Episode 134 - The Risks of Induction Part 2
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[00:00:00] Mel: Welcome to the Great Birth Rebellion Podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast. This is part two of our investigation into the risks of induction of labour. Last week was episode 133, and we covered the first steps of induction of labour, which was the assessment, ripening of the cervix, by various means. And this week, we're going to look at the next two steps, rupturing of the amniotic sac or the membranes, which is called breaking your waters and use of the artificial IV oxytocin that's used to start your contractions. Now, if you're watching this on YouTube you may realize that I'm looking a little bit comfy and that's because this is the real and raw me.
[00:01:06] Mel: I've been out to a birth this morning because I'm a real life midwife as well as this podcast host. I'm wearing the Vintage Great Birth Rebellion merch. So if you are interested in supporting this podcast, head out to www.thegreatbirthrebellion.com and get some great birth rebellion merch to support the work of this podcast.
[00:01:30] Mel: And if you're listening to this on audio on one of the podcast platforms, know that if YouTube is a platform of choice for you, you can also watch the full video versions of this podcast on YouTube. But I would normally get a little bit more dressed up, but I'm not, I'm actually still in the clothes that I'm in that I went to the birth. So You're welcome. This is just how it is. We are raw and real.
[00:01:54] Mel: So let's get into it. Part two of the risks of induction of labour. And we've got to remember that at every stage of induction of labour, we are layering on a combination of interventions. And each of those has their own unique set of risks. And as you layer them upon each other, you increase the risk or the chance that something won't go well.
[00:02:15] Mel: So this is also called the cascade of intervention, where Interventions have intended and unintended consequences and when you layer upon layer unintended consequences of interventions you layer upon layer the chances that something won't go right or that something will be more complicated. So part 1 episode 133 is essential listening if you're going to fully understand this episode that I'm recording now.
[00:02:44] Mel: because all the background information is in there and I'm not going to repeat it here. So we are going to just kick off where we ended off and so you are coming in halfway through the movie if you are listening to this episode. So go back, listen to 133 and get on back here and continue with part two.
[00:03:02] Mel: So let's get into it. The next steps in your induction are after your initial assessment and cervical ripening and possible repeat cervical ripening Now you may have gone into labour, but if not, you've been moved from the antenatal or day stay area where you will have spent the night and they're going to take you to the birth unit where hopefully your labour will commence if it hasn't already.
[00:03:27] Mel: Now you can take your support people with you to the birth unit. They may not have been with you overnight for the earliest steps because they don't allow visitors on the antenatal ward.
[00:03:37] Mel: Before we keep going, there's just a few things to note that those first initial induction steps that we spoke about in the last episode may actually been powerful enough to start your body into labour without needing these next steps that I'm going to talk about. And if that's the case for you, you might consider giving your body more time to keep labouring under its own power and physiology rather than proceeding with any further steps.
[00:04:04] Mel: So, You're not on an induction train that doesn't stop. It's not like once you start every single step of these, you can't stop and slow the process. There are moments, well, lots of moments actually, in the induction process where it may be safe and appropriate and fair to pause and reconsider your options.
[00:04:25] Mel: And one of these times is prior to them breaking your waters. So, if those early steps where perhaps a stretch and sweep, or the ripening of your cervix, an extra night in hospital, or maybe they've repeated those. If you're getting contractions and your body is responding to these earlier induction methods, maybe Your body is ready to labour, and it's okay to ask for more time.
[00:04:51] Mel: And I know this might not fit into the preferences of the hospital or the care provider that you've got, but if you and your baby are well, ask yourself, why not wait a little bit longer? Because by not layering and layering each induction step on top of each other, you can actually reduce.
[00:05:11] Mel: the possible complicating factors of having had an induction. So if your body is already starting to respond, you could consider waiting another 24 hours and seeing what else it does over that time. Maybe you'll go into labour without needing anything else. So next options are 1. The cervical ripening worked and your cervix is open and short enough for the practitioner to break your waters.
[00:05:36] Mel: But let's first talk about what happens if your cervix does not respond to any of those earlier steps. There's a few options. Either it responded and you've gone into labour, it responded and there's room to break your waters and it's time to start the rest of your induction, or none of those earlier steps works.
[00:05:55] Mel: Perhaps there's been multiple attempts to ripen your cervix and it's just not favorable to move on to the next stages of induction. Now, I did some scouting around to midwives and obstetricians to ask them what their hospital policy was in their facility if a woman's cervix remains unfavorable after the early steps of induction. What happens then for this woman because she can't move on to induction, but what do we do now? It varied. But, occasionally, midwives and obstetricians mentioned that their facility offered the woman an opportunity to go home and come back in a few days and try it all again.
