Induction - Do I really need it?

Induction — Do I really need it?

Induction Do I really need it?

Sara Wickham

Association for Improvements in the Maternity Services

AIMS — Association for Improvements in the Maternity Services

Supported by the Community Fund Published by AIMS © AIMS March 2004 ISBN 1 874413 16 9

Induction — Do I really need it?

Contents Foreword from AIMS

4

Author’s Foreword

5

Introduction

7

1 – REASONS FOR INDUCING LABOUR

13

Questions You Should Ask

15

National Guidelines for Professionals

17

Induction for Prolonged Pregnancy

19

Dating pregnancy

19

Dating by ultrasound

21

Considerations

22

Does induction save babies’ lives?

23

Induction and Caesarean section

25

Deciding about induction if your baby is overdue

25

Induction After the Waters Have Broken

26

Induction of Labour in Diabetic Women

30

Induction at the Mother’s Request

32

Induction of Large Babies

33

Induction in Twin Pregnancies

34

Induction for Other Obstetric or Medical Reasons

35

2 – THE PROCESS OF INDUCTION Women’s Stories

39 39

Place of Induction

43

Cervical Scoring

44

Sweeping the Membranes

46

Prostaglandins

47

Misoprostol/Prostaglandin E1

49

Vaginal Examinations

50

Monitoring the Baby

51

Artificial Rupture of Membranes

53

Syntocinon Drip

53

Failed Induction

55

3 – NON-MEDICAL INDUCTION OF LABOUR

57

4 – A FINAL WORD

59

5 – REFERENCES AND RESOURCES

61

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AIMS — Association for Improvements in the Maternity Services

FOREWORD FROM AIMS

This book has been written to give information and advice to women whose babies are ‘overdue’; those women who have gestational diabetes, or whose waters have broken but who have not gone into labour, or who feel that they want to be induced.

Estimating your baby’s due date, either by ultrasound, or by other means is not particularly accurate and instead of giving women due dates it would be far better a woman is told that the baby is due ‘at around the end of September’ (for example). This allows for some leeway without women becoming anxious that the baby has still not arrived, or planning around a particular day and getting more anxious if the baby has not arrived by then.

Only half of all babies arrive on their due date and the other half can be a week or so early or up to a fortnight late. Very few babies (if the pregnancy is otherwise progressing normally) are at risk of stillbirth because they are overdue. For every overdue baby 499 women are subjected to the additional pain and discomfort of an unnecessary induction.

We know from talking to women who contact us that there are often complex emotional and social reasons why women feel they would like the baby induced, but we are also aware that sometimes women are manipulated into making those decisions by staff and particularly if they are having private obstetric care.

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AUTHOR’S FOREWORD

There are plenty of information leaflets and web sites about induction of labour from a medical standpoint, which tend to take the view that induction of labour is often justified and generally a good thing. And, indeed, induction of labour can sometimes be a life-saving intervention for a few mothers and babies. But there are other people who feel that far too many women’s labours are induced without a good reason.

It is thought that this can happen for the convenience of the hospital, midwife or doctor, or because standard guidelines are being applied to all women without considering their individual circumstances and needs, or because health professionals feel, in this age of litigation, that it is better to do something ‘just in case’.

As I feel it is important for women to be aware of the beliefs of those providing information, I would like you to know that I am one of the people who believe that, although induction of labour can, occasionally, help save lives these days many more women are induced than really need to be. The aim of this book, however, is not to persuade you to my way of thinking, but to offer a balanced view to help you decide on a course of action which is best for you and your baby.

The booklet is divided into five sections. The first looks at the different reasons for inducing labour, along with some of the issues you might like to consider if you are told that your labour needs to be induced. Section one also considers the health professionals’ guidelines on induction, and the key issue of how the due date is estimated.

The process of induction is discussed in section two, which includes women’s own stories and feelings about being induced and also looks at the decisions you may make about your care, should you decide to be induced. Section three looks at non-medical ways of inducing labour; section four concludes the book.

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Finally, section five lists the references which have been cited in the booklet, along with a few web sites and organisations that may be able to help you further with advice or additional sources of information on this issue.

I would like to thank all of the women who allowed me to use their stories for this book, and the women who work tirelessly for AIMS with the goal of improving maternity care for all women. Special thanks to Nadine Edwards, Alice Charlwood and Pat Thomas for their work in checking, editing and publishing this booklet.

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INTRODUCTION

The dictionary definition of ‘induce’ generally refers to ‘bringing on’, ‘causing’ and ‘bringing about’, and the expression ‘induction of labour’ is commonly understood to mean the bringing on of labour in a woman who was not previously showing any of the signs of labour, such as contractions.

Induction of labour is not the same as the acceleration or ‘augmentation’ of labour, where a woman’s labour is speeded up, often using the same kinds of drugs and techniques that are used to induce labour. This can be confusing, but the key difference is that “induction” is the word used for the procedures when labour hasn’t already started on its own.

Rightly or wrongly, midwives have used their knowledge of herbs, physical techniques and traditional therapies to bring on women’s labours for thousands of year.1, 2 We can only guess as to why they might have done this, but it can be interesting to compare the approach taken today to induction of labour to the way our great grandmothers might have seen it. While induction itself might not be new, medical induction is a relatively recent phenomenon, and the reasons for inducing labour and how frequently it is done have changed over time.

In 2002, 21.5% of women who gave birth in England and Wales had their labours medically induced; this is more than one in five of all labours and births. The rate of induction and the reasons given for doing it seems to vary according to geographical area, and even between doctors working in the same hospital. This is important to bear in mind if someone suggests your labour should be induced.

While one doctor might tell you that labour should be induced at 41 weeks if the baby hasn’t been born, you may find that another will agree to wait until 42 weeks of pregnancy unless there is a problem. If you are offered induction, it is worth finding out what usually happens in your area and what the process is in the hospital you might go to.

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Many doctors and midwives tell women that induction is essential to save the life of the baby which will be seriously at risk if they do not comply. Not to put too fine a point on it, they are told their baby could die if they do not do what they’re told! This flies in the face of professional recommendations and a number of reports which have been critical of routine induction. Some of the key reports in this area include: Marjorie Tew’s article ‘Do obstetric intranatal [during labour] interventions make birth safer?’ — which suggests they do not, and may in fact create additional risks3 Cardozo who points out that if induction is done to reduce risk to the baby it may be failing because birth outcomes are poorer and APGAR scores lower in induced babies4 Alfirevic and Walkinshaw suggest as many as 500 inductions need to happen before one death from post-maturity would be prevented5 The problem is that an enormous scattergun approach is used to try to prevent the loss of a very few babies, whilst putting an awful lot of other mothers and babies at risk of missing out on a normal birth and subjecting large numbers of women to very painful labours. Different people take different views on whether birth is a natural or a medical event; find out more about this, and how it relates to your choices in AIMS’ book What’s Right For Me? Since childbirth became more medicalised, methods of inducing labour have become more invasive. Contractions can now be induced by pharmaceutical drugs, which are usually given by intravenous drip or by inserting gel or pessaries into the woman’s vagina.

A vaginal examination is performed to assess the state of a woman’s cervix, and a “score” may be calculated before administering gels or pessaries containing synthetic prostaglandins which ‘ripen’ the cervix. This score (sometimes known as a “Bishop’s Score”) is used to assess how successful the induction is likely to be. Points are given for the softness and openness of the cervix, and the position

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of the cervix and the baby’s head. Generally, the higher the score, the more likely the induction is to work. You can ask for information on the scoring systems used locally and what this means for you.

Because prostaglandins can cause strong contractions quickly, and make it harder for the baby to cope, monitoring will be recommended for around 30 minutes to an hour to check that the baby’s heartbeat remains within normal limits (see page 51 for more on this). Women whose labours are induced may find they are advised to be continually monitored, and may not be able to move around as much as they need to, because of drips, fetal monitor belts and sometimes a variety of other equipment such as blood pressure machines.

The process of assessing the cervix and giving gels or pessaries may be repeated a few hours later, until the cervix is ripe enough for the woman’s waters to be broken (using a plastic hook or one attached to a thimble-like tool on the midwife’s finger, again during a vaginal examination).

For a few women, having their waters broken may be enough to start labour, and practitioners will usually wait at least a couple of hours to see if this happens.

For most women, labour will not become well-enough established within the time given, and a needle will be put into the woman’s arm or hand and an intravenous drip started. This drip contains syntocinon, (a drug which mimics oxytocin and makes the uterus contract) and the midwife will turn it up every so often until contractions are regular and strong.

Vaginal examinations (VEs) are usually performed fairly frequently so that the midwife can find out how the woman’s cervix is dilating in response to the drug.

VEs can be painful and distressing and women have a right to refuse to have them. The baby’s heartbeat will also be monitored continuously after the drip is started to keep an eye on whether the baby becomes distressed.

If the induction is successful, and labour progresses well, the baby can be born as usual. However, after the baby is born, it is likely that the midwife will want actively to manage the birth of the placenta (the “third stage of labour”). This involves keeping the drip going whilst she removes the placenta by holding the

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uterus in place and pulling on the cord.

While this is not the same as a physiological third stage, (where the placenta is born naturally without the use of drugs or other midwife interventions), it may be advisable when labour has been induced because syntocinon disrupts the body’s natural release of oxytocin and women who have been induced are more likely to bleed heavily during the birth of their placenta. (AIMS publishes a booklet about the third stage of labour, Delivering Your Placenta - The Third Stage, which provided more information on this).

For the same reason, the oxytocin drip will usually be left up for an hour or two after the birth, because taking the drip down immediately can cause the uterus to relax and excess bleeding may occur. The main physical risks of induction include: more pain than with labour which starts spontaneously greater chance of needing pharmacological pain relief because of the increased pain higher risk of needing an operative or instrumental delivery, for several reasons:

because of the increased chance of having an epidural and then being unable to push the baby out effectively

because the drugs used can cause the baby to become distressed

because the induction ‘fails’ and it is deemed necessary to get the baby born by whatever means necessary — invariably this will mean a caesarean section. (It is very difficult to calculate what percentage of inductions fail; some doctors and midwives estimated this figure as high as one in four)

greater discomfort (additional to the pain of uterine contractions)

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caused by the limited number of positions that women can get into when they are being monitored or have had an epidural There are also a number of rare but more serious risks related to some of the drugs and techniques used, which are discussed later (see Section 2). Some women also experience psychological trauma and unwanted side effects, for instance: difficulty bonding with the baby problems establishing breastfeeding feeling they were not in control of their birth experience, sometimes leading to postnatal depression.

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1

REASONS FOR INDUCING LABOUR

The Royal College of Obstetricians and Gynaecologists’ (RCOG) guidelines place strong emphasis on the fact that doctors should help women to make informed choices about their care or treatment, and suggest that this should include written information as well as verbal discussion.6 They suggest doctors should offer information about: the reasons for induction the choice of methods to be used the risks and consequences of accepting or declining induction This section goes into some of the main reasons that women are given as justification for an induction. This doesn’t mean that they are all ‘good’ reasons for induction — although some of them certainly can be for some mothers and babies. The aim of this section is to provide a reference guide for you to be able to find out more about any reasons you might be given for needing an induction, and information which might give you an idea of whether — or when — induction might be appropriate in your case. Of course, it is impossible to write a booklet that can speak to every individual woman and take into account all the possible variations, so this is mainly intended as a starting point. You may also want to look up some of the information cited here, and/or use the References and Resources section (page 61) to find more information.

