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Induction of Labour – The Risks of Labour Induction
“A wizard is never late, nor is he early. He arrives precisely when he means to.” — Gandalf
Maybe you’re tired of being pregnant and sick of being so uncomfortable. You’ve been patiently waiting for this beautiful, tiny baby growing inside of you, and you really don’t want to wait any longer.
Perhaps your obstetrician won’t be available at the time of your ‘guess’ date or has put an induction on the table so you don’t have to be so uncomfortable any more. But labour is going to be pretty uncomfortable too, and caring for a newborn can be just as tiring and exhausting, if not more! Yet the sound of an induction suddenly becomes enticing and somewhat seductive.
Having an induction of labour (or in medical shorthand IOL) isn’t as simple as having a quick procedure to make labour start instantly, as it would if started on its own. Normal, natural labour involves a magnificent ‘dance’ of hormones released by mother and baby, which work together to get the process going and established. Not only do you need the labour hormone, oxytocin, to be circulating in your body, but your uterus also needs oxytocin receptors to be activated, something that only happens once labour is established, which takes time. Because your body may not be ready for labour, high amounts of artificial oxytocin (going by the drug name ‘syntocinon’ in Australia or ‘pitocin’ in the United States) may be needed to get labour going. And that in itself poses a risk to you and your baby, something that is often conveniently left out by your carer.
“Inducing labour involves making your body/baby do something it is not yet ready to do. Before agreeing to be induced, be prepared for the entire package i.e. all the steps. You may be lucky enough to skip one step, but once you start the induction process you are committed to doing whatever it takes to get the baby out… because by agreeing to induce you are saying that you or your baby are in danger if the pregnancy continues. An induced labour is not a physiological labour and you and your baby will be treated as ‘high risk’ – because you are.” — midwifethinking.com
It’s important to be aware that unlike naturally produced oxytocin, syntocinon does not cross the blood / brain barrier, therefore, it does not have the same benefits as natural oxytocin. Another important point is that labour induction doesn’t always work every time; some inductions become ‘failed inductions’ and require a stronger form of induction, or for some, an emergency caesarean section.
A midwife from a large Melbourne hospital confided that they see many women come in for inductions where both mother and baby are well and the reasons for induction aren’t clear cut, but sadly somewhere around 50-60% of first-time mothers being induced are ending up with emergency caesareans.
Doctor Andrew Pesce, former president of the Australian Medical Association, backs up the reality of that comment – he has been quoted in the media saying that avoiding inducing first-time mothers could help reduce the caesarean section rate. This was after an American study was published in the journal ‘Obstetrics & Gynecology’, which found that women who had their labour induced were twice as likely to need a caesarean. He also said, “People should also stop assuming that because a woman has had one caesarean, she has to have another – a vaginal birth is possible in most cases.”
Inductions Of Labour – Not Always Bad
This article is not for those who need an induction of labour for genuine medical reasons, for example pre-eclampsia. Don’t get me wrong, I am not trying to scare people about inductions. But if you have a choice, I think its extremely beneficial to learn all that you can before deciding on or accepting a medical procedure, because while we might all know that the outcome is baby being born one way or the other, we all don’t know the risks.
An induction has only one advantage. When given for true medical reasons, it may potentially save the life of a mother and or her baby. Of course, in a life threatening situation, we are all going to choose to induce – there is no argument that an induction would then be the best choice. Just like a caesarean, it has a place in life-threatening situations – and for that we are more than grateful, myself included.
However, with an induction for social reasons, convenience or without evidence cited by your doctor, I encourage you to seriously think twice. I don’t mean evidence such as ‘well you’re 10-days overdue, we should book you in for an induction now, because some babies die if they are overdue.’ We know that estimated due dates are inaccurate – only 3% to 5% of babies are born on their ‘guess date’ and full term is classed as up to 42 weeks of pregnancy. So for your baby to be born safely when he should be – when he is ready – you need supporting evidence that things are not safe to continue before intervening. This may be in the form of symptoms from your body, your baby or some abnormal test results, which means you need to discuss a plan of action.
Ultrasounds can be done to check the placental function as well as amniotic fluid levels. You can agree to more frequent monitoring, involving you coming in to have the baby’s heartrate monitored for a short period of time. At the end of the day, babies are designed to be born – mother nature has worked so well for millions of years. If she designed babies that refused to come out, then we’d have a population problem. But that’s not the case at all.
An induction only introduces real risks to what could be a perfectly normal birth. It greatly increases the likelihood of further interventions, from pain relief to emergency caesareans, as well as complications as a result of those things (infections for example, which are becoming harder to control). Every day, more obstetricians are admitting to the clear link between induction of labour and caesarean section.
