Resources to help you think about induction of labour (IoL)
I have been teaching pregnancy yoga for 19 years and over that time, the number of inductions has increased and they’re happening earlier. What I’ve also observed is that this has led to an increase in the caesarean rate, to currently 50% of births being by c-section in many UK hospitals.
In the last two years, I’ve noticed that the positive birthing stories come from second time mums who didn’t experience the birth they’d hoped for the first time and advocated for themselves this time around.
In the first pregnancy, you don’t know what you don’t know. That doesn’t mean that you can’t have the birth that you hope for, but you’ll need to advocate for yourself, become as informed as possible of your choices and be prepared to make decisions. This article contains resources to help you do that.
Due dates
When my mum was overdue with me and I was overdue with my two daughters, the policy was to induce at 42 weeks. It is now 41 weeks. Different countries have different policies about when to induce. All around the world there is now a fixation on the due date because of the use of ultrasound scans. It’s been described as an ‘induction postcode lottery’.
If you know when you conceived, this is the best way of working out your due date. Many women now chart their menstrual cycle, particularly when they are hoping to conceive. What the standard calculation misses out is that women have different length cycles – from 25 to 35 days is considered normal. Working out the due date from your last period doesn’t take into account this variation and 10 days makes a massive difference to how ready your baby and your body is for labour to begin.
If you have no idea about when you conceived or your last period was, you might feel the need to be guided by the ultrasound scan. It’s exciting to know when to expect to see your baby! I get it!! However, they’re not 100% accurate, including for determining the sex of the baby. (Source) Dating is most accurate in the early weeks of pregnancy within +/- five days whereas third trimester scans are most inaccurate with an accuracy of +/- 21 to 30 days! (Source) I would be taking the results of a late scan with a pinch of salt.
Unfortunately, it’s normal to get booked in for an induction appointment ‘in case you need it’. The issue with this is that it fixes an end point for the pregnancy that you then subconsciously are waiting for. It also makes induction seem inevitable if you haven’t gone into labour by that point, but it’s important to remember that it’s a somewhat arbitrary date based on policies and current thinking. If the maternity department is particularly busy, you might have to wait until the next day to be on the induction ward, having previously felt like it has to be that day. I suggest thinking of a due MONTH instead of a specific due date. This takes the pressure off when family and friends are getting excited and constantly asking whether the baby is due.
Any intervention has risks and benefits
When I was pregnant with my first daughter, I didn’t consider that a sweep was an intervention because a) it didn’t involve drugs and b) it was talked about so casually. A sweep is separating the amniotic membranes from the cervix with fingers and like any intervention has possible benefits and risks. A benefit is that it may trigger the prostaglandins to increase, in turn triggering the oxytocin to start, which drives contractions and gets the labour going. A risk is that in the process of the sweep, the membranes may be broken and then you will be on a ticking clock for when the hospital wants your labour to start. Another risk is that infection is introduced. If it doesn’t start naturally within 24 hours, induction of labour will be suggested (or pushed strongly).
With any intervention, it is useful to use the acronym BRAINS to get all the information you need to make an informed decision:
B – Benefits – What are the benefits of this intervention for baby and mum?
R – Risks – What are the risks of this intervention for baby and mum?
A – Alternatives – What are the alternatives? E.g. there are different types of induction.
I – Clinical Indication – What would the midwife/doctor do with the expertise they have? – And Intuition – What do you feel inside yourself would be the best thing to do?
N – Nothing – What if we wait and do nothing? (For 5 mins, 30 mins, a day depending on the situation)
S – Smile – You are just collecting information so you feel comfortable with what you choose to do next, it’s not rude or you being ‘too much’ / pushy / ‘one of those people’ to ask.
All these questions may seem like you don’t trust what the midwife or doctor is suggesting. Over the 19 years of teaching pregnancy yoga, the birthing stories that I see that are positive are because the parents understood what happened, even if it wasn’t what they were hoping for. They understood what was necessary and agreed.
Where I read negative birthing stories, the negativity is because the interventions were described in a way that informed consent couldn’t actually be given because not all of the risks were covered, the mum wasn’t being listened to, there was coercion (however subtle) or manipulation of the vulnerable state of someone in labour.
I recommend you read as much as you can around induction of labour before you go to an appointment because once you’ve started on an induction pathway or are in active labour it is much harder to consider all the information and your options. The next section shares sources of good quality information.
A really good option is ‘active management’ if you do not feel ready to go down the induction pathway. You could go into the hospital each day that you are ‘overdue’ to have the baby monitored. This way you can be reassured and discuss your options as each day passes.
Different reasons for induction of labour
The most common reasons that labour is induced is post-term pregnancy (currently 41 weeks), premature rupture of membranes (‘waters breaking’) or that the well-being of the mum or baby will be compromised otherwise (e.g. pre-eclampsia or worries over baby’s growth). (https://www.ncbi.nlm.nih.gov/books/NBK379826/)
There has been lots in the news about Black and Asian mums have a higher mortality rate and this article covers information about induction of labour and ethnicity if this is relevant to you.