One thing that may be important to note at the outset is that, if you are told your labour needs to be induced, it is hardly ever a dire emergency. If a doctor was worried that you or your baby were in any imminent danger, she would not be recommending induction of labour. She would be advising an immediate caesarean section. The reason for explaining this is that some women attend an

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antenatal appointment or go to hospital to have the baby’s heartbeat monitored and are told they need to stay and have their labour induced. Although there are a few exceptional cases, where a woman or baby has a condition which is not immediately life-threatening but may become more dangerous over the next day or two (in which case immediate induction may be warranted), it is usually possible to take some time to go home and think about the situation, discuss it with your family or friends and gather more information before you make a decision.

It is also worth bearing in mind that hospitals are bureaucratic institutions and, while it may be easier for the hospital to admit you immediately, you may want to think about other options, sort out your other commitments or simply take a little time to ‘get your head around’ what is being proposed and whether it is the best decision for you. The fact that women are sometimes given the impression that their labour needs to be induced immediately when this turns out not to have been the case is well illustrated by Claire’s story: “I went to my antenatal and they said I should be induced…I already sort of knew that because they said it the last time as well when I saw the hospital. They said ‘do you want to just stay in today cause we can fit you in’, so I thought I might as well, seeing as the kids were with my mum anyway.

“They were going to give me the gel that evening, but then they said they couldn’t …I think that first time it was because there weren’t enough midwives and too many women in labour already. So I thought, OK, well at least I’ll get a good night’s sleep. But of course you never do in hospital, do you?

“And this went on for two more days. They said the labour ward was full, and there were other women who were being induced as well. They wouldn’t start us all off at the same time. Finally, when they gave me the gel, it was the Wednesday evening, and I’d gone in on the Monday morning. And I thought, well I might as well have been at home, left the kids with Mum and had a rest rather than sitting there. I know they’re really busy, and the midwives did keep saying they were sorry, but it was always like, I couldn’t go home because they thought they might start me off in the next few hours. I was a bit afraid if I did go home I might miss my place in the queue!

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“That’s the bit that I wish had been different. Because when I had the baby I was so tired from not sleeping that I’m sure I would have enjoyed the first few days more if that hadn’t happened and I’d just come in when they were ready.”

Questions You Should Ask As scientific studies show that too many inductions are happening routinely with no benefit to the mother or baby, if induction of labour is being suggested, there are some useful questions you could ask: Why do you feel I need to be induced?

If you are clear on the specific reason (or reasons) for which induction is being recommended in your case, you can look at the evidence for this/these and make a more informed decision about what you would like to do.

Are my baby or I in imminent danger?

If this is the case then you may want to consider immediate induction. If not, then you may want to take time to think about your options and talk to your family before you make a decision. If you are being told that you are putting your baby at serious risk and you suspect that this is being said to persuade you to agree to an induction, you may want to seek a second opinion.

What are the benefits of being induced — for my specific situation?

This links with the first question above, and will give you a clearer picture about whether there is a specific reason why induction may be a good idea for you, or whether this is a routine recommendation. Being told “Oh, it is something we always do for everyone who goes overdue” is not necessarily a good reason for inducing your baby.

What are the risks of being induced?

All medical procedures carry risks, and the specific risks of induction are briefly outlined in the introduction and discussed further in section four. Asking this question can help you determine whether a health professional is being honest with you, or whether they simply want you to do what they suggest, perhaps by toning down or denying that there are risks involved. If you are told that

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there are no real risks, you are being misled and you may want to seek a second opinion. If the professional concerned is a doctor, you may wish to talk to your midwife about your options; if it is a midwife, then you can ask to speak to the Supervisor of Midwives. The resources section of this booklet also list contact details for people or individuals who will talk things through with you in an unbiased way.

What percentage of women who are induced in this hospital end up having a caesarean section or an instrumental birth (forceps or vacuum extraction)?

These figures should be available, and you should ask for the local statistics rather than making an educated guess.

You can also look at www.birthchoiceuk.com to see what the intervention (including induction) rates are for your local hospital, alongside national rates, which will give you an idea of the general philosophy and the likelihood of intervention in that unit generally.

Ending up needing an operative or instrumental delivery is a very real risk of induction, and a professional who is being honest with you should acknowledge this, rather than glossing over the fact.

What kind of monitoring do you suggest for induction? Can I choose not to have this?

Most hospitals want to put continuous monitors on women who are having a syntocinon drip, and for a while after the administration of a gel (see page 51). You have the right to decline any monitoring or other interventions that the hospital offers although, as discussed in Section 2 you should bear in mind that powerful drugs are used to induce labour, and that these can sometimes be damaging to babies.

How to Contact a Supervisor of Midwives Probably the easiest way to do this is to call your local hospital and ask for the contact details of a Supervisor of Midwives; a large hospital will probably have several Supervisors of Midwives. You might also want to ask for the name and contact details of the Head of Midwifery (who may also be a Supervisor). If you need further advice or help with finding out about your rights or how to make a complaint, you can contact AIMS.

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What are the alternatives to being induced?

There may be an alternative to induction, depending on the reason(s) why it is being suggested. If there is concern about your or the baby’s well-being, it may be possible to arrange regular monitoring instead, and to see how things go.

While you will want to take into account your caregiver’s knowledge in this area, you will be able to tell from their response to this question how open they are to helping you explore the different options available.

What if I leave it for a couple of days to think about things?

As above, this will help you determine whether your midwife or doctor is open to finding a solution that meets your hopes for your birth as well as their judgement about what the ‘best’ course of action is. Although professionals have knowledge about pregnancy and birth in general, you are the, often unacknowledged, expert on your body and your baby.

At the very least, even if you are told you need an immediate induction for what you consider to be a good reason, you might like to take a walk or find a place to sit for a few minutes outside the hospital with whoever is with you in order to think about the decision and get used to the idea.

Please feel free to contact AIMS for information and support.

National Guidelines for Health Professionals The Royal College of Obstetricians and Gynaecologists (RCOG) published a document in 2001, which offered guidelines to doctors based on research which had looked at different aspects of induction.6 The guidelines are also linked with the National Institute for Clinical Excellence (NICE) guidelines.7 Reference is made to the RCOG document throughout this booklet, as it is likely to be the foundation for the guidelines and policies developed in your hospital.

If you are given a reason for induction which is not supported by these guidelines, you can bring this to your caregiver’s attention. Many hospitals now base their induction policies on the RCOG and NICE documents which mainly reflect the opinions of doctors. It is worth noting that while childbearing

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women and midwives have a lot of knowledge about this matter, they were barely consulted as these policies were developed.

The RCOG guidelines only came up with four reasons which they felt justified induction on the basis of the research evidence. These were: “prolonged” pregnancy diabetes in pregnancy pre-labour rupture of the membranes (waters breaking before labour begins) maternal request Of course, women, midwives and doctors need to take factors and evidence other than that based on research into account when making decisions, and these recommendations are only guidelines for doctors, rather than fixed rules which must be followed by you. Even if you are recommended induction, you are under no obligation to consent to this, or any other treatment for that matter (for more about women’s rights, see AIMS publication, Am I Allowed? YES, YES, YES).

It is important to note that the four reasons given above are the only reasons the RCOG considers as justificaton for induction. The reviewers who wrote the RCOG document did consider other potential reasons for induction; macrosomia (a suspected large baby of more than 4000 grams, or 8.8 pounds), multiple pregnancy, and a history of precipitate (very fast) labour. However, they found there was not enough research evidence upon which they could draw conclusions in these situations.

It is certainly not clear-cut that either prolonged pregnancy or premature rupture of membranes are always good reasons for induction. This is discussed more fully on page 19. The question of diabetes in pregnancy and maternal choice are considered on page 30. There are a number of other reasons why some women

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may be told they need induction, yet none of these was found to be justified by the RCOG review of the research evidence. They are, however, discussed here along with some of the questions which you may want to ask if induction is proposed for one of these reasons.

Induction For Prolonged Pregnancy Being “overdue” (or ‘post-dates’) is the most common reason given to women to justify an induction of labour. Yet the exact timing of when a baby becomes overdue seems to differ according to where you live and depending on which research studies underpin local policy and the views of individual obstetricians.

Whereas even a few years ago the majority of women could expect their pregnancy to continue for up to 42 weeks without facing the prospect of induction, the ‘safe limit’ in some UK hospitals has now decreased to 41 weeks of pregnancy, a point at which the RCOG estimate that around ten per cent of all women are still pregnant.6 Many midwives and doctors have come to believe that pregnancy can become dangerous beyond a certain point in time. However, while some researchers and practitioners believe that all women should be induced at (or even before) forty weeks,8 others call for caution, and suggest that routine induction is not indicated simply because a woman’s pregnancy has gone on beyond a certain date. 2, 9, 10, 11

Dating pregnancy Only four per cent of babies arrive on their ‘due’ date12 yet this date is perceived as a “critical piece of information” by midwives and doctors,13 and often by women themselves. If women choose to have any antenatal screening tests, the due date can affect when these are carried out and, on a more practical level, it enables families to plan for the arrival of their new baby.

While both ancient Hindu and Roman cultures recognised that pregnancy lasted around nine months,10 it was Aristotle who first documented the average length of pregnancy as being ten lunar months, which is widely accepted as being 280

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days.11 This period of time was later used as the basis for ‘Naegele’s Rule’, a rule of thumb that calculates the baby’s due date by adding seven days and nine months to the first day of a woman’s last menstrual period before she became pregnant.

If you work this out with a few random dates, you will see that the two are not exactly aligned — most of the obstetric calculators used today give a due date somewhere between Naegele’s rule and 280 days. This, in combination with an understanding of the very real impact that even a few days difference in the due date can make to women, is one of the reasons why Anderson13 advises midwives to use caution when using these ‘whirly wheel’ calculators to calculate a woman’s due date and her current gestation at each antenatal visit. If a midwife or doctor uses one of these during an antenatal visit and tells you that you are a slightly different number of weeks and days pregnant to what you thought, this is almost certainly why.

Calculating dates with a wheel (or in your head, by using Naegele’s rule) is one of three ways of ‘dating’ pregnancy; the other two being ultrasound examination or being certain about the date of conception. This last example is usually only possible when conception has been assisted, or a woman can pinpoint conception, perhaps because she had intercourse only once in a few weeks.2 Some women also just know exactly when they conceive, although, sadly, this may not always be seen as valid knowledge by professionals.

Naegele’s rule has never been tested or substantiated by any large-scale research.11 It was proposed in 1838 and was based on observation of only 100 women14 — a number far too small to be considered of value in medical research today. Many people believe that this rule should be re-considered, for several reasons. There is a suggestion that Naegele’s rule should be calculated from the last (rather than the first) day of the menstrual period,2, 15, 14 which would make the average length of pregnancy 283 days — a theory that was supported by research conducted by other researchers.16, 17 Mittendorf also agreed that 283 days is a more accurate average than 280 days for women who had already had a baby, but suggested that the average length of pregnancy for women having their first baby was 288 days.18

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Other commentators have argued that it was Aristotle who was mistaken or has been misinterpreted. While an average gestational length of 280 days is felt to derive from his ‘pregnancy lasts for ten moons’ theory, van der Kooy points out that, if we take account of the fact that the earth moves while the moon travels around it, a moon cycle is 29.5 days, making ten moon cycles equal to 295 days.2 While Saunders and Paterson’s10 research agreed with this, Stronge and Rasmussen19 argue instead that midwives and doctors should admit that predicting due date is no more accurate than forecasting weather!