[00:06:33] Mel: Some would try again just straight away, after seeing that the initial ones didn't work. But it seems like hospitals, most of them, would just say sorry, that didn't work. It's time to schedule you for a cesarean section. And this cesarean section option was actually the majority of the responses, and even a few women wrote in saying, I'm not a midwife, but here's what happened to me.
[00:07:00] Mel: And the majority of people who responded, I know it's not a scientific study, but I was curious to know what was going on out there, because policies are different in different hospitals. But if your cervix doesn't ripen after steps are taken to start your induction, they may just offer you an elective caesarean section without even attempting the other steps.
[00:07:24] Mel: Can you imagine if you're a woman who is potentially diagnosed with gestational diabetes, for example. One of the big reasons why women are induced. And your blood sugars have been well controlled. There doesn't seem to be any other concerns, but because you're gestational diabetic, you're on the pathway for a planned induction.
[00:07:43] Mel: And you've agreed to this? But then when they go to do it, your cervix doesn't respond, and they say right now we're going to give you a cesarean section. This just feels like an unnecessary use of this kind of an intervention of a cesarean section, especially when there's not really anything actually wrong, it's just preventative or an assumed appropriate induction.
[00:08:09] Mel: So just know that if those early steps don't work that you might be offered a cesarean section and then you need to make a decision about that. It's really unfortunate and actually a lot of the people, midwives and obstetricians, who responded were also really angry at the idea that a failed induction process then puts the women at risk of a cesarean section without even having laboured.
[00:08:33] Mel: So a risk of agreeing to and going through those initial stages is that it's quite possible that you won't be offered the option of a vaginal birth but that you'll be advised to have a cesarean section. And let's remember, you know, the majority of Inductions that are happening are for women who are over 41 weeks, diagnosis of gestational diabetes and prolonged rupture of membranes.
[00:08:55] Mel: And if you've been following this podcast for long enough, you'll know that there are a wide range of clinical options for women in these circumstances that don't involve induction of labour. So we're asking why the cesarean section rate is so high. I'm going to suggest that. the high level of inductions and potentially failed ones are one reason for driving this.
[00:09:16] Mel: Now the other option available to you if they can't break your waters is to just start your induction with intact membranes. They certainly don't have to be broken for the oxytocin to work. The two are actually fairly unrelated in their activity and there is actually a lot of research that asks the question What if we just break women's waters later in the induction process?
[00:09:42] Mel: What if we started the oxytocin drip before breaking the woman's waters? Would this change anything? And it turns out that it's a completely legitimate way to commence an induction, to start oxytocin, Before breaking the woman's waters. Now, the majority of research suggested that there were no obvious dangers in delaying rupture of membranes.
[00:10:05] Mel: For example, delaying them until after the woman was four centimeters dilated or waiting four to eight hours after oxytocin starts to then rupture membranes. The main difference they found was that That labour seemed to progress faster in the Inductions if the woman's waters were broken artificially or ruptured before the induction started compared to after.
[00:10:32] Mel: So it seems like there's another option than going straight to cesarean section. You could ask to start the oxytocin drip without your waters being broken. Your practitioner might feel nervous about this because there's an old wives tale about amniotic fluid embolism risk increasing for induction of labour if you don't break the waters.
[00:10:55] Mel: Now, it's true that if you have an induction there's an increased risk of amniotic fluid embolism. That's true, and theoretically, if you break a woman's waters and there's less amniotic fluid, there's a theoretical reduction in the chance of amniotic fluid embolism. It's very, very rare as it is, but this has not really ever been proven.
[00:11:17] Mel: It's not like we know that there's a correlation, but I think that's probably what is holding people back from considering this option. But if your option's a caesarean section, or attempting oxytocin drip without rupturing your membranes, and the relative risk of an amniotic fluid embolism is very, very small, then this could be something maybe that you could ask your practitioner to consider in your circumstances.
[00:11:44] Mel: Because there are risks to caesarean sections too. And so it's not unheard of actually. to start oxytocin without rupturing membranes. That is completely possible. And this idea of the amniotic fluid embolism risk likely came from this study 2006 by Kramer et al in Canada, which was a huge study. It was based on 3 million births that showed that having an induction increased a woman's risk of amniotic fluid embolism.
[00:12:12] Mel: The usual chances of this happening is about six in 100, 000 singleton births. It's more in twins and things, but the study found that this nearly doubled to about 11 in 100, 000 births if you're having an induction. So roughly 50 % increase in amniotic fluid embolisms. Again, the numbers, if you're induced 11 in 100, 000 inductions.
