Monday, 17 April 2017

Induction - what exactly happens?

Induction is a medical process of artificially starting labour and stimulating uterine contractions.

This week, Gina explains the process of induction, why it can be medically necessary and how to make the right decision for you. 

 

Why does induction need to happen? 


The reasons induction may be recommended vary, and normally it would involve medical circumstances that mean that the pregnancy continuing could pose risks to mother or baby, or both. For example, pre-eclampsia, obstetric cholestasis, diabetes and other conditions are medical reasons that may warrant induction of labour. Also, a woman’s waters breaking without contractions starting for an extended period of time may be another reason for induction to be recommended. The woman’s estimated due date passing is not necessarily a medical indication for induction, particularly when mother and baby are both healthy and well and the placenta is continuing to function well. In circumstances where a woman agrees that it is medically necessary to induce the labour instead of waiting for things to start naturally, the following process takes place.

The Process of Induction

 

1. Have a Sweep

The process of induction may begin with something innocently called a sweep. This is normally carried out in the location where the woman usually sees her midwife. A sweep does not involve any drugs, but it is the first step in the process of attempting to artificially induce labour. A sweep is a vaginal examination which involves the midwife (or doctor) inserting gloved fingers into the cervix (the neck of the uterus), stretching the cervix and sweeping around the edges in an attempt to separate the membrane of the amniotic sac. This may assist in woman’s body releasing prostaglandins, which can prepare the cervix for labour and trigger labour. Sweeps are said to increase the likelihood for labour starting spontaneously within 48 hours. 

Risks associated with having a sweep include: bleeding and discomfort, possible introduction of infection as a result of the vaginal examination and accidentally breaking the waters prematurely.

2.  Prostaglandins Pessary


If the sweep doesn’t get things going, then the woman would be offered chemical induction. This takes place in the hospital maternity unit. A pessary, gel or tablet containing artificial prostaglandins is inserted into the vagina. Similar to the sweep, the aim of this is to prepare the cervix and thereby start labour by triggering contractions. Depending on the pessary, gel or tablet being used and the woman’s circumstances, the woman may be safe to go home to allow the prostaglandins time to work. However, some woman may find that they are asked to stay in hospital in order to be monitored during this process. 

Possible risks or side effects of having artificial prostaglandins include: backache, unusual feeling in the vagina, unusual uterine muscular activity, diarrhoea, nausea, stomach pain, vomiting, rare but sometimes serious allergic reactions and slow or abnormal foetal heart rate and foetal distress.


3. Break the Waters

If the woman’s waters have not broken yet by this stage, and labour has not started or strengthened sufficiently, the midwife or doctor may suggest artificually rupturing the membrane of the baby’s amnotic sac.  A surgical instrument is inserted into the vaginal and it is used to break the sac.  The reason for this is the hope that the waters going may finally get labour going.  

There are risks attached to artificically breaking a woman’s waters including introducing infection.
 

4. Synthetic Oxytocin Drip 


The next step in induction, if the above has not worked, is to put the woman on a drip containing syntocinon (also known as pitocin). Syntocinon is artificial oxytocin. Natural oxytocin is the feel-good, love hormone that naturally causes labour to start and makes the uterine muscles contract. The thing that triggers natural oxytocin levels to rise and start labour is baby’s lung development: baby signals s/he is ready once the lungs are strong enough to breathe independently and early babies often need respiratory assistance. Syntocinon causes uterine contractions, thus artificially producing labour, or it can also be used to strengthen labour that may have started naturally (this is called augmentation).  Unfortunately, the drug syntocinon does not include the feel-good effect that natural oxytocin provides. When a woman is put in the syntocinon drip, she is required to be in the hospital, and she and baby must be monitored throughout the labour. The flow of the syntocinon via the drip is regulated by the medical staff, not by the woman’s body (which is the case with natural oxytocin). The woman may experience a more intense labour on the syntocinon drip because her body is being forced into full blown labour, rather than gradually easing into it which is what happens with a natural labour.  Because the induced labour can be more intense, a woman may find that she needs pain relief drugs including entonox (gas and air), pethidine and epidural.  

The risks associated with being induced using syntocinon include headache, nausea, vomiting, slow or fast heartrate in mother and/or baby, rare but possibly severe allergic reactions, increased risks of tearing,  instrumental delivery and c-section, foetal distress and the risks associated with any pain relief drugs that may be used.  

Considering being induced?

 

As indicated above, there are many risks associated with being induced.  It is a medical procedure that is both useful and life-saving when there is a medical necessity.  Inducing a labour artificially when it is not medically essential can cause unnecessary difficulties and risks, without a commensurate benefit to mother and baby.  So, if you are considering being induced, please inform yourself, start with the the resources below and make use of the helpline on the AIMS website.

Wishing you a calm and comfortable birthing day. 

Gina x 

Gina Potts is Director of ZenBirth – Hypnobirthing UK. She comes from an academic research background, and since 2009 has spent much of her time researching into all aspects of maternity care, pregnancy, birth and women’s postnatal health. In 2011, she founded ZenBirth and has helped hundreds of couples have a positive birth experience. Gina now leads a growing team of ZenBirth instructors who provide antenatal hypnobirthing education courses across London and the South East of the UK.  www.zenbirth.co.uk/gina  


Resources:
•    Inducing Labour: Making Informed Decisions by Sara Wickham. AIMS. 2014.  www.aims.org.uk  

•    http://www.nhs.uk/conditions/pregnancy-and-baby/pages/induction-labour.aspx
•    Midwife Thinking - Induction of labour - balancingrisks
•    Midwive Thinking - Pre-labour rupture of membranes - impatience and risk