If you’re told you’re at risk of something, for example that your baby is big, your BMI is too high or you’re having a baby conceived through IVF, then read Sara Wickham’s excellent 5 questions to ask about induction.
She also has this article about what women think about induction having experienced it.
Dr Rachel Reed is another great source of information about inductions, including this one on big babies and the risk of rupturing the membranes as a form of induction (see also below).
They are both research midwives have written excellent books about induction if you want to read comprehensively: Sarah Wickham’s Inducing Labour, Making Informed Decisions and In Your Own Time: How Western Medicine Controls the Start of Labour and Why This Needs To Stop and Rachel Reed’s Why Induction Matters.
Different methods of induction of labour
The sweep may be offered before the induction appointment ‘to get things going’. As described above, this is not necessarily the benign activity that it’s made out to be.
Another option in some hospitals is the Foley balloon (or catherter or blub), also known as a cervical balloon, which is a mechanical way of encouraging the cervix to open by filling a ballon with water once it’s been inserted through the cervix. When dilation has happened, the balloon will drop out. Women in my classes have fed back that they thought this was a good way to be induced because it didn’t involve drugs and wasn’t too uncomfortable to be inserted. They said it felt like having a smear check or inserting a big tampon.
A third option is have a prostaglandin gel or pessary to ripen the cervix. There are also tablets. The effect lasts 6-8 hours and you can be offered second and third doses. After the intervention, the baby is monitored to check that s/he is not stressed and then you can return home.
Induction of labour using those three options may take up to 5 days, so you’re likely to be more tired and stressed from waiting. A home birth is still a possibility after the Foley balloon or gel/pessary.
After those three options, the midwife might offer to break the waters or do an Artificial Rupture of Membranes (ARM) to encourage labour to progress. One of the issues with this is that the amniotic fluid supports the baby in navigating through the pelvis. Imagine going down a swimming pool chute without the water: you’d get stuck on the dry surface and find it harder to go round the bends! See Dr Rachel Reed’s great article with more about this.
The next option is for a synthetic oxytocin drip. This requires you to be in the Obstetric Unit and to be monitored (more on monitoring later). For labours that started spontaneously but are slow to progress, the drug in the drip can shorten the labour by two hours. The contractions are often reported as being harder to cope with than those from natural oxytocin. This is because synthetic oxytocin doesn’t behave in the same way as the body’s own oxytocin (an endogenous hormone) that supports the brain to cope with the contractions.
Concentrations of synthetic oxytocin
A big issue that was highlighted by two whistleblower midwives is that the concentration of synthetic oxytocin used for induction of labour has increased greatly over the last 30 years. While it’s not uncommon for drugs to be used beyond their licensed amounts, they showed that there is a link between the higher concentrations and postpartum haemorrhage. The higher concentrations create stronger contractions, which can hyperstimulate the uterus and the baby can become distressed, leading to a caesarean birth. I recommend that you print off the article on the homepage of the Oxytocin Measures website (https://oxytocinmeasures.com/) and if you are being recommended to have a drip, that you show the article and ask about the concentration of synthetic oxytocin being used.
Lyn and Monica, the two midwives who published the data from the research from a freedom of information request to all the UK hospitals, shared their experience of midwifery over the decades at my State of Birth symposium. They said that at the beginning of this type of induction, a midwife had to be present at all times that a drip was active and that she would have to switch if off if she left the room. Now, women having the synthetic oxytocin drip are monitored centrally through CTG – see the next section.
CTG monitoring
One of the issues with having the synthetic oxytocin drip is that you will then have wires attached to you for monitoring and this can limit your ability to move around during labour. Being able to move around during labour supports your baby to move through different positions - if you come to pregnancy yoga you will hear again and again why it’s so important.
The cardiotocograph (CTG) machine generates a graph, showing the fetal heart rate and the activity of the woman’s uterus. This is literally where the name cardio- (heart), toco- (uterine contractions), -graph comes from. But CTG machines don’t DO monitoring. Humans do.
Dr Kirsten Small is a retired obstetrician who did her doctoral research on CTG and she shows that there is NOT good quality evidence for it being relied on so heavily. She says, ‘no robust evidence that CTG use prevents deaths or long term brain injury’ and that ‘the evidence is clear that CTG use increases the use of caesarean section and instrumental birth, and decreases non-instrumental vaginal birth’. (Source)
So what does she recommend as an alternative? She says in the same article that ‘Intermittent auscultation avoids the higher rate of unnecessary interventions for women seen with CTG use, and I would argue this makes it the better tool for fetal monitoring in labour… Hands down, the most effective form of fetal monitoring is to have a knowledgeable and experienced care provider, who is present all the time (allowing for toilet breaks).’ (Source)
Intermittent auscultation (IA) is the technique of listening to and counting the fetal heartbeats for short periods of time during active labour. It is usually performed using a Pinard stethoscope or a hand-held Doppler device, with the uterine contractions palpated by hand. The Pinard device is a hollow tube often composed of wood or metal. The Doppler device is a small hand-held ultrasound transducer that uses the “Doppler effect” to provide an audible simulation of the fetal heartbeats. Its advantages are that it can be used in various maternal positions, including water immersion, and that the real-time audio sound is shared with everyone present in the room. (Source)
The problem is that if you have an induction using synthetic oxytocin, the policy is that you should be monitored using CTG and then you will be restricted in terms of movement. Some doulas (labour support) I know have held the pads at the end of the wires for monitoring in place so that labouring mum can move and not disturb the graph. Some midwives will support you as much as possible to still have some movement available and to change positions, whereas others will get very twitchy and want you to stay still.