Certainly there is evidence to suggest that due date is based on many factors, and that the baby herself may be the determining factor. Some of the maternal issues which can affect when a baby is likely to be born can include the length of a woman’s mother’s and maternal grandmother’s pregnancies.20 Physical factors such as ethnicity, height, age and whether the woman has had a baby before could also impact on the length of pregnancy.21

Dating by ultrasound Some people seem to feel that ultrasound scanning can solve the problems raised by the debate over the accuracy of dating methods based on a woman’s menstrual cycle.22 However the studies which have been set up to evaluate this have generally looked at it in relation to Naegele’s rule and as this is not proven — and probably not very accurate — it seems ill-advised that this is the ‘benchmark’ against which the accuracy of ultrasound has been measured!

There are a number of other problems with the studies that have evaluated ultrasound dating. In several studies, women and their midwives knew what the dates were, so this may have influenced when the women actually gave birth. It is probably stating the obvious to say that babies come in lots of different sizes, yet this variation in size between babies can still result in a lot of potential mistakes when ultrasound is used to calculate due date.23, 24, 25 While medical reviewers26, 27 are calling for all women to be offered routine dating scans at early antenatal visits, or at least a combination of menstrual and scan dates, consumer organisations such as AIMS are continuing to voice concerns

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about the safety of ultrasound, which is not proven to be the safe or effective intervention which many women assume it to be.28 Although it has many supporters in the medical and midwifery professions, ultrasound is currently no more accurate than menstrual dating of when babies are due. While both can be useful tools,13 there is a need to acknowledge that birth professionals don’t know nearly as much about the average length of pregnancy and how to measure it as they might claim! This, obviously, has an impact on the question of whether induction at an arbitrary point in pregnancy can ever be justified.

Considerations You and your baby are the people who are going to be most affected by the way your due date is calculated. With that in mind, you could consider the following: if you think that the due date you have been given is incorrect, discuss this with your midwife or doctor, as it could have serious repercussions later in your pregnancy. It is far easier to negotiate those changes early in pregnancy than when you are facing a doctor who is suggesting you are induced at 40-something weeks of pregnancy if your menstrual cycle is longer or shorter than 28 days, or if your last period was unusual, this may o affect the length of pregnancy. Let your midwife know that you want this taken into account when your due date is calculated if you are sure of your menstrual dates, think carefully before you accept that an ultrasound date is more accurate. You may simply have a baby who is, at the moment, a bit bigger or smaller than average (you may also want to read more on this in AIMS booklet, Ultrasound? Unsound!) if you are reading this and not yet pregnant, or if you are planning to have more babies in the future, it is worth thinking about keeping

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charts of your menstrual cycle, so you have information about your own body which can help you and your midwife work out your due date (suggested resources for this are given on page 67) If you become more than a week overdue your midwife or doctor may suggest that you have an ultrasound to measure the amount of water around the baby.

Some women find this to provide useful information in their decision-making, but you should remember that no screening test is totally accurate.

This is one area where we need more research, and women who are more than 42 weeks pregnant will find that, because the majority of women are induced before they reach this point, we know very little about what the normal volume of fluid should be at this stage of pregnancy.

Does induction save babies’ lives?

The RCOG guidelines and similar documents recommend that women should be “offered” induction after 41 weeks, although they leave it to local hospitals and doctors to decide exactly when, after 41 weeks, induction should be offered. The rationale for this is that rates of perinatal mortality (the chance of a baby dying during pregnancy, labour or before it is 28 days old) and perinatal morbidity (the chance of a baby being unwell during this time) increase if pregnancy continues beyond 42 weeks. The RCOG also claims that induction does not increase the chance of caesarean section, although until recently it was generally accepted that it did.

Yet, if we look at the research data (some of which the RCOG quote in their report) in more depth, a different picture emerges. None of the prospective (forward-looking) studies found any difference between the health of newborn babies whose mother’s labours were induced and those whose mother’s pregnancies continued until labour started spontaneously.29 In some of the studies which compared induction with ‘conservative management’ (where doctors monitored women and their babies, but did not induce their labour unless there was an obvious problem), some babies died in both groups — yet there was no statistically significant difference found between babies who were induced and

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others who were not. It is reassuring to note that in a further seven studies, no perinatal deaths occurred in either group.2, 31, 32, 33, 34, 35, 36 The medical profession’s concern that more babies become unwell if labour is not induced is also not borne out by a detailed examination of the research.36, 37, 38, 39 Retrospective studies have also looked at perinatal mortality and morbidity.

While these are not considered as scientifically reliable as prospective studies, they can give us useful information about what actually happens in practice. One such trial which looked at the outcomes of 3262 births which occurred “at or beyond term” showed no difference in outcomes between induction and waiting for spontaneous labour.41 Another large trial looked at the records of 56,317 women who gave birth between 40 and 42 weeks of pregnancy.39 The only difference it found between women who gave birth at 40 weeks and those who gave birth at 42 weeks was that the babies born later were slightly larger, but this was not associated with more problems during labour or birth.

All of the trials mentioned above compare induction with waiting until around 42 weeks. Despite medical opinion to the contrary, there is no evidence to suggest that routine induction before 42 weeks reduces perinatal mortality according to Menticoglou42 who described the current situation of inducing all women at 41+ weeks as “nonsensus consensus”.

The question of what to do after 42 weeks is a more difficult one, not least because medical research has focused on developing policies to induce the majority of women before this time. Indeed, as long as the majority of women have their labours induced between 41 and 42 weeks of pregnancy, there is no way to collect data on what happens after 42 weeks!

However, three studies considered the question of whether it was safe to wait until 43 weeks, and compared women who were induced at 42 weeks, or were monitored until 43 weeks.31, 32, 40 Although they found that there was no additional risk to waiting until 43 weeks, it should be noted that the numbers of women in these studies were relatively small. At 42+ weeks of pregnancy there is so little useful research evidence that women will need to rely on their own

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instincts about whether it is preferable to continue with pregnancy (with or without additional monitoring) or to agree to induction of labour.

Induction and caesarean section It has been understood for years that induction for prolonged pregnancy leads to higher rates of caesarean section.43, 44 This is one of the main risk factors cited in criticisms of routine induction of “overdue” women.45, 46 Yet medical reviews of induction have recently claimed that this is no longer true. What’s more, the researchers suggest that induction for prolonged pregnancy actually decreases the likelihood of a caesarean section.6, 7, 29 It is certainly true that a few research studies showed a lower caesarean section rate in women who were induced.40, 47, 48, 49, 50 However, this has been questioned and remains controversial.29, 51, 52 It is worth noting midwives’ observation that, while research might not show an increase in caesarean associated with induction, the reality in hospitals where inductions are being carried out is somewhat different.53 Readers who are interested to know more about inductions and other medical interventions that may follow could refer to papers in the references section of this booklet including: Cardozo et al, 198654; Dyson et al, 198748; Martin et al, 198933; NICH, 199453; Herabuyta et al, 199232; and Otoide and Okonofua, 200155.

Deciding about induction if your baby is overdue Given the lack of evidence for routinely inducing labour before 42 weeks (and possibly not even then), each individual woman needs to make her own decision in the light of her personal circumstances. Hospitals are likely to continue to recommend induction despite research evidence to the contrary. We can only guess as to whether this is because of differences in philosophy, or for reasons that have nothing to do with the safety of women and babies.

Remember, if you are given an ‘induction date’ at an antenatal appointment and realise later that you are not happy with this decision you are entitled to change it. The maternity services are there to meet your needs, not the other way around!

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You (or your partner or a friend) can call the clinic or hospital and let them know.

You could get in touch with your midwife if you want to talk things through further. You could consider getting a second opinion.

Induction After the Waters Have Broken The amniotic sac, or bag of waters, that protects the baby in the uterus can break at any point before, during or at the end of the birth journey. For some women, this is the first sign that they are going into labour, and it will be followed soon afterwards by uterine contractions which get stronger until they give birth. Other women find that their waters break during their labour. Sometimes the membranes which contain the baby and the amniotic fluid can stay intact until the very end of labour, perhaps needing to be broken by the midwife as the baby comes out, so he can breathe air.

Occasionally the waters might break a few weeks before the due date and this can be a bit worrying. If this happens, and the baby is not yet due, the woman is likely to be offered monitoring until her baby has grown enough to be safely brought into the world. A few women’s waters will break around the time the baby is due but without any other signs of labour starting. In cases like these induction is likely to be advised at some point.

Researchers have calculated that, for every 100 women whose membranes break at term, but before the onset of labour: 86 will go into labour within the first 24 hours 91 will go into labour within the 48 hours 94 will go into labour within 96 hours 6 will not be in labour within 96 hours56 Dating of pregnancy is not always accurate (see page 19), so you should think carefully about whether you feel happy to be induced, especially if you are not

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sure you are ‘full term’ (which, in medical terms, is considered as being anywhere between 37 and 42 weeks pregnant).

Infection is the main risk of not being induced once the waters have broken. The amniotic fluid (“waters”) form a sterile environment around the baby, and, once broken, the chance of infection increases. This does not mean that every baby whose waters break will get an infection, and there are some things which you can do to reduce the risk of infection (although not all have been scientifically ‘proven’), such as: avoiding sex, or putting anything in or near the vagina (including internal examinations) having regular showers eating a healthy diet (including lots of fruit and vegetables, ensuring adequate amounts of protein and limiting sugar, saturated fats and ‘junk’ food) and drinking plenty of water checking your temperature regularly for signs of any rise that might indicate an infection. This may be something you want to discuss with your midwife to get more information about (see also Wickham 200457 for a full discussion on the issues surrounding Group B strep) The RCOG6 recommends that women who have what they call ‘prelabour rupture of the membranes’ (PROM) after 37 weeks (the point at which the baby is considered to have grown full-term) should be offered a choice of immediate induction or “conservative management” — that is regularly monitoring the well-being of the baby rather than inducing labour. If a problem should arise they would undoubtedly recommend induction.

The reviews of scientific research upon which the recommendation that women should be offered a choice between induction and monitoring looked at a number of studies which compared the outcomes of women who were induced with the outcomes of the women who waited for spontaneous labour.58, 59 Although

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there was a small reduction in the number of babies who had an infection in the group who were induced, this was not enormously significant. Between 37 and 56 women needed to be induced (the exact number depends on the way labour is induced) in order to prevent one baby developing an infection.

The authors of the review, which looked specifically at inducing labour with an syntocinon drip, noted that there could be bias in the studies — that is to say, the research was not as well conducted as it could have been, and the results may therefore be inaccurate.

The numbers of women and babies in the two studies which compared induction and waiting for labour were too small to see if this had an effect on perinatal mortality or morbidity. In other words, induction does reduce the risk of infection slightly, but the studies do not give us enough information about what the consequences were of the infections in both groups.

In terms of unwanted side effects, when women were induced with a gel inserted into their vagina, the risk of infection was greater than in the women who were not exposed to this intervention. However, these statistics are not as reliable as they might be.