If you have an induction, you are absolutely guaranteed to have other forms of intervention and you will require continuous electronic monitoring. Continual electronic fetal monitoring has been proven to increase the rate of caesarean section without improving outcomes.
In a recently updated review (2013) featured in the Cochrane Library, they have again concluded:
“Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. There was no difference in the incidence of cerebral palsy, however, other possible long-term effects have not been fully assessed and need further study.”
You can read the Cochrane review which has all the details of this conclusion here.
All of these above interventions can increase the risk of maternal dissatisfaction, post-natal depression and post-traumatic stress disorder – and the number of women experiencing these things is increasing rapidly.
Induction For Gestational Diabetes
Even where there is a medical condition involved, for example, gestational diabetes, it is worth studying and asking your obstetrician and / or midwife to see if induction is going to offer more risks than benefits. The American College of Obstetricians and Gynecologists has published a study, which you can read here (which you might wish to print and show your Obstetrician), which concludes:
Based on data from observational studies, labour induction for suspected fetal macrosomia (large baby) results in an increased caesarean delivery rate without improving perinatal outcomes.
“Summary statistics for the nine observational studies showed that, compared with those whose labor was induced, women who experienced spontaneous onset of labour had a lower incidence of cesarean delivery and higher rates of spontaneous vaginal delivery. No differences were noted in rates of operative vaginal deliveries, incidence of shoulder dystocia, or abnormal Apgar scores in the analyses of the observational or randomised studies.”
Apart from this, not many Gestational Diabetes babies or other babies believed to be ‘huge’ finish being born abnormally ‘huge’. I have heard more stories of these babies being born early through recommended inductions only to arrive tiny, of average size or to have breathing problems because of unexpected pre-maturity. One Midwife recalls a birth in early 2006:
“Overuse of inductions is a real concern to me. So many women coming in for induction and the reasons seem so vague sometimes. I was involved in a birth a few weeks ago where the woman was induced because of previous macrosomic (big for dates) baby. She had gestational diabetes with that pregnancy and previous shoulder dystocia (first baby, this was her 3rd). We attempted induction at 36 weeks and it failed. Induction was again attempted at 37 weeks, which was successful – baby was only 2750 g – hardly macrosomic! The ultrasound had estimated a baby weighing 3500 g so it wasn’t even close. I think if she had that baby at the first induction attempt at 36 weeks it would have had to go into Special Care as it would have been less than 2500 g, which is our cut-off. Frightening.”
This is a brilliant article on Gestational Diabetes by Henci Goer, an academic who wrote The Thinking Woman’s Guide to a Better Birth and Obstetric Myths vs Research Realities, both of which are excellent books.
Induction For Large Baby or Small Pelvis
If you are told your ‘huge’ baby won’t fit through your ‘small’ pelvis, well, this is an old-wives tale that was circulating even before our mothers birthed, but controversy began when these women started birthing subsequent babies at home – with no troubles whatsoever! Trying to find how big your pelvis is and if it is capable of birthing your baby is something that no scan or X-ray can detect during the pregnancy, because lying on a bed and being flat on your back is not the ideal position for being able to open your pelvis.
By squatting, it opens your pelvis and gives you up to 30% more pelvic capacity (Janet Balaskas talks about this in her excellent book, New Active Birth), which is not the way these testing procedures are done. It’s also impossible for them to see the effect of Relaxin in your body, as it works its magic in labour. Relaxin is a hormone, which helps soften your joints and makes you more flexible and open for the birth – your pelvis does what it needs to get your baby born – trust mother nature! For more information on this topic, you can also read our article Small Pelvis, Big Baby – The Truth About CPD.
Induction For Being ‘Past Your Due Date’
You are most likely to be offered an induction if you are post-date, remembering that a full-term pregnancy is defined as 37 to 42 weeks. The estimated due date you are given is only a ‘guess’ in the middle of that. Contrary to belief, your baby (and the placenta) don’t automatically expire like a use by date when they hit that magic ‘guess date’. Many women and men (understandably) become fearful of the risk of stillbirth if they go ‘too far over’ the baby’s estimated due date. However, in the study ‘prospective risk of unexplained stillbirth in singleton pregnancies at term’, published by the British Medical Journal, they actually found that inducing babies earlier increased risk. Its helpful to bear in mind that the risks are generally low, but according to this study, your baby has less chance of stillbirth at 42 weeks of pregnancy than 38 weeks of pregnancy.