[00:12:41] Mel: And so they theorize that if we break women's waters, then maybe there's less amniotic fluid, therefore less chance of an embolism. It's so hard to answer this question though, because it's such a rare circumstance. You have to have such a big study to even test this idea. So, if your clinician doesn't want to induce you without breaking your waters based on this theoretical risk and they're worried about 11 in 100, 000 as a risk factor, but they're cool with giving you a cesarean section, which puts you at greater risk of a lot of other things then I would question their risk assessment skills.
[00:13:23] Mel: You know, if they're saying, look, I can't start oxytocin because there's a risk of amniotic fluid embolism. Yep. There is a risk and 11 in 100, 000 risk. And they would sooner give you a cesarean section, which has far greater risks associated with it in far greater %ages. Obviously, I'm not going to cover them all now, but they have decided that they're willing for you to take the risk of cesarean section over amniotic fluid embolism.
[00:13:51] Mel: I would suggest that you make the decisions yourself. You decide if you want to go with the risk of amniotic fluid embolism and a slower labour, slower induction than the risk of amniotic fluid embolism. So this is something for you to decide. I'm only giving information, not suggesting what you should do with it, my point is, is there doesn't seem to be very conclusive evidence that it's an absolute no no to start an induction with oxytocin if your membranes are intact. In fact, there's a large number of studies that looked into this exact scenario, and you can see some of them in the resources folder.
[00:14:28] Mel: So the main disadvantage of not breaking your waters is that the labour seems to go longer than if you did break them. So if you're comfortable with that, with that being the payoff for giving the induction a go instead of going straight to caesarean section, there doesn't seem to be a sort of convincing reason why not to try. And then If the oxytocin is effective and your cervix starts to open and dilate, then they can break your waters partway through the induction.
[00:14:56] Mel: But let's say now that your cervix is favourable. All those early steps worked and there is an option of amniotomy or breaking your waters where they, they use an amni hook, which looks like a crochet hook, and they reach it up into your cervix with two fingers.
[00:15:11] Mel: So this is another vaginal exam, cervical exam, and be expecting vaginal exams somewhere in the vicinity of two to four hourly when you have an induction, depending on how things are going. So they'll put two fingers in and they'll locate the amniotic sac, which should have, if you're doing the amniotomy correctly, the baby's head should be well applied and firmly pressed upon the membranes.
[00:15:38] Mel: And they'll hook into the amniotic sac and release the amniotic fluid from around the baby. Now, the research shows that doing this now will help speed the induction process, and speed is important in a hospital system. It's not really important for a normal labour. They can take longer. But the time of induction is kind of important.
[00:16:01] Mel: It's a higher risk birth than a spontaneous labour where you just go into labour on your own, under your body's own power. But because it's an intervention, it's a induced labour, the longer it goes on, the more your risk compounds. So, hospital always love things to go faster and faster. But in the induction process, not letting it draw out can reduce the risks.
[00:16:27] Mel: So now if you look at brochures that a hospital will hopefully give you about induction, most of them will tell you that this step of amniotomy, of breaking the waters, is of no harm or consequence to your baby. And the number of times that I read in hospital brochures, as I was researching this topic,
[00:16:48] Mel: I looked at all kinds of online hospital brochures from various different facilities.
[00:16:53] Mel: Many of them, in fact, most of them said there is no risk to your baby. No harm will come to your baby through the process of amniotomy. And this was quite infuriating because apparently you're hearing this here first. But artificial rupture of membranes has the following risks, and it's absolutely not true that there are no chance of harm to your baby.
[00:17:17] Mel: The wording was so certain, it was very frustrating. So, in no particular order, the risks of amniotomy are as follows. Cord prolapse, where the cord slips out before the baby, if you're an experienced clinician and you've followed all the correct steps for an amniotomy, there's less and less chance of this happening.
[00:17:37] Mel: But if there's risk factors such as more amniotic fluid around the baby or the baby's head's not well applied, or there's more than one baby or the baby's breech, then this can be a real issue. And this is an obstetric emergency. It requires immediate birth of the baby. either vaginally, if the woman's fully dilated and she's pushing out her baby, or by caesarean section.
[00:17:59] Mel: And I've seen this first hand, working in the hospital as a student, and the midwife just, the woman was nearly fully dilated. She's doing so amazing, it was a spontaneous birth, no other dramas. The midwife just, routinely ruptured membranes. And most of them did at that time. And I was working as a student, you'd expect that as the woman was getting on into labour, it would just break your waters.
[00:18:23] Mel: There was a thought that this would speed things up. So this woman who was well on track to have her baby had the amniotomy, the cord slipped down and they raced her off for a cesarean section. And I remember being so angry thinking this did not have to happen. So that's definitely a possible risk.
