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Induction of Labour Part 2

With Induction of Labour becoming increasingly more prevalent in Australia today, it's important we understand why it is recommended and what risks come with having an induction. This episode dives deep into some of the many indications for induction today… opening up whether research fully supports those recommendations or not (hint – some of the reasons doctors may suggest you be induced actually aren’t supported by current research!) We take the risks of inductions seriously, looking at the cascade of interventions that may arise following steps of inductions. Like every week, it’s all about equipping you with knowledge and understanding so that you’re able to confidently go towards childbirth ready to advocate for yourself and your baby.

Before getting into the juicy details, I just want to point out that research is always changing and updating guidelines around indications for Induction of Labour (IOL) and sometimes the research can have some conflicting ideas. I’d say because of this every hospital or health district tends to have different policies around each of these factors. So as I share this information just remember that the specifics may look different in your hospital or through the care provider you choose so I’d be wanting to really look into the specifics for your case by talking through induction with your care provider, especially if any of these indications that I’m going into are relevant to you and your pregnancy.

So, to start with let’s look at some of the common reasons that induction is recommended for the sake of the mother’s health:

- Maternal choice is one of the main reasons women in Australia are being induced nowadays (according to AIHW report mentioned last week), however most clinical guidelines tend to not support this as a routine indication for induction. Guidelines that do speak on timing for induction based on maternal request state that it should only be offered under exceptional circumstances eg. partner is in the army and about to be posted overseas and if so the timing should occur after 39 weeks gestation. And we will get into the risks of induction soon, but basically this is just showing that we shouldn’t be jumping head first into an intervention when it’s not actually medically indicated.

- Mental health – I couldn’t find heaps out there about recommending induction for mental health reasons especially in terms of timing… Victoria Health include mental health as another reason for induction depending on individual woman’s circumstances but don’t really go into specifics of timing – I guess it’s just case by case

- Hypertension/preeclampsia (preeclampsia is what Tolly experienced if you remember back to her induction story last episode) – From what I can tell, most clinical guidelines recommend IOL for women who have hypertensive disorders but timing ranges from 37 weeks to 39 weeks, depending on whether its gestational hypertension or chronic hypertension and whether the woman is otherwise well. In terms of preeclampsia (PE), guidelines are pretty consistent in recommending induction for women whose onset of PE begins at 37weeks/term. However, if PE develops preterm, guidelines vary depending on the woman’s symptoms, with some guidelines recommending induction from as early as 34 weeks. Delivery is what resolves preeclampsia, so its becomes a bit of a juggle in terms of risks for mother vs risks for baby – and timing of delivery is chosen once the maternal risks are so severe that the baby needs to be born for the mothers sake – and the potential risks to baby being born early in comparison are more manageable.

- Cholestasis – is a liver condition which shows up in pregnancy as intense itchiness but no rash to show for it. It particularly defines itself as women complain of itchy palms of their hands and feet. There is some concern about the risk of stillbirth after 37 weeks (although this could just be associated with general population stillbirth rates) but often induction is recommended from 37 weeks. It generally depends on individual circumstances like maternal age, the baby being well and other clinical factors like increasing bile acid levels and liver enzymes. The only cure of cholestasis is delivering the baby so it’s another one of those times where you have to weigh up the risks of cholestasis and benefits of early delivery for the mother, with then the potential complications for the baby.

- History of precipitate/fast labour – I’ve definitely heard this talked about as a reason why women should be induced as there is concern that if their previous baby had such a quick labour, then who knows how fast the next one will be and heaven forbid you don’t make it to hospital in time… I understand this idea of giving birth before making it to the hospital can be super scary for women and their partners, but generally, if you’ve laboured that quickly and had a baby on the way to hospital or at home – you probably didn’t need help. Of course, it’s not ideal when you’ve planned a hospital birth but in terms of using this as a reason for induction, it seems like it’s generally not well supported in the guidelines.