It may also be important to think about the fact that women who are undergoing induction often have more vaginal examinations than women who are in spontaneous labour — each of these VEs carries the possibility of transmitting infection, even when sterile gloves are worn. The women who were induced with prostaglandin gel were also more likely to experience diarrhoea and also used more pain relief than women who waited for spontaneous labour.58 The current data is potentially flawed and, even though induction may decrease the rate of infection in babies, we don’t know whether this affects the babies in the long term. Given such uncertainty the RCOG’s recommendation that women should be “offered” a choice about what they would prefer to do if they experience prelabour rupture of their membranes is quite legitimate. We know a great many women are given the impression, nevertheless, that they have no say in the matter and must be induced.

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However, the RCOG only recommends waiting 96 hours (what they call ‘conservative management’), at which point they feel that all women should be induced.

Unlike most of its recommendations, which are clearly linked to research evidence, this recommendation is not.

There is certainly no evidence cited in the RCOG document which shows a benefit to women of being induced as soon as 96 hours have elapsed, although it is important to bear in mind the slight increase in the risk of infection. It may be that despite the lack of evidence (because 94% of women will have gone into labour already) the general attitude of the ‘medical model of care’ is that, where there is doubt, it is better to intervene than do nothing.

Women who have not gone into labour after 96 hours of their waters breaking will need to consider whether they agree with this philosophy, or whether they prefer to allow their labour to begin naturally. Because there is little scientific evidence which can help show which option is better, women may need to base a decision solely on how they feel and what they feel is right for them and their baby.

For women who decide to be induced at any point after their membranes have ruptured, the following information, which compared using prostaglandin gel with using a syntocinon drip, may also be useful:

women whose waters break around term and who are induced with prostaglandins alone (compared to those whose labour is begun with a syntocinon drip) have less risk of having an epidural or electronic fetal heart monitoring. They are more able to move around and have more natural labours

on the other hand, women who have prostaglandins (rather than starting with a syntocinon drip) seem to have a higher chance of getting an infection in the membranes which surround the baby, and are more likely to experience nausea and vomiting60

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Induction of Labour in Diabetic Women There are a number of general risks and benefits to being induced under any circumstances, as discussed in Section 2. If you are diabetic, however, there are some additional risks and benefits to induction which you need to carefully consider. It is likely that you will be offered induction of labour any time after your pregnancy reaches 39 weeks, and occasionally even earlier. Because the timing may be an issue, if you have diabetes, you may want to consider the issue of dating pregnancy as discussed on page 19.

It should be noted that the research in this area addresses the birth outcomes of women who have insulin-dependent diabetes, not women who develop “gestational” diabetes in pregnancy. There is, unfortunately, little evidence about the experiences of women with “gestational” diabetes, except to say that, as above, the RCOG do not consider having a large baby as a good reason for induction.

Indeed, some midwives and doctors are beginning to question whether gestational diabetes is even a “real” condition.

The two main causes for concern with diabetic women’s pregnancies going beyond 39 or 40 weeks are that: there may be a greater risk of the baby not surviving birth. the baby may be very large and the birth may be more difficult for the mother and/or the baby because of this.

Three studies have looked at the survival statistics of babies born to diabetic and non-diabetic mothers, and all found that babies born to diabetic mothers in the UK were around four to five times more likely to be stillborn than babies born to non-diabetic mothers.61, 62, 63 However, a closer look at these studies shows that they actually provide little or no information which can help a diabetic woman decide whether to be induced or not.

In the data used by Hawthorne, which was collected in the Northeast England in 1994, the perinatal mortality rate (i.e. the number of babies who die before they are a month old) for mothers without diabetes was ten in a thousand births.61

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The rate for women with diabetes was just under 42.8 in a thousand. This was a bit lower than for Hawthorne’s previous study, where the perinatal mortality rate was 48 in a thousand.63 However, there may be a problem with the statistics themselves.

The numbers of diabetic women who were included in Hawthorne’s studies were small; only 111 in the 1997 report and 304 (which probably includes the 111 women who were in the earlier study, although this is not clear from the paper) in the study published in 2000. When research is carried out on the outcomes of relatively small numbers of women, it is difficult to know whether the results are truly representative of the population (in this case, diabetic pregnant women) as a whole, or whether there just happened to be more or fewer women than usual with a particular problem. Just as the rate fell from 48 in a thousand to 42.8, the rate might fall again (or it might rise) in a study which looked at outcomes of even more women and babies.

In Casson’s study,62 while the outcomes of 462 pregnancies in 355 women suggest that the risk of fetal death in diabetic women was between four and five times higher than for non-diabetic women, this may be misleading as can be seen below.

Out of 462 pregnancies: 24 women terminated their pregnancies 78 women had miscarriages before the baby was mature enough to survive outside the womb.

351 live babies were born 9 babies died at or around the time of birth.

For the women who suffered miscarriages and had terminations, induction of labour would not have been an issue. It is possible that earlier induction may have made a difference to the number of babies who died around the time of

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birth, but it is also possible that those women were induced, and it made no difference, or induction may even have played a part in the babies’ deaths. We have no way of knowing this, because no information is given about whether or not the women in this study were induced, or at what stage in pregnancy they gave birth.

This is almost certainly because the authors of the study never intended that it should be used to decide whether or not to induce diabetic women. They were showing that, in general, diabetic women have a lower chance of a live healthy baby than a non-diabetic woman. The statistics above show that the majority of the babies who died did so at such an early stage in their mother’s pregnancies that induction of labour would have been irrelevant. Nevertheless, the RCOG uses Casson’s statistics to support a policy of induction at 39-40 weeks.

Only one study has compared the difference between inducing and not inducing diabetic women who reached 38 weeks of pregnancy. Again, the numbers were small (only 200 women were included) and no difference in the perinatal mortality rate was noted.64 The RCOG notes that its recommendation for induction of diabetic women is based, in part, on the fact that it is ‘usual practice’ rather than because it is based on sound research.

As far as the risks of mortality go, there is evidence to suggest that babies born to diabetic women are (on average) larger and obstetricians often assume that this will lead to more difficult births or birth injury.62 As above, assessment of when the baby is due is not always accurate and inducing babies before they are ‘due’ can lead to them having respiratory problems. All these issues need to be taken into account when making decisions about being induced before term, and a more recent survey of the evidence has noted that the benefit of induction in this instance is unclear.65

Induction at the Mother’s Request A few women have a good reason for requesting induction of labour before they are considered to be ‘overdue’, and feel that, on balance, the risks of induction are outweighed by the advantages for them. The RCOG recommendation to doctors is as follows:

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“Where resources allow, maternal request for induction of labour should be considered where there are compelling psychological or social reasons and the woman has a favourable cervix.” 6 While this recommendation does recognise that some women may have compelling reasons for wanting induction, it also gives doctors leeway to deny a woman her request for induction, on the grounds of scant resources or because her cervix is not ‘favourable’ (see page 44). Because some doctors tend to favour intervention in labour rather than natural birth, some women who request induction find that this is seen as a ‘good choice’ by their doctor, and have no problem achieving their aim.

Others, however, find that it can be just as hard to persuade a health professional that you want or need to be induced as it is to persuade a health professional that you don’t want or need to be induced. If this is your experience, some of the organisations listed in the References and Resources section may be able to help and support you. The information on Section 2 may also be useful in enabling you to be more informed about the process of induction so that you can discuss your views effectively with the people who are caring for you.

Induction of Large Babies Some women are offered induction because of concerns that the baby may be growing too large; the medical term for this is macrosomia. One of the worries with a baby who is thought to be large is that, if the baby grows much more, the birth may be complicated, or the baby may become ‘stuck’, causing birth injury.

The RCOG does not support induction because of a large baby on the grounds that there is no evidence that this is beneficial.6 This is a situation where it may be important to take individual factors into consideration. For instance, some women tend to grow larger babies, and have no problems birthing them. Almost every midwife who has been practising for a few years will be able to tell you a story about an eleven-plus pound baby who came out with no problems. Very rarely, babies do get stuck, and this can be serious, but

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this situation is not only linked to the size of the baby; other factors play a part too.

One of the most important things to think about is whether you feel your baby is large, or whether this is only the opinion of somebody who has ‘felt’ the baby.

Even ultrasound is not infallible in estimating the size of a baby, and midwives’ and doctors’ assessments are sometimes unreliable, as the story below shows: “I was looking after a woman who I thought had a fairly small baby, although I wasn’t really that worried about it. It was her fourth, and she and the baby were obviously doing well.

She gave birth at about 40 weeks to a healthy seven pound baby boy without any difficulty

— but imagine my surprise when another baby was born immediately afterwards! This one was a girl who weighed six pounds twelve and was really healthy too. I will never again take for granted that some babies just seem to ‘hide’ well in there, and you can’t always tell by feeling or scans exactly how big or small the baby is going to be.”

— Marcia, Community Midwife Moreover, the absolute size of the baby is less important than the relationship between the size of the baby and the size of the mother’s pelvis. In the absence of complications such as diabetes, most women tend not to grow babies that are too big for them to push out.

If you have previously given birth to large babies without problems, you may not consider induction to be necessary. Even if this is your first baby, you may discover that other women in your family tend to grow large babies, and asking them about their births may be helpful in weighing up your own decision.

Whether or not you suspect you have a large baby, it may be a good idea to read about active birth, and how being upright and mobile in labour (rather than on your back or sitting on a bed) can increase the internal dimensions of your pelvis and make it easier for all babies to be born (see AIMS publication Birthing Your Baby — The Second Stage). It may also be worth getting some advice about nutrition.

Induction in Twin Pregnancies The RCOG guidelines state that it is not possible to make recommendations for or against induction in twin pregnancy because there is not enough evidence to

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suggest that this is beneficial.6 As with diabetes, the rate of perinatal mortality is higher with twins than with single babies, but there is not necessarily any benefit to be gained from induction of labour. Twin births are more likely to be early than late, and the combination of this and the current medical trend for recommending caesarean section for twin births means that induction may be a moot point (see AIMS forthcoming publication on twins, due out in late 2004).

Induction for Other Obstetric or Medical Reasons There are a number of ‘obstetric’ reasons for recommending induction which relate to a condition which has appeared in this or a previous pregnancy.

These are some of the reasons given to women to explain why they were recommended to have their babies induced: having had a previous fast labour having had a previous caesarean section for a baby who was deemed too large to come through the birth canal, or who took ‘too long’ to be born expecting a baby who is in an unusual position, or having an unusually shaped pelvis Some of these could actually be seen as reasons not to have induction, especially where the position of the baby or the shape of the pelvis is an issue.

Medical reasons for induction might include medical conditions such as: pre-eclampsia pregnancy-induced high blood pressure obstetric cholestasis, a temporary disorder of liver function concerns about the baby’s well-being (perhaps because of possible infection or antibody problems)

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a pregnant woman who has a disease which cannot be treated until the baby is born The RCOG did not find any of these to be justifiable reasons for induction of labour. However, you may decide that one of them is a justifiable reason in your case. If you are offered induction for a medical or obstetric reason, some of the following suggestions may be useful: use the questions in the introductory section of this booklet to help you explore why this is being offered in your circumstances ask whether it is routine to induce somebody in your situation or whether there are specific indications which apply to you find out as much as you can from books, research articles, the Internet and groups such as AIMS so that you are well informed about the most recent information relating to your situation. Remember that not all information is equally valid and sometimes you need to take a careful look at whether it is carefully argued and based on accurate data, or whether it is personal opinion which may come from someone with a philosophy quite different from yours call AIMS or one of the other telephone helplines which are set up for women who need support and information if you feel it would be useful to talk through the decision or the issues with someone who is not involved Another reason that some women are offered induction is because their baby has died. While there is no evidence which suggests that automatically inducing labour is beneficial on a physical level,66 this is a very personal decision for women to make. Some of the risks of induction to babies become irrelevant in this situation, although there are still risks for the mother herself.