35 weeks is 1:500
36 weeks is 1:556
37 weeks is 1:645
38 weeks is 1:730
39 weeks is 1:840
40 weeks is 1:926
41 weeks is 1:826
42 weeks is 1:769
43 weeks is 1:633
They commented: “Interestingly, at 38 weeks the risks of stillbirth near term exceed those at 42 weeks, when delivery is usually recommended. Delivering women routinely at 38 weeks would lead to a high incidence of caesarean section with its attendant risks, either primarily or from failed induction, in addition to a small risk of iatrogenic neonatal respiratory morbidity.”
Inform Yourself About the REAL Facts of Induction
Inductions of labour trigger the cascade of interventions. What is that exactly? The excellent clip below has been taken from the documentary, The Business of Being Born (essential viewing for anyone having or planning to have a baby – just make sure you have the right region DVD or watch it in live streaming). Several women (including talk show host Ricki Lake) speak of their experiences with pitocin and other induction drugs, followed by an easy-to-understand cartoon which explains how inductions can quickly result in an emergency caesarean section. Check it out below.
It’s important to research, research, research – discover if the reason for your induction is warranted and what evidence there is to need it – now. A good sign of an emergency is urgency from your carer. If they are sitting there in front of you asking you what you want to do, or are having a relaxed conversation with you, then clearly they don’t think this is urgent enough. Question everything. Get yourself informed and empowered about the effects of an induction for both mother and baby during labour and post-birth. The BellyBelly forums now have an Induction Education & Information forum for women unsure about induction choices, or are seeking advice or information on their situation.
Dr. Marsden Wagner who for 15 years was the Director of Women’s and Children’s Health for the World Health Organisation (as featured in the DVD, The Business of Being Born) has this to say about the seduction of the induction and what the Doctors aren’t telling you:
“What are these aggressive, invasive obstetric interventions that have been proven scientifically to cause permanent damage to the pelvic floor and urinary tract and also lead to more, otherwise unnecessary, Caesarean section? One example is the use of powerful and dangerous drugs to start or accelerate labour, a practice that has doubled during the past 10 years. These drugs make labour abnormal with violent contractions that can damage the uterus and pelvic floor. The only reason women agree to such induction is because they are not told the truth about the drugs, for example that Pitocin (artificial Oxytocin, known as Syntocinon in Australia), a drug used for decades to induce labour, doubles the chance the woman will have urinary incontinence in the future. By withholding such facts Doctors seduce to induce.”
Obstetrics is one of the least evidence-based and studied medical professions, which may be surprising to you. Why? Watch this from the magnificent, but sadly late, Marsden Wagner:
You can watch the full documentary, The Business of Being Born, HERE.
How Synthetic Labour Hormones Differ To Natural Labour Hormones
Knowing about how induction can affect you and your baby is not limited, not only medically but also physiologically. Induction can even interfere with Endorphin (hormone of pleasure and transcendence) production. The following few paragraphs are excerpts from Dr Sarah Buckley’s article, Ecstatic Birth (references to evidence and text can be found in the article as linked).
Synthetic oxytocin (oxytocin is the labour hormone) administered in labor does not act like the body’s own oxytocin. First, Pitocin-induced contractions differ from natural contractions, and these differences can have significant effects on the baby. For example, waves can occur almost on top of each other when too high a dose of Pitocin (Syntocinon in Australia) is given, and it also causes the resting tone of the uterus to increase.
Such overstimulation (hyperstimulation) can deprive the baby from the necessary supplies of blood and oxygen, and so produce abnormal FHR (fetal heart rate) patterns, fetal distress (leading to cesarean section) and even uterine rupture. Birth activist Doris Haire describes the effects of Pitocin on the baby:
The situation is analogous to holding an infant under the surface of the water, allowing the infant to come to the surface to gasp for air, but not to breathe.
These effects may be partly due to the high blood levels of oxytocin that are reached when a woman labours with Pitocin. Theobald calculated that, at typical levels used for induction or augmentation / acceleration, a woman’s oxytocin levels become 130 to 570 times higher than she would naturally produce in labour. Direct measurements do not agree, but blood Oxytocin levels are difficult to measure. Other researchers have suggested that continual administration of this drug by IV infusion, different from its natural pulsatile release, may also account for some of these problems.