- Other pre-existing maternal medical conditions eg. cardiac, renal etc…

And then some reasons an induction is recommended due to concerns with the baby:

- Postdates or prolonged pregnancy – most guidelines recommend IOL between 41 and 42 weeks gestation. I’ve mentioned in previous episodes that although women are given an Estimated Date of Birth (EDB), it is normal to give birth anywhere from 37-42 weeks gestation and its pretty unlikely that you’ll spontaneously have your baby on your due date. The reason induction is recommended for prolonged pregnancy is that the rates of stillbirth rise to 1:1000 at 42 weeks gestation. Women may be offered increased monitoring from about 41 weeks until bub is born (whether spontaneously or by IOL), just to make sure bub is ok.

- Decreased movements – this is something we take very seriously. Pregnant women are the only people able to know what amount or type of movement is normal for their baby. And if the mother is concerned, then we too are concerned. All guidelines agree that decreased fetal movements is an appropriate indication for IOL. Timing of induction would be based on gestation, concern by the mother along with fetal wellbeing tests – so of course, it’s different for every woman.

- Low fluid/oligohydramnios – Amniotic fluid is what the baby is floating around in inside of their mothers. It’s essential for a healthy pregnancy as it acts not only as a cushion to keep baby safe, but it also promotes expansion and development of the baby’s lungs. A decreased amount of amniotic fluid is not normal. Again, the timing of induction for oligohydramnios would depend on the severity of concern and results from testing fetal wellbeing. It is also important to know if ‘oligo’ is isolated in an otherwise low risk pregnancy or in conjunction with other risk factors which may be cause for more concern. Generally, a term induction would be offered (37-38weeks) or if the mother prefers, and there aren’t other risk factors, increased monitoring would be recommended if choosing expectant management (which is to wait for labour to start on its own).

- Suspected IUGR (Intra-Uterine Growth Restriction) – Growth restriction is associated with higher rates of stillbirth as well as other perinatal morbidities. If reduced fetal growth is suspected, extra monitoring throughout pregnancy is important (eg. US) and sometimes ending the pregnancy early may be recommended to care for the baby. The majority of guidelines recommend induction based on the severity of the growth restriction and results of fetal wellbeing testing – so that ongoing monitoring of baby’s wellbeing.

- Suspected big baby/macrosomia – Macrosomia increases the risk of the obstetric emergency known as Shoulder Dystocia and there is some research which shows that the incidence of clavicle fractures in baby’s is reduced when labours are induced. However, suspected macrosomia alone is generally not considered an acceptable indication for IOL unless its partnered with other risk factors. Although there are some guidelines that recommend induction for ‘confirmed’ cases of macrosomia (which in and of itself can be questioned as confirmation is generally by ultrasound which isn’t an exact art). These guidelines recommend timing of induction to be around 38 weeks, but again it depends on how big the baby is measuring in relation to its gestation.

- Prolonged Rupture Of Membranes (PROM) – can occur preterm (less than 37 weeks) or at term (at or over 37 weeks gestation where waters break but labour does not start naturally).

· If preterm – guidelines consistently recommend that IOL should not occur if waters break before 34 weeks unless there are additional complications like concern that the baby is unwell. Whereas if the woman is 34-37 weeks IOL can be offered or women can choose expectant management. These two options are generally recommended depending on the risks and benefits to both mother and baby.

· If PROM happens at 37 weeks or greater, guidelines can be a bit more conflicting. Basically, what’s happened is that the waters have broken but labour doesn’t naturally start and so there is concern that infection can arise because the baby is no longer protected by the bag of waters. Some guidelines recommend IOL should occur ASAP or within 24 hours of the waters breaking and other guidelines say that expectant management can be offered if the woman desires and the baby is well. Some guidelines also differ if the woman has had a positive GBS (Group B Strep) swab (normally happens around 36 weeks) whereby women who are positive should have an IOL with greater urgency than those who had a negative swab. I’ll do another episode on GBS because the way it is tested for can be a bit controversial so should be understood properly.

