parents pause to consider their options before consenting to interventions they later regret, or feel pressured to agree to, or coerced into.

      Even in the face of these circumstances, it’s important for parents to research the evidence-based practice for their particular situation, rather than just hospital policy, and make an informed decision about their route of care.

      Options for natural induction 

      So many people come to me looking for ‘natural induction’ methods.

      And I always gently explain that there’s really no such thing.

      Labour happens naturally when a baby’s lungs release proteins into the maternal bloodstream, signalling they are ready to be born. This results in a natural rise of oxytocin levels, triggering the uterus to contract.

      So whether labour is induced medically or physically in a hospital setting, or at home using more traditional methods, it is still a form of intervention.

      f you are facing a medical induction, firstly remember the importance of informed decision making and know your options, including the right to decline.

      Also consider the BRAIN acronym:

      • Benefits: Ask for the evidence-based benefits of their recommendation
      • Risks: Ask for the evidence-based risks, and resources to support them
      • Alternatives: Research the alternatives available to you
      • Instinct: Trust your instincts. What is your intuition telling you?
      • Nothing: And what if you did nothing, or waited a while while you consider your options

      You may also like to try some of these popular natural induction methods first, which have all been used to naturally increase oxytocin and bring on labour gently.

      • Nipple and clitoral stimulation
      • Sexual intimacy
      • Laughter and humour
      • Chiropractic and massage
      • Acupuncture and acupressure
      • Pelvic alignment
      • Herbs and homeopathics

      My closing thoughts

      As a professional birth doula and childbirth educator I encourage my clients to do their research, ask questions and make an informed decision before consenting to an induction.

      I have had many women come to me saying they need to be induced without really understanding why or what it involves. I also regularly have women coming to me sharing disempowering, traumatic experiences from previous inductions, which happened with no medical reason.

      We need to have more conversations, share more information, ask more questions and know our rights!

      The rates of induction are going to continue to rise if we don’t.

      It’s time to become empowered with more information, and be the centre of the decision making during your pregnancy and birth.

      By Shelly Langford | Doula, Birth Educator, Pregnancy Massage Practitioner and Body Worker

As a doula and birth educator, my role is to support birthing families in making informed and empowered decisions about their birth. As part of this process, I want to share the latest evidence-based information and statistics on a wide range of interventions that are now so common, but not always necessary, in the Australian maternity system. And induction is where I often see the cascade of interventions begin. If you’d like support with planning your informed, empowered birth, or you’d like to discuss your options around induction, book a free meet and greet with me

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