[00:18:38] Mel: That is a risk to your baby. There is another risk of piecing the blood vessels in the amniotic sac in the case of a velumentous or marginal cord insertion or undiagnosed vasoprevia. And we spoke about these things in episode 41 about unusual cord insertions. And these are often diagnosed and picked up on ultrasound, but not always.
[00:19:03] Mel: There can be undiagnosed circumstances of marginal velimentis cord insertion or undiagnosed vasoprevia. And in this case, there's blood vessels that are running through the amniotic sac. They're usually protected and within the placenta, and then that attaches into the cord. But if not, if they're through the sac and you rupture the membranes and there's blood vessels going through there, if you rupture those vessels, that's the baby's blood.
[00:19:32] Mel: And that is what's coming out of the vessels. The baby could actually bleed to death. It's rare, but it is a risk. So there is a chance of harm to your baby. Don't believe that phrase. There is no chance of harm to your baby. Not true. There is a chance of accidental damage to your baby. I've also seen this firsthand where the woman said, my waters have broken.
[00:19:58] Mel: I said to the midwife, yeah, her waters have broken. And the midwife was almost certain that no, the waters had not broken and repeatedly attempt to break the waters. Actually what we noticed had happened is after the birth, it was obvious that the midwife was hooking into the baby, the skin on the top of the baby's head.
[00:20:21] Mel: And there was quite a laceration on the top there from that attempted amniotomy, which didn't need to happen. So that is. Also possible, something I've witnessed the other risk of prematurely rupturing the membranes is causing malpresentation of the baby. So for babies that are poorly positioned or need to do more rotating or tucking in the head or something needs to happen, they often need that amniotic fluid as padding and a tool to help with their rotation.
[00:20:51] Mel: So if you deprive them of that, it's possible that they can't get into the position they need to get into to be born. The other risk is increased compression and pressure on the structures for the baby, including its own vascular supply, which could lead to stress on the baby, and also increased pressure for the woman.
[00:21:12] Mel: of her baby on her cervix and bony structures. So women have reported that labour is more painful after an ARM, artificial rupture of membranes, than before because of the loss of that cushioning. And there is some kind of reflexive response from the baby. So what you'll notice In hospital is they'll listen to your baby's heartbeat before they ruptured membranes, and then they'll listen again afterwards to ensure that your baby is okay and responded to that intervention without issue.
[00:21:42] Mel: So yes, possibility of harm to your baby. Now, the other thing that happens after you break waters is that you start to exponentially increase the risk of infection for the mother. So once the waters are broken, and in particular, if you are doing that in conjunction with the multiple vaginal examinations that are going to go along with the induction process, then the risk of intrapartum infection for the woman increases statistically.
[00:22:08] Mel: So these are all the possible risk factors. for artificial rupture of membranes. So if you see somewhere that says there are no dangers to the baby or the mother of artificial rupture of membranes and you've been told a big furphy it's not true. The resources are in the resource folder if you want to have a look at that if you're on the mailing list.
[00:22:31] Mel: So now at this juncture most hospital policies will simultaneously rupture your membranes or break the waters. and then start the IV oxytocin. They either start it immediately or shortly after. But here is another opportunity to do some waiting. So if you break the waters alone, that can be enough to put you into labour.
[00:22:58] Mel: So you've had your cervix ripened, so you can wait after you've had your cervix ripened, that maybe put you in labour. Then they break your waters. And you could wait after they break your waters to see if you go into labour. In fact, there's some studies that have tried this. What if we just break women's waters and wait and see what happens?
[00:23:17] Mel: And a large %age of those women, not all of them, not even 50%, but 40, 40 odd %, after 24 hours might go into labour. And I have a memory of two particular clients who had. Indications that induction was required. Both were over 42 weeks and both were experiencing some unrelated complications to being over 42 weeks, but there was a complication and we thought it's time to get the baby out.
[00:23:46] Mel: But each of them went with the recommendation to be induced and considering their gestation we considered the possibility that just rupturing their membranes alone might be enough. And so we didn't do any of the other steps. No cervical ripening, we just broke the waters. And let's see what happens. And in both circumstances, within hours, labour started on its own.
[00:24:10] Mel: They laboured under their own power with no oxytocin or medicines. So they needed minimal intervention. We didn't have to put a CTG on we didn't have to do much to get their labour started. There was fewer steps, fewer interventions, which then significantly reduces the risk and complicating factors of being induced.
[00:24:28] Mel: So they're only exposed to the intervention of artificial rupture and membranes, which is probably one of the lower risk parts of induction.
[00:24:37] Mel: And in this scenario, if everything kicks off after an artificial rupture of membranes and you don't need the oxytocin, then you could also consider not accepting continuous CTG monitoring. So these two particular clients, they could have intermittent monitoring because they weren't having all the other elements.