- Twins - The concern for twin pregnancies is that the risk of stillbirth rises with advancing gestational age. There are some guidelines which recommend women with uncomplicated twin pregnancies where twin one is head down (in good position for vaginal birth) that they be induced around 37 or 38 weeks gestation. There are also some guidelines that go more specifically into earlier dates for induction based on the type of twin pregnancy – whether babies are in the same bag of waters or not. Interestingly the World Health Organisation does not recommend IOL for women with an uncomplicated twin pregnancy at term.

- Maternal age – The risk that comes with ‘Advanced Maternal Age’ which forms the grounds for induction is that risk for stillbirth is increased. Most guidelines on IOL for AMA basically state to offer induction for women who are 40 years old or over between 39 – 40 weeks. Interestingly though, Victoria Health guidelines state advanced maternal age on its own is not an acceptable reason for induction. (So it makes you just think twice about the fact that.. one place says it’s not a valid reason for induction whereas others say it is a valid indication…)

- Gestational Diabetes Mellitus (GDM) – there seems to be a big variation in recommendations around induction for women with gestational diabetes. It seems that some recommend induction from 40weeks if there are no other indications for concern… But if the pregnancy has further complications, like the woman requiring insulin to manage the diabetes, or concern that the baby is Macrosomic (large – brings with it extra risks) than IOL between 38 and 39 weeks is recommended.

· Women who have T1 or T2 diabetes are often recommended induction as well, depending on the management of the diabetes and again any further complications with mum or baby.

Okay…

As you can see there are SO many reasons why an IOL may be recommended. And this is not a complete list by any means. Although, even though the reasons I’ve touched on above may be appropriate for induction in some cases, in others they may not mean an induction is required so every case is different, and each individual will need to speak with their care provider about their own individual case. I feel like one of those radio ads or whatever where they have that monotone voice come at the end stating the disclaimer but legitimately, everything discussed in today’s episode is for informational purposes only. It is not intended as a substitute for professional medical advice and should not be relied upon or used as personal advice. Formal hey! Just want to make it clear though…

So finally, it’s worth knowing what risks come with having an induction. I touched on the idea that sometimes it’s a juggle to determine the right time for induction or delivery based on health of the mum vs risks that may arise due to early delivery for the baby… so again, I think it’s important to unpack those potential risks.

Having an IOL, as with all interventions during labour and birth, does bring with it increased risks to both the mother and baby and research also shows inductions are associated with less maternal satisfaction. So, it’s not something you should go into lightly, and is definitely an intervention that needs to be explained and discussed (both benefits and risks) very clearly. It’s really important that health care providers offer the research and recommendations based on research – but more importantly they need to respect the questions, concerns and ultimate decision making that the mother and her partner make once fully informed.

Different methods of induction bring with them their own risks.

- Medical methods by use of prostaglandin (the gel and the Cervidil) have the potential to cause uterine hyperstimulation (where the uterus is contracting so often that there isn’t enough rest between contractions) – which means the baby can get distressed due to lack of oxygen which shows as drops in the baby’s heart rate known as decelerations. Depending on how bad the decelerations are – different steps may be taken – the first being to remove the prostaglandin gel/cervidil to hopefully stop/slow contractions and give the baby a rest. Hyperstimulation is also possible with the use of the oxytocin infusion and if it occurs, the infusion rate should be reduced or paused to allow the baby to rest. If the baby remains in distress generally delivery will be recommended and this would normally be by Caesarean section unless the cervix is fully dilated and the baby is close to being born vaginally in which case the mum would either push baby out or an instrumental delivery would be needed. The risk of hyperstimulation is one reason why women need to be monitored during the induction process. The CTG monitors the baby’s Heart rate – and will pick up any decelerations that may occur. The CTG also tracks the frequency of contractions (which your midwife will also be palpating for…).

- Often having an induction is spoken about as starting a ‘cascade of interventions’ – where one intervention leads to the need for more interventions. Like the example I’ve just spoken about – baby is in distress because of the induction process so needs to be delivered by Caesarean... Other interventions that come with induction include the use of CTG which I touched on before… Continuous monitoring by CTG is known to increase the rate of Caesarean Section and instrumental births. It’s also known to limit women’s abilities to move and change positions in labour as well as have access to the birth pool/bath which can impact women’s coping strategies for pain… which can then lead to women requesting medical pain relief options… so as you can see… just starting with one little intervention, may actually have you snowballing into a range of other interventions..