Some women feel that they would prefer to allow the labour to start spontaneously, as it almost always does, while others may feel more comfortable with having their labour induced quickly.

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If you are facing this decision, you may wish to reconsider any birth plan you have made in the light of the situation; some women decide that they would prefer to labour and give birth in their own homes, even though they had previously planned to give birth in hospital. Others might find that their feelings about whether or not they would choose pain relief change in this situation. It may be well worth taking a little time to think about how you feel about your options before you rush into any decisions, and your health professionals should be sensitive and respectful of this.

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2

THE PROCESS OF INDUCTION

While research evidence looks at induction from a medical point of view, we also need to know about women’s experiences and views. The names of the women whose stories follow have been changed to protect their privacy, and details which would identify hospitals or midwives have been omitted.

Women’s Stories “I was 11 days late with my third baby earlier this year and I asked to be induced. I was extremely large and could feel no signs of the baby coming and was finding it very difficult to lift my children, sleep or basically function at all. My first child had also been induced

— I had gone into labour a week overdue, gone to hospital and then everything completely stopped. They had then had to induce the labour but I had been given an epidural and my daughter was born 18 hours later by forceps.

“For my third baby I went to hospital in the morning for the induction. Once the procedure started I had to stay in the ward, with five other women, until I wanted to push — which happened about 3 hours later. Those 3 hours were extremely unpleasant (I can’t remember much now but my husband says I was in agony!) and I felt I was basically being ignored and was given no pain relief. It was also very embarrassing crying or whatever in front of the other women.

“When I said that I wanted to push I was rushed to the delivery room where, with the help of a fantastic midwife, the baby actually arrived about 6 hours later. (He arrived safely on gas and air and pethidine. He was OP [occipito posterior] and weighed 11lb 2oz).

“The time on the ward was really nasty but, to be honest, I have mainly forgotten it and I definitely do not regret the induction as I was getting too big and too tired and just wanted the baby to come.”

— Theresa

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“I had proudly announced for nine months wherever I went that I was to have a water birth at home. Friends, family, even strangers were in awe, ladies on the Marks & Spencer checkouts included. A few wise mums had warned, ‘Don’t be too disappointed if your birth plan doesn’t work out.’ Inside I disregarded what they said as things had always gone to plan for me.

“My dates had baby due 3rd February, the scan had shown baby due 30th January — fantastic as my best friend’s baby was due that very same day. These dates came and went (so did my best friend’s baby.) So I upped my dosage of caulophyllum given by my homeopath, nothing happened. My midwife set an induction date, it didn’t bother me as none of my friends had got to theirs and I certainly wouldn’t.

“We walked, in snow and ice everywhere and embarrassingly we went the next week to our antenatal class even though the previous week we had said goodbye and taken all that luck with us — fat lot of good that was!

“And so my induction day came and off to hospital I went leaving behind my birthing pool and cosy home. Filled with fear, anxiety and sadness due to the last time I had been in “that hospital” because of a miscarriage I went to my side room to start my induction, as I couldn’t face a main ward. The baby’s heart rate was 180+ so the prostin gel wasn’t applied until 11pm that night. Thank goodness I had a tens machine as it helped with the pains that came and went during the night.

“Next morning the examination showed just 1 centimetre dilation but never mind if had more prostin gel and I walked and walked the baby would come, after all we had learnt at antenatal classes the best labour was an active one. It was going home time for my husband, but don’t worry the midwife will call you if anything happens during the night. I felt gutted to see him walk out of my door for the second time in 24 hours, why can’t he stay or why can’t I go home and come back if anything happens. By this time I was fed up with the back pain, feeling very low but most of all tired so a sedative and painkiller did the trick and I fell in and out of sleep.

“As the doctor approached the next morning I felt sure I must have dilated some more — ‘Yes you can go across to central delivery suite you are 4 centimetres dilated! I will arrange for your waters to be broken and the baby will pop out.’ Assured the doctor. As I looked

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up at the doctor and his trainee and the ward midwife and whoever else stood over me. I asked ‘Do you have to break my waters yet, can we wait?’ ‘Well you are 15 days over due now and we really need this baby to be born because of certain risks’…so on and so forth.

Because of the risks that might be due to my waters being broken too soon I asked for it to be delayed until my midwife arrived. I didn’t back down after all my antenatal classes had taught me this. At 10am my husband and I went across to central delivery suite — a nice room awaited, rich golds and warm terracottas, yes this would be cosy after all.

“To my surprise a doctor and her assistant arrived to break my waters just a few minutes after I entered the delivery room, I don’t know why but I let them just get on and break my waters. As the doctor had four attempts all I could think was I hope she isn’t scratching that hook on my baby’s head.

“I was feeling so excited as my midwife who I hadn’t seen since entering the hospital was on her way even though it was her day off but more importantly so was my long awaited baby on its way! I cried when my midwife came in as I had been through so much and felt alone without her beside me, now all that was to change, it was real, I was in labour and I felt very secure once again! The contractions were coming and I was enjoying my active labour walking about the room. I decided I wanted to go into the birthing pool as things were progressing well. Surprise, surprise we hadn’t left the waiting game, further dilation was progressing slowly and the contractions faded. So at 3pm the person in charge of the Maternity Unit suggested the syntocinon infusion, but this would mean I had to leave the pool, have a monitor and I would have to be stood still in one place. The drip went in at 5pm.

“To my disappointment I began to see myself go down the winding road to the dreaded caesarean section, so from this moment onwards I was determined that I would stick to my guns and have just gas and air so I could stay in control of things and I was certainly not going to let them talk me into a section. We had learnt at antenatal class that birth by section was 33% in my hospital, a little knife happy compared to the rest of the country.

“At one point during the haze of things I remember a doctor in his operative gear coming in to the suite and introducing himself to us, which firstly worried me but more importantly gave me more strength to deliver this baby on my own. Apparently they were worried that the baby was getting tired and could see its heart rate changing. A little later I remember

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seeing my midwife’s face looking stern as she came back into the delivery suite and I think she had had words outside, something on the lines of we are fine and do not need any help. A bit of luck came my way after 11 hours of labour, a mum had come into have her twins, by caesarean section so we knew we had a hour where we would be left alone by those outside. Relief.

“I had decided I would deliver in the upright position and during the labour I had used my feet a lot and they hurt, so I asked for the floor mattress to be brought across. It worked a treat, my feet were now comfortable. The pushing had begun, it was great, I can honestly say once again I was enjoying labour, but I knew I had to go for it and get this baby out and quick because the doctor would be back. Luckily enough Erin was born after 12 hours and 14 minutes with the help of just gas and air, but with an unusual twist. As we know all babies’ heads are born in one contraction and the body comes in the next contraction, mine proved to be quite different, Erin popped out in one contraction and flew past my midwife’s hands and down onto the mattress! What a surprise to all of us!

“Looking back on the induction I feel it went well. I would have a second induction as a last resort but only because I was able to have a natural delivery that time. If the doctor had persisted and given me a section, then I would not go for induction next time around.

Rather I would have reflexology which I have since heard from so many other mums to be a good alternative.”

— Isobelle

The following story comes from a woman who was not induced, but had her labour speeded up. It has been included because there are similarities between the experience of induction and augmentation, and because it illustrates ways in which women can use the power of their minds to alter their experiences.

“The threat of induction hung over the last few weeks of my pregnancy as my baby was felt to be unusually large (he was 3.75 kilos at birth, which was 39 weeks). In the end, the contractions started naturally and I experienced the first few hours of labour at home.

However, after a 45-minute journey to hospital my contractions — which were at least every three minutes and 60 seconds in length when we left the house — had, unsurprisingly, almost stopped completely. The IV went in as a matter of course, and so too would

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the drug have done if I hadn’t protested. It was simply assumed that I would want my labour kickstarted again, and when I refused the clock-watching began, which put more pressure on my already nervous uterus. I eventually relented and agreed to ‘augmentation’ because I did not see how I could ever relax sufficiently in those hospital circumstances for labour to recommence, and asked for an epidural too to ease what I knew would be an unnatural amount of pain. I thereby proved what I already knew to be true, that intervention begets intervention.

“The progress of my cervix was checked every hour, and each hour the midwife shook his head and held up only three gloved fingers, then upped the dose of oxytocin. Three hours, three investigations, and an awful lot of drugs later, I had had enough. A mantra came into my head — ‘I am as open as the universe’ — which I chanted silently in my head, and I lay back and thought of open skies and billions of stars. An hour later, the same weary midwife came along with the same negative expectations of my bleak progress…only to discover that I was fully dilated and the baby’s head was halfway down the birth canal (remember the epidural was still in effect). He arrived three pushes later, safe and well.

“Apart from the joy and wonder of the arrival of my beautiful baby boy, there were two personal triumphs for me: 1) having accepted augmentation and an epidural I was thrilled not to have ended up in the operating theatre having a caesarean; and 2) having accepted augmentation that then seemed not to ‘work’ initially, I managed to regain some sense of control through the power of my mind.”

— Bea

Place of induction Medical inductions almost always take place in hospital. As a general rule, you are likely to be admitted to an antenatal ward, where you will be examined by a midwife (and possibly a doctor). This will usually include a vaginal examination to assess the state of your cervix (see ‘Cervical Scoring’ next page) and the baby will be monitored for at least 20-30 minutes. If there are aspects of the induction process you want know more about, this is the time to ask questions and discuss it further. You may find things move quite quickly after this, and it may be more difficult to stop the process and/or ask questions later on.

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Often, you will be in a room with other women whose labours are also being induced. You can request a side room if you would prefer this, but one may not be available, or you may be told you need to pay for the privilege. You may like to bear in mind that privacy has been shown to be hugely important to labouring women, and labour often doesn’t start (or if it has started, it may stop) in situations where women feel they are being observed.

If you have a gel inserted into your vagina to soften your cervix and start labour, you will probably move to the labour ward once your contractions have become strong, if you feel you need pain relief, or when the decision is made to break your waters and/or put up a drip.

Women who have obstetric or medical complications may go straight to the labour ward when they come into the hospital. Some hospitals also have special areas which are close to the labour ward for women who are being induced.

You may want to ask more about where you will be before you agree to induction because a major problem for many women is that their partners or birth companions are not allowed onto the antenatal ward, or if they are, they have to leave overnight (which is often when you want them with you the most). Partners can usually stay with you once you are on the labour ward, but you may be in early labour on the antenatal ward for quite a while before this happens. Being unexpectedly separated can be distressing if you wanted your partner with you, and may affect the progress of your labour, so you may want to discuss this with the hospital staff ahead of time.

Cervical Scoring One of the reasons for doing a vaginal examination when you arrive in hospital is to assess the state of your cervix (the opening of your womb). During late pregnancy and early labour, the cervix becomes softer and moves forward. As labour progresses, your cervix thins (effaces) and opens (dilates), so that the baby can pass through the birth canal. An internal examination to assess the softness, position, thickness and dilation of your cervix, will help determine what methods are most appropriate to induce your labour.