[00:24:57] Mel: Now, continuous CTG monitoring from this point onwards after the rupture of membranes. and the commencement of oxytocin is considered standard practice in all hospitals with induction. And if you listen to the episodes with Kirsten Small on the use of CTG in labour, I'll link it in the show notes below.
[00:25:17] Mel: But she spoke about one of the only times that CTG seems to make any difference to outcomes in a positive way, is during induction of labour. So induction of labour increases the risk that the baby could be damaged because of oxygen deprivation. And CTG seems to be protective for some of those babies. So it didn't bring it down to pre induction levels, but it does seem to reduce the risk of induction for a baby.
[00:25:46] Mel: This comes with lots of nuance, of course, and I would encourage you to listen to that episode with Kirsten about CTG to get a full picture of that. And we will talk about the risks of CTG later in this episode, but for now, let's look at the next step in the induction process. If your contractions haven't yet started after cervical ripening or spontaneous rupture of membranes, the next step is starting your contraction, and this is done using oxytocin.
[00:26:12] Mel: So in Australia, we call this product Syntocinone. In America, it's regularly called Pitocin. So they're the same medicine. It's artificial oxytocin, same thing, just different name. So how is this done? So using oxytocin to induce contractions, it requires a continuous IV drip. So this is inserted using a cannula into your vein.
[00:26:36] Mel: So there's a needle involved. They'll also want to take some bloods before they start all this. They'll take some routine induction bloods. So there's a needle for that. There's also another needle for the cannula that goes into your vein, and that's going to be set up to an IV tube. So that stays in for your whole labour and it's all taped on.
[00:26:55] Mel: An IV tube that leads to a bag of fluids into which they'll put the oxytocin medication and they deliver the oxytocin medication by drips through that fluid. So the longer your induction goes on for, the more fluid you are loaded with. Now, this is significant and it can be so significant in fact that there's caution around how many bags of fluid you can give to a woman during induction to avoid overloading a woman because there is something called water toxicity and you can overload women with fluids and there's also acknowledgement that.
[00:27:32] Mel: The baby also experiences this, so much so that there are some calls to weigh babies who were born by induction. the next day. So don't weigh them at birth because the additional fluid that they've taken on through the induction process gives an inaccurate estimated weight at birth. And then when they weigh them later in the week or a few days later for discharge, it looks like they've lost heaps and heaps of weight, more than 10 % of their weight, they haven't lost heaps of weight.
[00:28:05] Mel: They've just drained all the extra fluid that they were carrying, but this can mean that babies have to stay in hospital longer, they think they're not feeding properly, they might investigate them for reasons of poor weight gain, when in fact they weighed more than they should have at birth because they were overloaded with fluid.
[00:28:22] Mel: So that's one possibility, it happens to the baby but it also happens to women.
[00:28:25] Mel: So the fluid and the oxytocin medicine is delivered through an IV machine which is programmed to deliver you a preset dose and the machine Beeps all the time. So they'll start you off on a particular dose and every half hour it gets increased depending on how your body is responding. But this machine, it beeps if it gets blocked, if the fluid stops flowing, if the bag is empty, these bloody machines seem to just beep all through labour. So much so, there's actually a mute button located on most of the screens. But honestly, of the times when I've worked with clients who are labouring in hospital, the number one reason we have to call the midwife into the room is to remedy whatever the machine is beeping about.
[00:29:13] Mel: And it might seem trivial. But having a machine constantly alarming in the birth space is incredibly irritating to me and imagine how much more irritating it would be to a woman who's trying to labour. It makes it hard for the woman to rest. It takes attention of the woman's support people and care providers because they, they have to take their attention off the woman to fix this bloody beeping machine. And the noise is just constant noise. The beating of the CTG machine, the beeping of the IV machine. The woman's in this noisy environment, tethered to the IV pole and the machine. And it just makes it difficult to be in that environment for labour.
[00:29:59] Mel: So adding to the constant noise is also that the CTG and the IV poles usually have cords. There are some CTGs with what we call telemetry. So there's no cords attached, which helps the woman not be tethered to every single machine in the room. But it makes it hard for the woman to move freely because the more you move around with those CTG monitors if you don't know what a CTG is, you've got to listen to our CTG episodes.
[00:30:30] Mel: But basically there's two big round, about the size of a, I guess, Tennis ball. It's not round, but it's a flat disc about the size of a tennis ball. Two of those are strapped to your belly when you're having a CTG, and if you're being induced, they'll stay on the whole time. But if you move too much, and they move away from where they get in contact with the baby's heart, then your midwife is going to come in and constantly be trying to adjust the CTG receivers because they lose contact or they move around.