Second, oxytocin, synthetic or not, cannot cross from the body to the brain through the blood-brain barrier. This means that Pitocin, introduced into the body by injection or drip, does not act as the hormone of love. However, it can interfere with oxytocin’s natural effects. For example, we know that women with synthetic oxytocin infusions are at higher risk of significant bleeding after the birth and that, in this situation, the numbers of Oxytocin receptors in the labouring woman’s uterus decreases, so her uterus becomes unresponsive to the post-partum Oxytocin peak that prevents bleeding. But we do not know the psychological effects of interference with the natural oxytocin that nature prescribes for all mammalian species.
The Doula Book, by Klaus, Kennell & Kennell, contains a study on Doulas and induced labour in Cleveland, USA. The overall epidural rate for those who were induced was 81% and Caesarean rate 43%. This includes women who had professional support people with them and others without.
Artificial Oxytocin And How It Affects Baby
ACOG (the American College of Obstetricians and Gynacologists) has published on its own website details of a study presented to them about the effects of Pitocin on a baby (something that is not given anywhere near enough attention considering it’s purpose) with the researchers saying that it is the first study of its kind to present data on the adverse effects of Pitocin use on newborns.
The study included more than 3,000 women delivering full-term infants from 2009 to 2011. The primary investigator, Dr. Tsimis, said, “As a community of practitioners, we know the adverse effects of Pitocin from the maternal side, but much less so from the neonatal side. These results suggest that Pitocin use is associated with adverse effects on neonatal outcomes. It underscores the importance of using valid medical indications when Pitocin is used.”
Researchers found the use of synthetic oxytocin was linked to NICU (newborn intensive care) admissions for full term infants and lower APGAR scores.
Inductions, Uterine Rupture & VBAC (Vaginal Birth After Caesarean)
As mentioned above, a risk of induction is hyperstimulation which may result in uterine rupture – something most doctors are ‘scared’ of happening if you’ve had a previous caesarean (less than 1% risk of rupture for previous c/s). So why is it that women wanting a VBAC get such rank pulled over them or hurdles placed in front of them for less than 1% risk when doctors seem to have absolutely no problem with handing out induction offers to all and sundry, knowing there is a rupture risk for that too?
My personal opinion is that because of the mess obstetrics made with inducing VBAC women with misoprostol (a drug used for terminations) in the 1990’s, causing all those ruptures and stillbirths, they have scared THEMSELVES off trusting women’s bodies, all because of a lack of study before using a dangerous drug – and this is not the first time they have ‘experimented’ on pregnant women.
Women pregnant for the first time need to be aware that if their induction turns into a caesarean section, it can effect your choices next time – you may have to fight for a normal birth if that’s what you would like to do. Because it’s not ideal for VBAC women to be medically induced, a repeat caesarean is often touted as the only option. There are many restrictions placed on VBAC women in labour, so if you want to have an empowered, normal birth, you’d be best to research your options and consider an independent midwife or pro-vbac doctor (check for any restrictions they have).
I’m not trying to portray an anti-obstetrics message here, because you need to trust your carer to do the best for you. But what I am trying to strongly get across is you cannot hand yourself and your baby over to your doctor on a silver platter. You need to be responsible for yourself, your baby and your rights. You need to do your research so you can decline procedures based on evidence and what you feel is right for you.
Being Offered An Induction
A very important thing to consider when being offered a medical induction is risks vs benefits. Ask yourself this: ‘What risks am I happy to accept in relation to the benefits?’ This is a very personal question and there is no right or wrong answer for YOU, but for a healthy, low risk pregnancy, the likelihood of a medically required induction is low.
Ultrasounds are notoriously inaccurate for pinpointing the day of birth (around 3% to 5% of babies are born on their guess date). Ultrasounds are plus or minus 7 to 10 days either side of the estimated due dates. This results from calculating these dates based on mathematics and averages, not your baby and the unique rate at which he or she grows or your unique cycle. Even first-trimester ultrasound can be inaccurate by 5 days either side and not every woman has a 28 day cycle, ovulating on day 14.
Babies can be born from inductions unexpectedly premature (namely, were not as advanced for dates as ultrasound detected) based on miscalculated guess dates, then might have breathing problems resulting in artificial-breathing assistance, not a pleasant experience for all involved. They may also be more prone to infection.
Another reason your baby might not have arrived when you expected is that occasionally the problem is anxiety or stress in the mother resulting in the slow onset of labour. You need high amounts of oxytocin in labour and adrenaline is not helpful to oxytocin production. Imagine a set of scales – as adrenaline goes up, the oxytocin goes down. When you have low adrenaline, the oxytocin can go right on up and get that labour going.