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If the cervix is easy to reach, soft, thinning and has dilated a couple of centimetres (not uncommon, especially for women who have already had a baby), then it may be possible to break the waters immediately and see if that starts contractions.

“When I had my first baby I opted for home birth — everything went brilliantly — she was born on the day she was due and no complications either in pregnancy or birth. Sixteen months later my second baby was due on 25th March, again at home. Completely different pregnancy, and when she became a week overdue I was sent to the hospital for a check up. I told them I wanted a home birth so they gave me another week’s chance but despite enormous enemas by my community midwife she refused to budge.

“On 9th April I was admitted eventually to hospital and put in a single room — settling down in a noisy ward isn’t easy. During the evening the medical staff decided I would need a good night’s sleep before being induced at 8am the next morning and gave me two sleeping tablets and I looked forward to sleep! But at midnight they came in to see me and said as they had a lot of births/inductions the next day they were going to take me there and then to induce me.

“I duly arrived in delivery suite and my waters were broken. When contractions started I was left on my own, being told to time contractions and intervals between! By the time I saw nurses again I was so woozy that I couldn’t remember how long anything was or where the call button was.

“Things moved so quickly — there was panic stations when they came back and realised I was almost ready to push, and at 5.50am my second daughter was born.

This was nothing like my home birth experience. I had a lot more pain, and I was cut. In fact, when the doctor came to stitch me up (internally as well as externally) all he could talk about was patchwork quilts! The baby ended up in SCBU (special care baby unit) for 24 hours as they said they couldn’t get her warm. I was very relieved that I hadn’t had this experience for my first birth — especially as she arrived so quickly my husband couldn’t get to the hospital in time to see her born as he had the first time.”

— Muriel If the cervix is still high, hard and not yet thinning or opening, the midwife or doctor will recommend using one or more doses of prostaglandin gel (or possi-

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bly another substance) to help the cervix soften and open. It is not uncommon for women to have one pessary or dose of gel, be assessed again several hours later, and then have another one and wait. Induction can be a long and tiring process, although in some women labour can start quickly.

“Sweeping the Membranes” You may request, or your midwife may offer you a ‘stretch and sweep’, (also known as ‘stripping’ or ‘sweeping’ the membranes). This is a technique which midwives have used for years to try to bring on labour, which can be performed at home or during an antenatal check.

The midwife will insert her fingers into the woman’s vagina, as in a normal vaginal examination, and will try to get a finger through the cervix so that she can ‘sweep’ the membranes away from the cervix. This is thought to stimulate the natural production of prostaglandins, and is done in an attempt to help women’s labours to start. These days, it is often performed at the request of women who are facing medical induction of labour and who want to try and avoid this.

One medical review set out to evaluate the effectiveness of this procedure.67 It found that, when sweeping the membranes is performed, fewer pregnancies go on beyond 41 weeks. It did not increase the risk of infection in women or babies, although it did cause discomfort to some women and carried a slight risk of local bleeding. The doctors who wrote this review felt that sweeping the membranes should not be done routinely, as it does not lead to “clinically important benefits”.

They did not seem to give any importance to the views of women who thus avoided the increased pain and side effects of medical induction methods.

However, they did acknowledge that it was effective in starting labour in a proportion of women, and women who are facing medical induction may wish to weigh up the risks and discomfort against the possibility that this may prevent the need for medical induction.

The RCOG recommends that women should be offered this procedure prior to formal induction of labour.26

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Prostaglandins Prostaglandins are hormones produced naturally by a woman’s body at the end of pregnancy and in the early part of labour, which help the cervix to become soft and ready to open. Pharmacological versions of prostaglandins are used widely in labour induction, generally in the form of a pessary or gel, which is placed high in the vagina during vaginal examination, usually with the aid of plastic applicators (similar in the size to a plastic tampon applicator).

Your midwife will slide this along her fingers until she can feel it is in the correct place, then release the pessary or gel and remove the applicator and her fingers.

Women are usually asked to lie down for half an hour after insertion of a pessary or gel to prevent it moving or leaking from the vagina and, fetal monitoring will be advised for about the same length of time.

Prostin®, Dinoprostone® and Prepidil® and brands of pharmaceutical prostaglandin E2, known to cause a number of side effects: nausea and vomiting68 diarrhoea60 dlight hypotension (lowering of blood pressure)68 increased need for pain relief compared to when labour begins naturally60 uterine hyperstimulation (where contractions become extremely strong)68 fetal distress68 very rarely, uterine rupture —a serious condition necessitating emergency surgery. many women report that vaginal examination is more painful than usual following the administration of prostaglandins.

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Upjohn Pharmaceuticals, the makers of one of the major brands of prostaglandin E2, suggest that there are a number of circumstances where it should not be used, including women: who have previously had a caesarean section or major uterine surgery who are pregnant with more than one baby who have polyhydramnios (an excess of amniotic fluid) whose membranes have already ruptured whose baby’s head has not yet engaged in their pelvis who have had unexplained bleeding during pregnancy who have epilepsy They also advise caution in the use of prostaglandins in women who have heart, lung, liver or kidney problems or who have asthma or glaucoma. They suggest that at least 12 hours should elapse after the use of prostaglandin gel before an oxytocic drip is started, although the RCOG only recommends waiting 6 hours.6 The dosage and total amount used should be adjusted to reflect your personal circumstances, including the number of babies you have had before, and you may want to discuss this with your caregivers.

Midwives report that women who have been given synthetic prostaglandins often experience a short period of intensely painful contractions, which subside after a while. These are sometimes colloquially called “prostin contractions”.

It may be worth bearing in mind that these kind of contractions do not usually last for long because you will then know that there should be an end to the extreme discomfort. Also, it can be tempting to think that contractions this painful must be dilating your cervix rapidly, when this may not be the case.

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Misoprostol/Prostaglandin E1 This is the less commonly used form of prostaglandin, although you may still encounter its use in parts of the UK if you are asked to participate in a research study evaluating it.

Misoprostol (spelled “Misoprostil� by some people) is actually a drug for treating stomach ulcers, but the tablets were somehow discovered to be effective in inducing labour. Some doctors are advocating its more widespread use for labour induction because it is much cheaper than the substances they currently use. It is thought to be more effective and it can be stored at room temperature (whereas prostaglandin E2 preparations need to be kept in a fridge) and can be given orally as well as vaginally. However, it is as yet unlicensed for use in pregnant or labouring women, and its safety has not been established in large scale trials.5 The makers of Misoprostol are on record as saying that it is a drug which is strongly contra-indicated for pregnant women and women in labour, yet doctors have persisted in attempting to investigate its use in induction. In one study, Carlan discovered that, while it is effective in starting labour, it causes excessively strong contractions and subsequent medical intervention at a much higher rate than prostaglandin E2.70 There was no investigation of what the women felt about these very painful and intense contractions.

A number of birth activists, including American midwife Ina May Gaskin and retired perinatologist Marsden Wagner, have highlighted some very serious

A note for vegans and vegetarians Many of the drugs used in maternity care are derived from animal products, and tested on animals, and the drugs used for induction are no exception. The hormones in the drugs used for induction are animalderived; prostaglandin gel is made from pig semen, and syntocinon preparations contain pituitary extracts from mammals.73 There are, to my knowledge, no pharmaceutical alternatives which can induce labour yet which do not use animal-derived material.

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risks of Misoprostol, including a higher rate of uterine rupture and maternal death than should be expected with induction of labour. They have become so concerned about the data and the fact that some members of the medical profession are continuing to use this drug without evidence of safety or appropriate licensing, that they are trying to reach women directly by publishing articles about the risks.

Links to some of these articles can be found in the resources section. The RCOG acknowledges that the safety of misoprostol for labour induction is unclear and recommends further clinical trials.6 Anecdotally, in some areas, so many women have declined to take part in these trials (on the basis of the concerns which have been raised elsewhere) that some of these trials have had to be abandoned.

Note: Some hospitals are also using Misoprostol during the third stage of labour —this is a different issue which also raises questions, but where the safety record is less dubious.

Vaginal Examinations (VEs) Women whose labours are induced often have many vaginal examinations during the process. Staff will want to examine you before they insert a gel or pessary, break your waters or put up a drip. The actual insertion of a gel or pessary, or the breaking of your waters are both done via vaginal examination. If a drip is put up, regular vaginal examination is carried out, sometimes every two hours, to assess progress. Vaginal examinations may also be performed if you request pain relief or if there is concern about the baby’s well-being.

Vaginal examinations can be embarrassing, uncomfortable and/or painful, and they carry risks of introducing infection into the vagina or uterus. You have every right to ask if each vaginal examination is really necessary, and/or to ask that these be kept to a minimum.

You do not have to allow midwifery or medical students to examine you if you do not wish to. Although they are a requisite part of induction, as they enable assessment of your progress, you have every right to decline or to negotiate with your caregivers how often these are carried out, and by whom.

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Monitoring the Baby All hospitals are equipped with cardiotocograph (CTG) monitors which measure the baby’s heartbeat using ultrasound and, with much less accuracy, the strength of your contractions. Continuous monitoring is where the CTG transducers (the circular disks which pick up the sound) are attached to your abdomen with belts and left on for a while. Midwives often want to monitor for half an hour or so to check the baby is well, following the insertion of prostaglandin gel. After an induction it is not unusual for staff to want to continuously monitor, using a CTG, until the baby is born.

Intermittent monitoring may be done using a Pinard (ear-trumpet), a hand-held ‘sonicaid’ (another ultrasound device), or by the midwife holding one of the transducers from the CTG (rather than having it strapped to your abdomen with a belt). It is an equally effective way of ‘listening in’ to the baby’s heartbeat on a regular basis, and assessing the baby’s well-being as continuous electronic fetal monitoring using a CTG machine. The frequency of intermittent monitoring will depend on your situation and what stage of labour you are in (the advantages of intermittent monitoring are detailed more fully in AIMS’ Birthing Your Baby — The Second Stage).

The RCOG recommends that different kinds of monitoring be used at different times.6 How long the monitoring should last is a rough guide only, as this will depend on hospital policy and the condition of your baby (e.g. sleeping babies have a different heartbeat pattern, and the midwife may ask you if she can leave the CTG on until the baby wakes).

Women often complain that they are left for long periods of time on a CTG monitor without midwives coming back to check the trace and that all is well with the baby because they are so busy. It is important to appreciate that continuous monitoring should only be done if it is thought that the baby’s well-being may be compromised, so it is essential that you are not left unattended on a CTG for long periods of time. If all is well with your baby, continuous monitoring should give way to intermittent monitoring and the belts removed as soon as possible.

If there is concern about the baby, or you have a particular risk factor, the CTG

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may be left on for longer because it is assumed that this improves the safety of the baby. However, there is little research to support this.

Generally, the RCOG guidelines on monitoring suggest: continuous monitoring (for around 30 minutes) before induction, to check that the baby is well continuous monitoring (for another 30 minutes to an hour) immediately following the insertion of a prostaglandin tablet or gel, to ensure that the baby’s heartbeat stays within normal limits once the baby’s well-being has been established after the insertion of prostaglandin tablet or gel, intermittent monitoring until re-assessment of your cervix continuous monitoring before and during the use of a syntocinon drip although there are no specific guidelines about monitoring before, during and after artificial rupture of membranes (breaking the waters), it is likely that the midwife will listen to the baby’s heartbeat before she does this and for a couple of minutes afterwards Fetal monitoring is not an exact science. Occasionally there will be a ‘false negative’ trace where the baby will appear to be healthy on the monitor, but may actually be poorly when it is born. Another, far more common problem is with ‘false positive’ CTG traces, which indicate a baby is in distress. Sometimes this is regarded as a serious emergency and the woman is rushed into theatre for a caesarean section, yet the baby is delivered in perfectly good health.