[00:31:02] Mel: And it makes it hard to get a consistent fetal heart rate trace on the baby. Now, in some hospitals, they will remedy poor contact By suggesting to the woman that she accept what's called a fetal scalp electrode, which is a small metal spiral, it's about three or four millimeters across and it spirals like a little spring.
[00:31:27] Mel: And it's got a sharp end like a needle and that's pressed up against the baby's head and it's spiraled into the baby's scalp, the skin on the baby's scalp, which gives direct contact to the baby and it can detect the baby's heart rate. supposedly more accurately than the CTG monitor on the outside of your belly.
[00:31:48] Mel: Now, some people will describe this as a little clip on the baby's head. But it's not. It's a spiral shaped needle and it's anchored into the baby's head. It's coming out of your vagina and then it's taped to your leg. This is the alternative to the CTG.
[00:32:05] Mel: Alternatively, if you've got a CTG, you might end up just choosing not to move as much to avoid losing contact. So if we're talking about layering of risk factors in this context, the fact that a woman's experience of CTG is usually that it makes it harder to move around and get comfortable. What we already know is that limiting a woman's movement in labour not only reduces the chance of an unassisted vaginal birth, but it also makes it harder for the woman to manage pain and the sensations of labour.
[00:32:38] Mel: So women should feel free and comfortable to move in labour without feeling restricted. And moving freely in labour, it helps to relieve pain, especially because women report that The induction of labour contractions are far more painful than naturally occurring ones. So, there are lots of reasons for this to be true, not only because that's what women report their experience to be.
[00:33:05] Mel: So add to that, and, less capacity to move freely in labour because of CTG and IV pole. And then you've got yourself a perfect storm where these types of labours can be harder to manage because of these types of restrictions. So one risk of induced labour contractions is that many women describe the contractions as more painful, and it's extra important to be prepared with pain management strategies.
[00:33:31] Mel: This could include, moving freely, but we've just learned that CTG and IV pole, this can be harder. You could use water in the shower or a bath. However, many hospitals have a policy that excludes you from accessing water for pain management. It can be done, but some of them simply won't, especially if their CTG equipment is not waterproof.
[00:33:55] Mel: And many won't allow it because you are having an induction. And inductions are higher risk than spontaneous labour. But heat packs are still possible. Massage, TENS machine, support from a loved one or a midwife or a doula. You can use music, hypnobirthing or calm birth techniques, the birth comb, a birth sling.
[00:34:16] Mel: There's a whole episode of The Great Birth Rebellion on managing the pain of labour without medicine. So, I'll link that in the show notes as well. But just know that the induced labour contractions are not equivalent to naturally occurring contractions. So if this is your first experience, know that next time it won't be like that if you go into spontaneous labour.
[00:34:38] Mel: And if you've laboured before and now you're getting ready for an induction, just maybe reset your expectations and be prepared that it will be different. So an additional risk of labour that is induced is that many Women experience it to be more painful, and then there's documented evidence that women who have inductions also have higher rates of using an epidural.
[00:35:01] Mel: No surprises there, makes total sense. So while I don't have time to explain all the risks of an epidural, that would take whole episode in itself to explain all the risks of an epidural. We know that epidurals are an intervention that are not a no risk option.
[00:35:19] Mel: So if you do have an epidural, in addition to your induction, you can stack those risks on top of the ones already inherent in the induction process. So remembering also, if you have an epidural, you'll also have a urinary catheter, which again, adds to the layering. Every intervention has an intended and unintended consequences.
[00:35:38] Mel: And we also speak about this on the Cascade of Intervention episode, which is episode 74. So when you have an induction of labour, You are certainly spiraled into the cascade of interventions. So that cascade of intervention episode is great to help you understand the scenario you might be facing when you agree to an induction.
[00:36:01] Mel: So the final step in your induction, step three, is the creating of contractions. And as I mentioned, this is done through a pump controlled IV drip, and it gets set to deliver the medication, oxytocin, at a low dose to start, and then every 30 minutes or so, depending on the workplace policy, the dose is increased until the time where you're getting around three to four contractions in a 10 minute period.
[00:36:28] Mel: Now the dosage is monitored very closely because it's a delicate balance of giving you enough medication to have effective contractions. And then not overdoing it, so as to overstimulate your uterus and increase the risk of your baby getting distressed and increase the risk of uterine damage or damage to the placenta.
[00:36:49] Mel: So let's first have a look at the risks of the medications themselves. And I've used some of the medicine \ inserts for this information. So these information leaflets are in the box of the medicine of the Syntocinone or the Pitocin. And actually something new that I learned that I didn't know before is that if you have a latex allergy, Syntocinone is contraindicated.