You might be familiar with the ‘flight or fight’ response we have as human beings. If we feel anxious, unsafe or afraid, our body produces adrenaline, which pumps blood out to our limbs ready for escape or action. This means the response prevents more blood going to important locations for labour, including the uterus. Labour just shuts off or slows. In ‘flight or fight mode’, we don’t want our babies to come until we are in a safe place so we can ‘let go’.
The information below, on reasons for induction, was compiled by Midwife, Brenda Manning.
Doctors may suggest an induction for any of the following reasons, according to their opinions and / or beliefs:
- ‘Post-dates’ (which varies, but most doctors recommend an induction about 7 to 14 days past your due date)
- Where continuing the pregnancy poses a threat to the mothers health (mental or physical)
- Pre-Eclampsia / high blood pressure
- Multiple pregnancy
- Blood group incompatibility
- Foetal and / or maternal compromise
- IUGR (inter-uterine growth restriction) or a small-for-dates infant
- Foetal abnormality
- Chronic renal disease
- Abnormal liver function tests
- Blood dyscrasias
- Previous stillbirth
- Fetal death in utero
- Poor past obstetric history (complications and / or lost or damaged babies)
- Membranes rupture but no labour after 72 hours, less if you are GBS positive (this period differs between hospitals)
- Where continuing the pregnancy is harming your baby, namely, it isn’t growing or is unwell and would be safer out than in.
- Antepartum haemorrhage (not placenta praevia)
- Large-for-dates infant
- Placental insufficiency
Cases where an induction is not clinically advisable:
- Abnormal presentation (for example, transverse)
- Fetal distress
- Placenta praevia
- Cord prolapse
- Vasa praevia
- Social reasons
- Obstructed labour
Reasons induction of labour may be requested but is not appropriate / best for your baby:
- Social – namely, convenience or just wanting to know the date your baby is coming
- Maternal age – namely, inducing you because you are ‘older’
- Because it is your caregivers ‘standard management’
- For hospital convenience (unless lack of anaesthetic cover is a consideration)
- Mother being “over it” or sick of waiting
- Doctor / midwife going on holiday / golf / conference / disruption to consulting sessions
- Partner going on holiday
- Family staying from out-of-town and needing to return home
- Wanting your baby born on a specific date
- Wanting a smaller baby (unless medical indication)
- ‘9 to 5 obstetrics’ – some hospitals, mainly private ones, have a 90% induction rate termed 9 a.m. to 5 p.m. obstetrics, so the care-giver is not woken overnight to attend births.
Methods of Induction
Your labour can be induced in several ways, dependent upon your cervix and if it is deemed ‘favourable / ripe’ (a slightly open cervix), or ‘unfavourable / unripe’ (a closed, long cervix). A midwife or doctor examines you to determine this.
Your doctor may not tell you about some risks listed in this section, and it may seem worrying or disturbing, however, if you were to be given a packet of the drugs used for the induction, that’s what you’ll get on the included drug information about its use and effects. It is not intended to frighten anyone, but to help you make a balanced, informed decision based on the risks or benefits. Of course, when used for life-saving benefits, there is no risk we wouldn’t take. But if your or your baby’s life is not in danger, it is worth considering if it’s worth the risks to you and your baby.
1. Sweeping Membranes / Stretch & Sweep
If you have a ‘favourable’ cervix this may be offered to you first as a ‘drug-free’ induction with fewer side effects and risks compared with other methods. It’s not usually painful but may be uncomfortable and result in some bleeding afterward. Sweeping the membranes involves a vaginal examination, your Doctor or Midwife places his / her finger inside your cervix and ‘sweeps’ the membranes to separate it from your cervix. It is said to be effective, often within 48 hours of the sweep. A ‘stretch and sweep’ is the same sort of procedure, only your cervix is also stretched at the same time.
2. ARM (Artificial Rupture of Membranes)
Should your cervix be favourable and your baby is in the pelvis, this choice may be given to you for an induction. The waters are broken in the hope this leads to labour, however, you are often given a short time for contractions to establish – sometimes only an hour or two – before being put on an IV (intravenous) Oxytocin drip. Of course, once the membranes have been ruptured, you are also on a time line as your chance of contracting an infection is increased. Some midwives have also noticed that the early rupturing of the membranes can result in more posterior or malpositioned babies.
It is important that the baby is in a good position before the membranes are ruptured – if the baby is too high, there is a risk of cord prolapse, where the baby’s umbilical cord slips through the cervix before the baby, putting pressure on the cord. This can be a very serious situation as the baby’s blood and oxygen supply becomes compressed.