There are resources listed in section five if you want more information about fetal monitoring. You do not have to consent to being monitored, although if you are induced, you may want to be monitored because of the potential effects of the drugs used for induction on the baby.

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Artificial Rupture of Membranes Artificial rupture of the membranes (ARM), or “amniotomy”, is a procedure where the midwife uses a small plastic hook or thimble-like device during vaginal examination to break the waters in an attempt to start or accelerate labour.

This procedure may be done without using synthetic prostaglandins if the cervix is ripe, or following one or more doses of prostaglandins.

There is little data comparing ARM with other ways of inducing labour, and, as it is usually used in combination with other methods, its efficacy may be difficult to establish.71 Like other methods of labour induction, ARM can: speed up contractions cause pain to increase faster than if you were in spontaneous labour increase risk of infection and umbilical cord prolapse (where the cord slips in front of the baby’s head necessitating an immediate emergency caesarean) cause fetal distress and bleeding72 Once ARM has been performed, the woman and her caregivers are committed to the continuation of the induction, since the risk of infection to the baby is increased by breaking the waters. This, then, also carries the risk that, if the ARM and concurrent methods of inducing labour are not successful, the woman may end up having a caesarean section.

Syntocinon Drip Oxytocin is a hormone which is produced naturally by women in labour, during breastfeeding and in other natural processes. Pharmaceutical companies produce a synthetic form called syntocinon which can be given intravenously (via a drip and needle inserted into the arm or hand) to start and/or speed up labour.

Oxytocin causes uterine contractions, but the contractions produced by syntocinon

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may become much stronger and more painful more quickly than the contractions of spontaneous natural labour. Some women request that the speed of the drip be turned down if the contractions become too overwhelming In order to control the strength and duration of syntocinon-induced contractions as much as possible (both for the woman’s comfort and because strong contractions can be hazardous to both the mother and baby), the drip will be started at a slow rate and then gradually increased over time. As there are risks to using syntocinon, the contractions and the baby’s heartbeat will be monitored continuously once a drip has been started. The midwife should stop increasing the drip once contractions are strong enough to be dilating the cervix as measured by vaginal examination.

Women who have had prostaglandin gel and/or artificial rupture of membranes should be able to walk around once the baby’s well-being has been established through a period of fetal monitoring but women who are being given intravenous syntocinon are usually monitored continuously.

As this involves the attachment of two transducers to the mother’s abdomen by belts, and wires connecting the transducers and the CTG machine itself, it can be very difficult for her to walk around or to change position. This can be a cause of serious additional discomfort and sometimes distress to some women, because moving around and changing position can reduce the pain of contractions. As a consequence of this, and the increased pain of contractions caused by artificial syntocinon, women who have this drip are more likely to want an epidural — indeed, many hospital will offer this at the same time as putting syntocinon up.

The risks of syntocinon are similar to the risks of prostaglandins, and include: hyperstimulation of the uterus, causing very painful contractions which can cause the baby to become distressed lowered blood pressure uterine rupture

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Failed Induction For some women, no amount of drugs will bring on labour, and the decision may be made that, despite all efforts, the induction has ‘failed’ and a caesarean section is necessary For others, the side effects of the drugs used may cause fetal distress or hyperstimulation of the uterus — both potentially serious situations likely to necessitate a caesarean delivery.

Do not think you have failed if your body does not go into labour, if your labour does not progress as fast as the professionals would like, or if your baby becomes distressed as a result of the drugs you have been given. Although the language used can sometimes make it sound like it is your ‘fault’, it is Western medicine and inductions which sometimes fail; women’s bodies do not.

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3

NON-MEDICAL INDUCTION OF LABOUR

There are a number of time-honoured ways in which women attempt to encourage their labours to start, including eating certain foods (e.g. hot curry, fresh pineapple), making love, riding down bumpy roads in the car or bouncing on a birth ball, having a glass of wine or taking a brisk walk. Whether or not these things work to stimulate labour is perhaps secondary to the fact that they are things that women might do anyway, and they are unlikely to do any harm.

Some women also know (or are told by their midwives) that there are non-medical ways of inducing labour which might be more effective, such as acupuncture, herbs, reflexology and homeopathy. These methods are an alternative to spending the early part of labour in a hospital and can be an attractive alternative to women who want their labour to start, but without the drugs, monitoring or interference which are often involved in the process of medical induction.

These methods have generally not been tested for effectiveness and relative safety, primarily because they are not valued by the sort of bodies who allocate money for medical research, but also because the people who use them understand that scientific experiments are not always the best way of testing such methods. However, as has been discussed already in this booklet, some aspects of the medical methods of induction have not always been tested as rigorously as you might suppose either.

The decision to try a method of non-medical induction of labour is often made in response to the pressure put on women to accept medical inductions they would rather avoid. Any method to try to induce should be carefully considered because of the effect on the baby and because the baby may not be ready to be born (see page 19 for more on dating pregnancy).

However non-medical methods of induction can be a positive choice for some

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women. They can enable women to have the home birth they planned, or to retain some control over the early part of their labour before they go to hospital once strong contractions are established. They can make the difference between feeling very pressured because a hospital-imposed ‘deadline’ is looming, and feeling that they are taking some control back. The choice of non-medical induction is a very personal one and women might like to explore some of the different methods and think just as carefully about the issues surrounding this option as they would about medical induction.

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4

A FINAL WORD

This booklet has explored some of the complex issues surrounding what has become a very common intervention at the end of pregnancy.

Do consider these issues and decide which option is best for you. There are pros and cons to be considered for most of the decisions you will make about what’s best for your baby during the childbearing year and for many years to come, and whether or not to have an induction is no exception.

Midwives and doctors do not understand the mechanism by which labour starts although it is known that it is the baby itself who triggers labour. Many women feel that they would rather trust their baby to arrive when it is ready rather than rushing it into the world with man-made drugs based on estimates that may not be accurate.

The bottom line should be — get as much relevant information as possible and then choose what feels right for you, rather than going along with what anybody else thinks. The resources in the following section provide ideas of where to go if you would like to follow up some of the things discussed here in more depth.

About AIMS The Association for Improvements in the Maternity Services (AIMS) has been has been at the forefront of the childbirth movement for the last forty years. Our day to day work includes providing independent support and information about maternity choices and raising awareness of current research on childbirth and related issues. AIMS actively supports parents and healthcare professionals who recognise that, for the majority of women, birth is a normal rather than a medical event.

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5

REFERENCES AND RESOURCES

References 1 Oteri O and Tasker M (1997). Get Set and Go: Conventional Action. New Generation, December 1997, 10-11.

2 Van der Kooy B (1994) Calculating expected date of delivery — its accuracy and relevance. Midwifery Matters, 60: 4-7,24.

3 Tew M (1986) ‘Do obstetric intranatal interventions make birth safer?’ British Journal of Obstetrics and Gynaecology 93: 659-674.

4 Cardozo (1993) Is routine induction of labour at term ever justified? British Medical Journal 306: 840-841.

5 Alfirevic Z and Walkinshaw S (1994) Management of post-term pregnancy — to induce or not? British Journal of Hospital Medicine 52.5: 218-21 6 Royal College of Obstetricians and Gynaecologists (RCOG) (2001) Induction of Labour.

Evidence-Based Clinical Guideline Number 9. RCOG Press, London.

7 National Institute for Clinical Excellence (2001) Induction of Labour. Inherited Clinical Guideline D. London: National Institute for Clinical Excellence.

8 Sande HA, Tuveng J, Fonstelien T (1983) A prospective randomised study of induction of labor. International Journal of Gynaecology and Obstetrics, 21: 333-36.

9 Warren C (1986) The dilemma of prolonged pregnancy. Midwifery Matters, 29: 17-18.

10 Saunders N and Paterson C (1991) Can we abandon Naegele’s rule? The Lancet, 337: 600-601.

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11 Rosser J (2000) Calculating the EDD; which is more accurate, scan or LMP? The Practising Midwife, 3(3), 28-29.

12 Attico NB, Meyer DJ, Bodin HJ and others (1990)

Gestational age assessment.

American Family Physician, 41: 553-60.

13 Anderson T (2000). How to calculate an EDD. The Practising Midwife, 3(3): 12-13.

14 Baskett T and Nagele F (2000)

Naegele’s rule: a reappraisal.

British Journal of

Obstetrics and Gynaecology, 107: 1433-1435.

15 Olsen O and Clausen JA (1997) Routine ultrasound dating has not been shown to be more accurate than the calendar method. British Journal of Obstetrics and Gynecology, 104: 1221-22.

16 Bergsjo P, Daniel W, Denman III DW et al (1990) Duration of human singleton pregnancy; a population-based study. Acta Obstetrica Gynecologica Scandinavica, 69: 197207.

17 Backe B and Nakling J (1994) Term prediction in routine ultrasound practice. Acta Obstetrica Gynecologica Scandinavica, 73: 113-18.

18 Mittendorf R, Williams MA, Berkey CS and others (1990) The length of uncomplicated human gestation. Obstetrics and Gynecology, 75: 929-32.

19 Stronge JM and Rasmussen MJ (1991) Naegele’s Rule (correspondence) The Lancet, 337: 910 20 Wickham S (2002) Challenging births 3. Midwifery Today , no 61, pp 34-35 21 Mittendorf R, Williams MA, Berkey CS and others (1993) Predictors of human gestational length. American Journal of Obstetrics and Gynecology, 168: 480-84.

22 Gardosi J and Geirsson RT (1998) Routine ultrasound is the method of choice for dating pregnancy. British Journal of Obstetrics and Gynaecology; 105: 933-36.

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23 Campbell S, Warsof SL, Little D and others (1985) Routine ultrasound screening for the prediction of gestational age. Obstetrics and Gynecology; 95: 613-20.

24 Moore WMO, Ward BS, Jones VP and others (1988) Sex differences in fetal head growth. British Journal of Obstetrics and Gynaecology; 95: 238-42.

25 Moore WMO (1991) Naegele’s Rule (correspondence) The Lancet, 337: 910 26 Crowther CA, Kornman L, O’Callaghan S, George K, Furness M, Willson K (1999) Is an ultrasound assessment of gestational age at the first antenatal visit of value?

A randomised clinical trial. British Journal of Obstetrics and Gynaecology, 106: 1273-79.

27 Neilson JP (2003). Ultrasound for fetal assessment in early pregnancy (Cochrane Review). In: The Cochrane Library, Oxford: Update Software.

28 Beech BAL (1999) Ultrasound — weighing the propaganda against the facts Midwifery Today, 51: 31-33.

29 Crowley P. (2003) Interventions for preventing or improving the outcome of delivery at or beyond term (Cochrane Review). In: The Cochrane Library, Oxford: Update Software.

30 Augensen K, Bergsjo P, Eikeland T, Ashvik K, Carlsen J. (1987) Randomized comparison of early versus late induction of labour in post-term pregnancy.