[00:37:15] Mel: I did not know that. So that's not unusual for women to have. Latex allergy, so there you go. And the other main reason not to use Syntocinon is if you've had previous surgery on your uterus or cervix because oxytocin induction increases the risk of uterine rupture. Both with and without a uterine scar, but especially if you have uterine scars.
[00:37:38] Mel: And as I mentioned before, a prolonged induction of labour can cause water toxicity and increased water retention for women and their babies. And the other risk that's not related to pre existing medical conditions includes uterine hyperstimulation or overstimulation, uterine rupture, and placental abruption, where the placenta attaches from the wall of the uterus.
[00:38:03] Mel: Now, these are fairly rare, but hyperstimulation is common, and administration of the oxytocin is often altered in response to hyperstimulation. So there's a lot of what your midwife is doing during your induction, is watching the CTG to make sure your baby's heart rate seems normal.
[00:38:24] Mel: They're also closely monitoring how many contractions you're having and the gaps in between and how long they're lasting because you were at risk of hyperstimulation, of having too many contractions in response to the oxytocin and we heard in the last episode too many contractions or too many long contractions without a big enough break leaves your baby deprived of oxygen because oxygen supply to the baby is interrupted during contractions.
[00:38:54] Mel: That's a normal part of having contractions is that the baby's receive less oxygen, they can cope with that except when the contractions are lasting too long and they're stronger than they would normally be, than what a baby is designed to tolerate, then it can increase the intensity of induction and reduce oxygen supply to your baby.
[00:39:15] Mel: So hopefully your midwife is watching closely and the CTG is on so they can respond quickly if this happens. And, an induction does require intense attention from a care provider. So if you feel like people aren't watching closely enough during your induction, probably because it's a busy day on the ward, then make sure you make some noise about that.
[00:39:38] Mel: Actually demand to have the attention of a care provider. You're in a high risk situation.
[00:39:45] Mel: So those are some of the risks that are listed on the medicine package, but they're not the only risks. And I've again, put all of these things in the resource folder for you to have a look at. So let's have a look at the other risks probably that they won't mention in the medicine package because they're kind of directly related.
[00:40:02] Mel: They're related to the induction process. The process of induction also increases the woman's risk of postpartum hemorrhage, and not just by a little bit. So one study done in 2023 called Induction of labour and the Risk of Postpartum Hemorrhage in Women with Vaginal Birth. So it's a full text article and it's in the resource folder.
[00:40:23] Mel: This shows that if women are induced, they have a 13. 3 % chance of postpartum hemorrhage of between 500 and 1000 mils. So, induction PPH rate is 13.3%, compared to spontaneous labour, which in this study carried an 8.6 % chance. So there's an approximately 40 % increased chance of a minor PPH, postpartum hemorrhage, if you're induced.
[00:40:53] Mel: And there's a a similar increase, %age increase, in major postpartum hemorrhage. So if you're induced, you've got a 3.1% chance of a postpartum hemorrhage that's over a thousand mils, compared to spontaneous labour, which is 1.9%. And this is not including births that happened by caesarean section.
[00:41:16] Mel: This is all births that ended up being vaginal. So caesarean sections usually have higher blood loss. So this is induced labour where the result was vaginal birth. The chances of having a postpartum hemorrhage after induction are approximately 40% higher than if you had spontaneous labour. Another thing that is more likely to occur if you've had an induction of labour is shoulder dystocia.
[00:41:40] Mel: So there's one study where there was 57, 000 deliveries, births, this study called them deliveries, I'm sorry, I didn't change that word. 57, 000 births, resulting in 175 cases of shoulder dystocia. Now, of these 175 cases of shoulder dystocia, 73 % of women were induced compared to 27 % of these shoulder dystocias were from women who had laboured spontaneously.
[00:42:11] Mel: And these are in women without gestational diabetes. So this study excluded them. So if you're being induced because your doctor is worried about the size of your baby and wants to prevent shoulder dystocia from a large baby, then consider the possibility that induction of labour could cause a shoulder dystocia anyway.
[00:42:31] Mel: So just to go over those stats, of the 175 shoulder dystocia cases from 57,000 births, 73% of the shoulder dystocia cases were, for the women who were being induced, with 27% who had laboured spontaneously. Now there's also a risk to the baby with regards to fetal distress.
[00:42:51] Mel: Now in episode 133, one of the medication inserts suggested that there was a risk of around, I think it was said 10. 8% or 11% risk of fetal distress with the particular medication during induction. But the stats on this are hard to find and they're dependent on so many factors, so I can't give you an exact number.
[00:43:13] Mel: But stress is possible in any labour, but in induced labour, it's often related to the excessive contractions that deprive the baby of oxygen. So, you know, as I said, they can cope with this to a degree, but where the labour is induced and the contraction pattern is not what the baby's made for, then the chances of this are more likely.