- Inductions tend to mean women labour for a longer duration than a spontaneous labour (one study finding approx. 6-7 hours longer). It is found that women who have been induced are more likely to request medical methods of pain relief and in particular an epidural than those who’ve laboured spontaneously. And of course these medical methods of pain relief bring with them their own risks which you can find out about in episode 12.

- Potential for ‘failed induction’ which is where methods to ripen the woman’s cervix don’t work – so there’s no way to get to the bag of waters to break them… or the waters may have been broken and the oxytocin drip started but after hours and hours there is no change to the mothers cervix… it’s just not dilating. If this occurs, the next step is to have a caesarean section.

- An ARM (artificial rupture of membranes) has the potential risk of cord prolapse, where the umbilical cord falls out of the cervix before the presenting part – this is most risky if the baby is not engaged as the ARM is performed and if a cord prolapse occurs it is an emergency as it can mean the blood and therefore oxygen circulation is cut off

- An ARM also brings with it an increased risk of infection for both the mother and baby

- In terms of newborn health, the rising rates of induction has been linked with the rise in preterm birth and its associated complications (like we touched on where you have to weigh up the risks to mums health vs risks to baby by being born early… sometimes it needs to happen – but that means baby needs extra support in SCN etc). It is clear that babies born preterm (before 37 weeks) as well as what’s known as ‘early-term’ which is 37-38+6 weeks have higher rates of morbidity as well as need for additional health care resources during their first year of life, compared to babies born at 39-40 weeks.

- Long term outcomes comparing children born by induction verses children who are born following expectant management are minimal

- Another risk which I highlighted earlier is that IOL lead to decreased maternal satisfaction. Research shows that often women feel they don’t have much of a choice in the matter when induction is recommended and a large number of women report negative experiences and dissatisfaction following an IOL. And I know I did an Instagram post a month or so ago and there was definitely a fair few of the Mum Will Know community who felt either traumatised or disappointed by their Induction experience. It’s so important that women are included and respected in the decision-making process around their birth.

These are just some of the risks associated with IOL and the research is constantly updating and changing around these topics so of course talking to your health care provider is the best way to go… but going into those conversations prepared will mean that hopefully you’re taken seriously (not that you shouldn’t be taken seriously otherwise) but I think showing your care provider that you’ve got some prior knowledge and questions gives them the opportunity to properly talk through all the risks and benefits in your specific case. And again, ideally they should do that anyway, for all women… but as the research shows, often women don’t feel like they’ve been properly informed or included in the decision making.

Of course, IOL is a necessary intervention when the risks of continuing the pregnancy outweigh that of the risks that come with intervening. But the fact that induction has risks means that you wouldn’t want to go into it lightly especially if you’re not yet 39 weeks… and of course every case needs to be looked at individually, comparing the risks of remaining pregnant with the risks of prompt delivery.

I’ll do another episode on non-medical ways to induce labour as this is something I get asked about and any woman who is at her due date and wanting to avoid medical IOL starts googling her options!

Anyway – listen, subscribe, review – all that jazz.

Thanks guys


For further reading on Induction of Labour check out these resources:

Evidence on: Inducing for due dates

https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/

Induction of Labour: Monitoring and pain relief for induction of labour (2008)

https://www.ncbi.nlm.nih.gov/books/NBK53623/

Induction of labour: Experiences of care and decision-making of women and clinicians (2020)

https://www.sciencedirect.com.acs.hcn.com.au/science/article/pii/S1871519219302318#bib0030

Induction of labour with oxytocin (2020)

https://www.uptodate.com.acs.hcn.com.au/contents/induction-of-labor-with-oxytocin?search=induction%20of%20labour%20pph&source=search_result&selectedTitle=1~139&usage_type=default&acc=36422

Photo by @austinbirthphotos

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