British Medical

Journal, 294: 1192-1195.

31 Heden L, Ingemarsson I, Ahlstrom H, Solum T. (1991) Induction of labor vs conservative management in prolonged pregnancy: controlled study.

32 Herabutya Y, Prasertsawat PO, Tongyai T, Isarangura Na Ayudthya N. (1992) Prolonged pregnancy: the management dilemma. International Journal of Gynecology and Obstetrics; 37: 253-258.

33 Martin JN, Sessums JK, Howard P, Martin RW, Morrison JC. (1989) Alternative approaches to the management of gravidas with prolonged post-term postdate pregnancies. Journal of the Missouri State Medical Association, 30: 105-111.

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34 National Institute of Child Health and Human Development Network of MaternalFetal Medicine Units. (NICH) (1994) A clinical trial of induction of labor versus expectant management in postterm pregnancy. American Journal of Obstetrics and Gynecology, 170: 716-723.

35 Suikkari AM, Jalkanen M, Heiskala H, Koskela O. (1983) Prolonged pregnancy: induction or observation. Acta Obstetrica Gynecoogical Scandinavica Supplement, 116: 58.

36 Witter FR, Weitz CM. (1987) A randomised trial of induction at 42 weeks of gestation vs expectant management for postdates pregnancies. American Journal of Perinatology, 4: 206-211.

37 Yeh S and Read JA (1982) Management of postterm pregnancy in a large obstetric population. Obstetrics and Gynecology, 60, 282-87.

38 Matijeviae R (1998). Outcome of post-term pregnancy; a matched pair case-control study. Croatian Medical Journal, 39(4); 11-14.

39 Alexander JM, McIntyre DD, Leveno KJ (2000) Forty weeks and beyond: pregnancy outcomes by week of gestation. Obstetrics and Gynecology, 96(2): 291-4.

40 Bergsjo P, Gui-dan H, Su-qin Y, Zhi-zeng G, Bakketeig LS. (1989) Comparison of induced vs non-induced labor in post-term pregnancy.

Acta Obstetricia Gynecologica

Scandinavica 68: 683-687.

41 Duff C and Sinclair M (2000) Exploring the risks associated with induction of labour: a retrospective study using the NIMATS database. Journal of Advanced Nursing, 31(2): 410417 42 Menticoglou SM and Hall PF (2002) Routine induction of labour at 41 weeks gestation: nonsensus consensus. BJOG: An International Journal of Obstetrics and Gynaecology, 109(5): 485-491 43 Vorherr H (1975) Placental insufficiency in relation to post-term pregnancy and fetal maturity. Evaluation of feto-placental function, and management of the post-term gravida.

American Journal of Obstetrics and Gynaecology, 168, 557-563.

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44 Gibb DMF, Cardozo LD, Studd JWW, Cooper DJ. (1982) Prolonged pregnancy: is induction of labour indicated? A prospective study. British Journal of Obstetrics and Gynaecology, 89; 292-95.

45 Griffin N (2001) Let the baby decide: the case against inducing labour. Mothering, 105: 64-71 46 Goer H (1995) Obstetric myths versus research realities. Greenwood Press, Westport CT. 47 Hannah ME, Hannah WJ, Hellman J, and others (1992) Canadian Multicenter PostTerm Pregnancy Trial Group. Induction of Labour as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. New England Journal of Medicine, 326: 1587-1592.

48 Dyson D, Miller PD, Armstrong MA. (1987). Management of prolonged pregnancy: induction of labour versus antepartum testing. American Journal of Obstetrics and Gynecology 156: 928-934.

49 Egarter CH, Kofler E, Fitz R, Husselein P. (1989) Is induction of labour indicated in prolonged pregnancy? Results of a prospective randomised trial.

Gynecological and

Obstetric Investigations 27: 6-9.

50 Katz Z, Yemini M, Lancet M, Mogilner BM, Ben-Hur H, Caspi B. (1983) Non-aggressive management of post-date pregnancies. European Journal of Obstetrics Gynecology & Reproductive Biology; 15: 71-79.

51 Kierse MJNC (1993) Post-term pregnancy: new lessons from an unresolved debate.

Birth, 20(2), 102-5.

52 Wickham S (2003) Seeing women in the numbers. MIDIRS Midwifery Digest, 13(4), 439-444.

53 Anderson T (2002) Prolonged pregnancy, prolonged labour. Paper presented at the Midwifery Today Conference, The Hague, Holland.

54 Cardozo L, Fysh J, Pearce JM. (1986) Prolonged pregnancy: the management debate.

British Medical Journal; 293: 1059-1063.

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55 Otoide VO and Okonofua FE (2001) Outcome of prolonged pregnancy revisited in a Nigerian tertiary centre. Journal of Obstetrics and Gynaecology, 21(3), 261-65.

56 Savitz DA, Ananth CV, Luther ER, Thorp JM. (1997) Influence of gestational age on the time from spontaneous rupture of the chorioamniotic membranes to the onset of labour.

Nerican Jornal of Perinatology. 14: 129-33.

57 Wickham S (2004) The War on Group B Strep. AIMS Journal, 2003/04, 15(4) 7-9 58 Tan BP, Hannah ME. (2003a) Oxytocin for prelabour rupture of membranes at or near term (Cochrane Review). In: The Cochrane Library. Oxford: Update Software.

59 Tan BP, Hannah ME. (2003b) Prostaglandins for prelabour rupture of membranes at or near term (Cochrane Review). In: The Cochrane Library. Oxford: Update Software.

60 Tan BP, Hannah ME. (2001) Prostaglandins versus oxytocin for prelabour rupture of membranes at or near term (Cochrane Review). In: The Cochrane Library. Oxford: Update Software.

61 Hawthorne G , Irgens L M , Lie R T (2000). Outcome of pregnancy in diabetic women in northeast England and in Norway, 1994-7 British Medical Journal; 321: 730-731 62 Casson I F, Clarke C A, Howard C V, and others. (1997) Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population cohort study British Medical Journal; 315: 275-278 63 Hawthorne G, Robson S, E A Ryall, and others; on behalf of the Northern Diabetic Pregnancy Audit. (1997) Prospective population based survey of outcome of pregnancy in diabetic women: results of the Northern Diabetic Pregnancy Audit, 1994 British Medical Journal; 315: 279-281.

64 Boulvain M, Stan C, Irion O (2001) Elective delivery in diabetic women (Cochrane Review) In: The Cochrane Library. Oxford, Update Software.

65 Sacks DA; Sacks A (2002) Induction of labor versus conservative management of pregnant diabetic women. Journal of Maternal-Fetal and Neonatal Medicine, 12(6), 438-441.

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66 Enkin M, Kierse MJNC, Neilson J, Crowther C, Duley L, Honett E and Hofmeyer J (2000) A Guide to Effective Care in Pregnancy and Childbirth. 3rd edition. Oxford University Press, Oxford.

67 Boulvain M, Stan C, Irion O. (2003) Membrane sweeping for induction of labour (Cochrane Review). In: The Cochrane Library. Oxford: Update Software 68 Upjohn Pharmaceuticals (2003) Prostin® Product Information. Can be accessed at: www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs /CPS-%20(General%20Monographs-%20P)/PROSTINE%20E%20VAGINAL%20GEL.html 69 Alfirevic Z. Oral misoprostol for induction of labour (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.

70 Carlan SJ; Bouldin S; Blust D; and others (2001) Safety and efficacy of misoprostol orally and vaginally: a randomized trial. Obstetrics and Gynecology, 98: 1, 107-112 71 Bricker L, Luckas M. (2003) Amniotomy alone for induction of labour (Cochrane Review). In: The Cochrane Library. Oxford: Update Software 72 Shiers C (2003) Prolonged pregnancy and disorders of uterine action. Chapter 29, pp 531-549. In Fraser DM and Cooper MA (Eds) (2003) Myles Textbook for Midwives.

Churchill Livingstone, London.

73 Monarch Pharmaceuticals (2003)

Keeping a Record of Your Menstrual Cycle Information and downloadable charts to help you keep a record of your menstrual cycle and when you become pregnant can be found at: www.irh.org/nfpchart.html http://cycledaily.com/download.htm

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Recommended books include: Margaret Nofziger’s “A Cooperative Method of Natural Birth Control”.

(1992) The Book Publishing Company, Summertown, Tennessee Toni Weschler’s “Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health” (2001) HarperCollins Publishers

Information About Non-medical Induction Smith CA, Crowther CA (2003) Acupuncture for induction of labour (Cochrane Review). (Date of most recent substantive update: 24 November 2000) In: The Cochrane Library. Oxford: Update Software, issue 2, 2003 This and similar Cochrane reviews www.rccm.org.uk/static/Review_Cochrane.asp

can

be

accessed

at

There is a large document consisting of archives of ‘e-group’ conversations between midwives discussing non-medical methods of induction at: www.gentlebirth.org/Midwife/natinduc.html See also: Martin P (2002) Homeopathic induction: beyond cimicifuga and caulophyllum. Midwifery Today, Autumn 2002, 63: 28-30. Available at: www.midwiferytoday.com

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Fetal Monitoring A variety of medical guidelines on fetal monitoring can be found at: www.gfmer.ch/Guidelines/Pregnancy_newborn/Fetal_monitoring.htm Midwifery guidelines for fetal monitoring are discussed at: www.radmid.demon.co.uk/Evidence.htm An “Informed Choice” leaflet about fetal monitoring is available from the Midwives Information and Resource Service (MIDIRS). Your midwife may be able to lend or give you a copy, or you can contact MIDIRS direct via their web site at www.midirs.org

Links to more information about Prostaglandins Home Birth Reference Site: www.homebirth.org.uk/pe2.htm Links to more information about Misoprostol include: Marsden Wagner’s letter to the British Medical Journal available at http://bmj.com/cgi/eletters/318/7190/1056 Ina May Gaskin on Misoprostil available at http://dir.salon.com/ health/feature/2000/07/11/cytotec/index.html Midwifery Today Article by Marsden Wagner available at: www.midwiferytoday.com/articles/cytotecwagner.asp Report of risks in “The National” available at www.cbc.ca/ national/news/forcedlabour/ Home Birth Reference Site: www.homebirth.org.uk/misoprostol.htm

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Useful Contacts Contacting AIMS

Other Organisations

AIMS Helpline 0870 765 1433 AIMS on the web www.aims.org.uk

Active Birth Centre 25 Bickerton Road London N19 5JT 020 7561 9006 www.activebirthcentre.com

Association for Improvements in the Maternity Services (AIMS) 5 Ann’s Court Grove Road Surbiton Surrey, KT6 4BE

Association of Radical Midwives (ARM) 62a Greetby Hill Ormskirk, Lancashire L39 2DT 01695 572776 www.radmid.demon.co.uk

In Scotland: 40 Leamington Terrace Edinburgh EH10 4JL 0131 229 6259

Independent Midwives Association (IMA) 1 The Great Quarry Guildford GU1 3XN 01483 821104 www.independentmidwives.co.uk

In Northern Ireland: 23 Station Mews Todd’s Hill Saintfield, Co Down 01238 511786 AIMS provides telephone support and also publishes a wide range of booklets and papers on a variety of topics of interest to prospective and new parents.

Publications lists are free from the above addresses.

National Childbirth Trust (NCT) Alexandra House Oldham Terrace London W3 6NH 0870 444 8707 www.nct-online.org

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