[00:43:37] Mel: Now , I could go on and on about. the risks, because actually I haven't finished yet. I haven't even covered the immediate postpartum or early neonatal risks of induction simply because I cannot fit it in. Already I have presented enough research and information to write a small book on this topic. So I'm going to finish up the podcast with leaving you with
[00:44:05] Mel: some stats from a 2021 study done by some of my most favorite researchers.
[00:44:13] Mel: And I love them because of how dedicated they are to an accurate research process. They are meticulous. This study team was headed by Professor Hannah Dahlen And it's called Intrapartum Interventions and Outcomes for Women and Children Following Induction of labour at Term in Uncomplicated Pregnancies. And it was a 16 year population based linked study.
[00:44:37] Mel: And they found, so of 69,000, women who had an induction of labour for non medical reasons there were the following stats. So if you're having your first baby, primip women. With an induction of labour, versus spontaneous, so the first stat that I'll say in all of these is if you've had an induction, and the next stat is if you've gone into spontaneous labour.
[00:45:00] Mel: These are the differences in the stats. So for spontaneous vaginal birth, if you've had an induction, your chances of a spontaneous vaginal birth where you don't have a cesarean and the baby is not removed from you via vacuum or forceps is 42.7% if you're having your first baby. If you go into spontaneous labour, it's 62.3% 42.7 versus 62.3% for spontaneous vaginal birth. If you're a first time mom having an induction of labour. Your chances of instrumental birth, so vacuum or forceps, are 28% versus 23.9 if you've had spontaneous labour. The chances of you having an intrapartum caesarean section, so a caesarean during labour if you've had an induction of labour as a primip, first time mum, 29.3% vs 13.8 % if you wait for labour to start spontaneously. Use of epidural if you're a first time mum having an induction of labour. you are likely to have an epidural 71 % of the time versus 41 % for spontaneous labour. And this is what we were talking about with the increased pain during induction.
[00:46:18] Mel: There's no surprise why 30 % more women would require an epidural. Episiotomy If you're induced, there's a 41. 2 % chance that you're going to get an episiotomy versus if you went into spontaneous labour as a first time mum, 30%. Still way too high, but less than an induction. Postpartum hemorrhage, as we already saw in the earlier studies, the postpartum hemorrhage rate was 2.4% for primips having an induction versus 1.5% And there was a similar trend, statistical trend, for women who'd had babies before, except the cesarean section rate was lower for multips if they had an induction than if they went into spontaneous labour. But everything else was higher risk if you're induced.
[00:47:13] Mel: Oh, this has probably been one of the trickiest episodes or series of episodes I've ever had to write for the Great Birth Rebellion podcast. That's because the topic is so nuanced. The interventions are so overused, the decisions about when they're necessary and when they're not necessary are so varied and nuanced as well.
[00:47:36] Mel: So, these episodes were not intended to frighten you off induction of labour, just to give you a full picture of the potential consequences and risks of being induced, so that when you're coming up to the chance or opportunity to be induced, you maybe have a bit more information to be able to weigh the risks of staying pregnant.
[00:48:01] Mel: or accepting an induction of labour. It's entirely possible that an induction of labour carries less risks in your circumstance than it does to stay pregnant. That's something for you and your clinician to decide. That's not something I can give you an answer to. This is just some statistical information that may help with your decision making process.
[00:48:23] Mel: So I encourage you to engage with this. This is particularly important for these routine inductions that are now happening for all women diagnosed with gestational diabetes. And we know that gestational diabetes diagnosis is so fraught with inaccuracies. And even women who have normal blood sugar levels all through their pregnancies are being exposed to induction of labour.
[00:48:47] Mel: without consideration of how much extra risk these women are being put at. Now also post dates. So if you're beyond 41 weeks, this is the other reason why induction is routinely recommended for women over 41 weeks. And that's because there's an increased risk of stillbirth. Now the due dates episode of the Great Birth Rebellion podcast talks about the stats on the risk of post date pregnancies.
[00:49:14] Mel: So you can weigh those up against the risk of. an induction of labour. And the other reason is if your waters have broken for longer than 24 hours, you could be exposed to induction. Again, we've got a whole episode on those
[00:49:27] Mel: so if you're in a situation where you need to decide on staying pregnant or being induced, I do hope this has helped with some of the decision making process. And I encourage you to engage with the resources that are in the resource folder. You can, get access to the resource folder through the mailing list and discuss this with your care provider.
[00:49:47] Mel: That has been this week's episode of the Great Birth Rebellion podcast.
[00:49:52] Mel: To get free access to all the research that's used to create each podcast episode, you can join the mailing list at melaniethemidwife. com.