If your labour is not progressing after the membrane rupture, you are probably going to have a Syntocinon drip put up (which you can consent to or not consent to – it is your body and your choice), possibly followed by pain relief and depending on the option you choose for pain relief, you may require help by way of an instrumental delivery. All this is called a ‘cascade of intervention’ where one intervention leads to another and another and so on. However, some women go on to labour well and not require all these things – it’s just something to consider from both sides.
3. Artificial Oxytocin (Pitocin, Syntocinon)
Syntocinon is administered through an intravenous drip and may be used if your waters have broken but there are no contractions, or if contractions don’t start on their own. Because you are having this drug, you must be monitored continually as your Doctor needs to know what effect this is having on your baby. So if you planned to have an active labour and move around freely, this could leave you confined to the bed. Being restricted to the bed, reclining or semi-reclining during labour works against gravity and is not helpful to the normal processes of labour. It also means that you won’t be able to use a bath and probably a shower for pain relief too. You can still use a bath and shower for pain relief with intermittent monitoring; it’s just more awkward so it depends on the hospital and staff available at the time.
It may be argued that you can be induced starting at a low dose, which may bring you some comfort at the time. But this ‘low dose’ can be continually increased during your labour, usually every half an hour the dose can be doubled – so you can imagine how quickly this builds until you start labouring at the rate required and so your labour keeps progressing. Once you are on an Oxytocin drip, most Doctors say that unless your baby becomes distressed, they want the drip on until your baby is born, so your labour doesn’t stop. So if you decide you don’t want it after an hour or so, or it gets too much, know that you do have the choice and power to have it turned down or turned off – however, if your labour slows or stops they want it back up again. Sometimes it just takes some Syntocinon to get labour going, however, by accepting an induction in this way you do risk requiring the drip for the whole labour.
BellyBelly midwife, Alan Rooney suggests, “an example of a dose you might have prescribed is 10 u of Syntocinon added to 1000 ml of fluid. The drip rate is usually started at between 15 to 30 ml per hour. It is then increased by between 15 to 30 ml per hour every 30 minutes. So if we were to start with 30 ml per hour, after 30 minutes the rate would be raised to 60 ml per hour, and after 1 hour the rate would be raised to 90 ml per hour.”
Side effects include:
- Hypotension (low blood pressure)
- Water intoxication
- Hypertonic uterus
- Uterine rupture
- Uterine inversion
- Heart abnormalities
- Because it acts on the smooth muscles asthma could be a problem
This excerpt is taken from the packaging of Syntocinon, which has been recently updated:
The following adverse reactions have been reported in the mother: Anaphylactic reaction, Postpartum haemorrhage, Cardiac arrhythmia, Fatal Afibrinogenemia, Nausea, Vomiting, Premature ventricular contractions, and Pelvic Hematoma.
Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.
The possibility of increased blood loss and Afibrinogenemia should be kept in mind when administering the drug.
Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.
The following adverse reactions have been reported in the foetus or infant:
Due to induced uterine motility: Bradycardia, Premature ventricular contractions and other arrhythmias, Permanent CNS or brain damage, and fetal death.
Due to use of Oxytocin in the mother: Low Apgar scores at 5 minutes. Neonatal jaundice, and Neonatal retinal haemorrhage.
If your cervix is not ripe or favourable, prostaglandins are likely to be used to soften and open your cervix. Should this be effective and your cervix becomes at least slightly open, your waters can then be broken (ARM – see above). Prostaglandins may need several doses to work, so you may be asked to come in for extra doses. Various prostaglandins are used in hospitals, with the most common two being in gel and pessary form as described below.
Once the prostaglandin has been administered, you are advised to lie down and rest for about half an hour. A Midwife monitors your baby’s heart rate (CTG) as well as check your blood pressure and pulse regularly before and after administration. You are also given a further vaginal examination to check your cervix.
Some rare side effects include nausea, vomiting or diarrhoea. Following the Prostaglandin application, if all is well occasionally you may go home while awaiting its effects.
Prostin gel – Prostin gel is placed in the vagina near the cervix during a vaginal examination. It works by softening and dilating the neck of the womb and stimulating contractions. A second vaginal examination is performed to check your cervix. If your cervix has opened the Doctor or a Midwife may be able to break your waters. You may need another dose if there has been little or no movement. Prostin Gel may result in ‘Prostin-pains’ once applied, which isn’t established labour and may be uncomfortable. Uterine
Cervadil Slow Release Pessary – Cervadil is inserted into the vagina and placed behind the cervix as a pessary, similar to a tampon – it has a tape that hangs for removal.
The pessary is removed if:
- Hyperstimulation occurs
- Your waters break
- Labour establishes
- 12 to 18 hours has passed
Following its removal you may then be recommended to have your waters broken, if they haven’t already, and / or be put on a Syntocinon drip.
Side effects include:
- Hypertonic uterus
- Uterine rupture
Still not sure what to do? Well imagine if your baby could make the decision for you. Would he / she prefer to go through a harder induced labour over a natural one? Would you prefer to go through a harder, induced labour than a natural one? An induced labour makes the uterus work hard, producing long, strong contractions. While some mothers feel that their induced labour was no different from a normal labour, many mothers who have had both induced labours and non-induced labours feel that their induced labour felt as if they were completely out of control, which resulted in pain relief when they didn’t want any. One mother said:
“My daughter (firstborn) was born vaginally without drugs or induction. It was a 7 hour labour and I look back on it with so much pride. I can recall moments throughout the entire labour and it was one of the best and most joyful things I have ever done. My son was born 18 months later and I was induced at 38 weeks due to my Obstetrician thinking was my son was “huge”. He wasn’t huge at all and it turns out that the induction was, in hindsight, totally unnecessary. My labour with my son was only 2 hours: too fast. I can’t remember much about it, because the pain and the speed were all way too much. I certainly adore my son, but regret the induction, as whilst it did him no harm, I feel as if we were robbed of the natural birthing rhythm.”
And another mother:
“I wish those contemplating a social induction only realised the pain involved in a medicated induction. It is just SO much worse than labouring naturally. I have NEVER felt so out of control as I did when I was augmented. Seriously, the pain and intensity of the pain and contractions after Syntocinon is unreal. I really thought my heart would stop from the pain. I knew that I could deliver without drugs, I’d done it twice before, but that ‘synto’ had me agreeing to an epidural…”
“Soon after having the Syntocinon drip to augment (speed up) my labour, I was having very strong contractions – much more than earlier contractions that were at 5 cm dilation. They were on top of each other and I can remember screaming at the top of my lungs for it to stop and I said that I was going to die – in some very choice words, which was unlike me. I couldn’t open my eyes, I tightened up against the pain, I was bawling and felt as if I was having a bizarre out-of-body experience. At that point, I realised that my longed for drug-free birth was out the window.
I tried gas, which was useless, and I began to scream for an epidural, over and over as they couldn’t understand what I was saying (as a result of the gas that made everything feel as if it were in slow motion, my speech included). Even getting the epidural in was a nightmare, it took three jabs in my spine before it went in all the way as I couldn’t stop writhing through each painful contraction. While the pain stopped with the epidural, I couldn’t feel my baby being born, I had to have a urinary catheter and couldn’t get up after the birth and do much at all. I felt so vulnerable and robbed of what I expected birth to be; I had NO chance against the syntocinon. The labour had kicked into gear in an instant and my body had no opportunity to build up into the harder contractions or have a break from them. I hate it and I know that if I had to have syntocinon again (which I would only ever have if it were in life-saving circumstances), I would not be able to cope without pain relief because it is such a powerful drug, so I choose not to be induced."
Some women can have an induction with no pain relief – our uteruses have unique levels of sensitivity to synthetic oxytocin, however, the vast majority soon have pain relief, often epidurals, after an induction or augmentation.
What Does Induced Labour Feel Like?
Someone once told me how to imagine and compare a normal labour with an induced labour like this:
1. Hold your hand out flat, as you would to receive money from someone.
2. Clench your fist and hold it closed for a second
3. Release your fist back into a flat position again.
If you repeat the above over several times, this is how a normal labour would be to the uterus. You can see how it’s not so bad and the circulating blood, hence oxygen, would be restricted but the uterus has time to recover. Now for the ‘induced’ analogy.
1. Hold your hand out, clench, out, clench, out, clench, out, clench, out, clench, out, clench, out, clench, out, clench, out – keep going for a minute or so – is your fist tired or sore yet? Imagine how this would feel for your uterus to do this for hours on end and what difference this could make during your labour and for your baby.
Some mothers say their inductions were a breeze. Firstly, there are different methods of induction – having your waters broken is certainly very different to hours on syntocinon/pitocin. Secondly, some mothers seek pain relief right away or very quickly, so the labour didn’t feel awful for them, but the baby is still having to cope with the labour even while they don’t feel it. That said, I have supported one client in labour who was induced with syntocinon and she did not accept any pain relief, she was able to cope through the contractions, which is possible. In my experience though, induced labours and pain relief pretty much go hand in hand.
How Do I Know If I Need to Be induced?
If you are offered an induction or augmentation and the situation is not life threatening, it’s always useful to use B R A N D:
- What are the BENEFITS? (of this being done)
- What are the RISKS?
- Are there ALTERNATIVES? (other than this being done)
- Does it need to be done NOW?
- Can we have some privacy to make a DECISION?
Of course, it’s important to be under the care of a midwife or obstetrician whom you trust. Hopefully, you have included your wishes about inductions in your birth intentions or birth plan (which your carer has read, signed and supported). Alternatively or in addition, talking with your midwife or obstetrician before labour may help better communicate your wishes for birth and you can also learn under which circumstances your carer wants to induce labour. If you feel you would need help when deciding, consider hiring a Doula who can support you and your partner, as well as help you with your birth plan and advocating for you.
Induced labours are not just a full-speed roller-coaster ride for babies. Induction can sometimes result in uterine hyperstimulation – this means contractions that are strong, close together or on top of one another and longer.
Think about this before you make a decision to cave in to the lure of an induction: given everything in your pregnancy has been well, you’re lining up at the starting line with the best possible chance of the best possible outcome during birth for both yourself and your baby. Are you sure that you want to make it more likely that you need intervention, assisted delivery or even a caesarean?
So if you are contemplating an induction, imagine if you could ask your baby what sort of experience they would prefer as their welcome into the world. You may feel as if you’ve had enough of being pregnant now, but how would you feel if your baby was born unexpectedly premature and had problems breathing on its own and required help? If not thought through properly, this is a reality of an induction and what it can mean.
One mother said this about trusting her body and her baby to do what they needed to do, in their time:
“My pregnancies were all long. My twins were born by induction at 40 weeks and the next baby was born by induction at 42 weeks. By child number 4 I decided on a homebirth – which meant that I would need to go into labour naturally. Finally at 43 weeks and 4 days that happened. It isn’t recommended going that long, however, he was fine, although his skin peeled off everywhere. Baby number 5 was 42 weeks and 3 days, also born at home. I tried acupuncture, I drank gallons of raspberry leaf tea, I had so much sex I was sick of it. I believe that some women naturally have longer pregnancies and some have shorter. The women who spontaneously labour have their babies at 37 weeks fall into the ‘normal’ category and the unlucky women who go longer than 40 weeks unfortunately get landed with all the interventions. Choosing to wait for labour to occur naturally was very hard work as there was a tremendous amount of pressure to agree to an induction, however, I believed that my body must eventually labour spontaneously. I did agree to regular monitoring in the last week to check that the baby was OK.”
Letting your baby choose its birth date while all is well is the best gift you can give to your unborn baby. So if you are healthy and your baby is healthy, give that gorgeous belly of yours a nice rub and let your baby know he or she is welcome into the world whenever natural oxytocin beckons – and when he or she is ready for the world.
- 40 Reasons To Give Your Baby 40 Weeks Of Pregnancy
- Being Seduced To Induce: What Women Need To Know
- Let Labour Begin on It’s Own (YouTube clip)
- BellyBelly Forum Discussion (members comments on inductions) HERE.
Kelly Winder is a birth attendant (aka doula), the creator of BellyBelly and mum to three beautiful children. Like this article? Please follow Kelly on Google+ and Tumblr and become a fan of BellyBelly on Facebook. BellyBelly is also on Twitter. Please note that all of my suggestions and advice are of a generalised nature only and are not intended to replace advice from a qualified professional. BellyBelly.com.au – The Thinking Woman’s Website For Conception, Pregnancy, Birth and Baby.
Some parts of this article were extracts from Dr Sarah Buckley’s article Ecstatic Birth, with contributions made by Brenda Manning (MIPP) and Midwife Alan Rooney.
1. Declercq E, et al. Listening to Mothers: Report of the First U.S. National Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, October 2002.
2. Freidman EA, Sachtleben MR. Effect of oxytocin and oral prostaglandin E2 on uterine contractility and fetal heart rate patterns. Am J Obstet Gynecol 1978;130(4):403-7.
3. Stubbs TM. Oxytocin for labor induction. Clin Obstet Gynecol 2000;43(3):489-94.
4. Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis: BMJ. 1999 July 31; 319(7205): 287–288
5. Comparing continuous electronic fetal monitoring in labour (cardiotocography, CTG) with intermittent listening, Alfirevic Z, Devane D, Gyte GML.
6. Induction of labor versus expectant management in macrosomia: A randomized study, Gonen O, Rosen DJ, Dolfin Z, Tepper R, Markov S, Fejgin MD.
7. Elective Induction Versus Spontaneous Labor After Sonographic Diagnosis of Fetal Macrosomia
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