So the decision to go down the route of induction is a big one because it has consequences. They may be consequences that you are willing to accept because of the situation you find yourself in e.g. pre-eclampsia. However, you might weigh everything up and think that you’re not ready to compromise on your ability to move around and risk contractions from the synthetic oxytocin that are too strong to cope with. In three days’ time, you might have reassessed and feel ready to go down that route. It’s not that you have to make a decision and stick with it until the baby is born, you can reassess every day.
Two birthing stories
I wanted to share two birthing stories with you from second time mums who wanted the labour experience to be different from their first time around. If you’re a first-time parent, I invite you to read as many stories as you can because that’s where you will understand the role of the maternity system and the little details of what happens in labour to help you anticipate what it is like. I’ll share some books with birthing stories at the end of this section.
Ruth’s birthing story – October 2024
“My son arrived yesterday morning at 8.14am in Rushey [Midwife-Led Unit]. We were home by the afternoon and now settling into being a family of 4.
We went to the assessment unit on Friday evening at 8pm because I thought I was having endless braxton hicks that started to ramp up after yoga on Thursday! Sometimes they were 2 minutes apart but not painful. While we were in the waiting room they started to get more intense, so I was taken into a side room and found to be 2cm dilated. They were happy for me to stay in and the amazing midwife opened up Rushey for us as it was closed.
We got to rest and nest overnight in a really calm room. My husband could sleep and as things increased I was able to sit on the birth ball, rock against the wall, lean over some pillows and following what my body wanted to do.
I used a tens machine this time too which I found brilliant and would really recommend to others. I listened to your hypnobirthing track on repeat and found it so calming and grounding.
We moved into the pool room when I was 5-6cm. They had to get me out of the pool for some additional monitoring and thought they might have to transfer me downstairs, but it was all because he was ready to be born. He was born on the bed next to the pool at 8.14am after only 2 hours of active labour! We got to have lots of newborn cuddle time and were home by 4pm. He's beautiful 😍 .
Just like last time, I've loved your pregnancy yoga class being part of my pregnancy journey and have taken so much from it.”
If you are induced, you are likely to be on a ward with other women and their birthing partners so it may be harder to relax and even sleep. Often, being 4cm dilated is the time that you will be admitted to the maternity department. Given that Ruth was having such intense and frequent contractions was probably the reason she was admitted at 2cm. The amount of cm of dilation is not a predictor of how long it will take for the baby to arrive!
Currently (November 2024), the local Midwife Led Unit is underutilised and is probably the reason for it being closed when Ruth arrived at the hospital. Being able to open it is dependent on staffing numbers, but if this is your wish you and your birthing partner should make this very clear.
I’m so happy that Ruth was able to listen to her body and make herself comfortable – this is a big part of what we practice in the pregnancy yoga classes.
Rebecca’s birthing story (October 2024)
We welcomed our baby daughter on Wednesday last week [at 40+6]. I started feeling a bit sore mid-afternoon and called the triage line and we agreed that I'd wait at home for a bit longer. About 20 mins later the pain had intensified, and my waters broke which had some meconium in so we called back and were advised to come in to the labour ward.
I had been hoping for the midwife unit, but I didn't mind because at this point I was thinking I'd like an epidural. We got to the ward and into one of the rooms and I asked for an epidural and they said that would be fine but baby just needed 10 minutes of monitoring first.
The baby had different plans and within the next 10 minutes she was born!! They asked me to stand up just to keep things moving and as soon as I stood up I knew I wanted to push. I think there were just 3 or 4 contractions of pushing before she appeared!
She's been feeding well and we are so happy to have her!
The breathing techniques from the class were so helpful especially keeping me calm during the car journey and although I didn't use too many positions for the labour and birth as it was so quick I'm sure things like sitting upright/forward in the run up helped get her in a helpful position. Much faster than my first labour!”
No wonder Rebecca was feeling that the contractions were so intense – the baby was ready to be born! With an induction using synthetic oxytocin, the feeling of the contractions being too intense to manage may arrive sooner because the oxytocin levels are higher (there is the synthetic AND natural / endogenous oxytocin).
I’ve included both of these stories to show you how the onset of spontaneous labour can look very different for two individuals. How we labour and when we go into labour varies from person to person.
You can find lots more stories in these great books:
Leah Hazard – The Father’s Home Birth Handbook [Good even if you’re not planning a home birth] https://www.amazon.co.uk/Fathers-Home-Birth-Handbook/dp/190517750X/
Tessa Venuti Sanderson – Pearls of Birth Wisdom [My book! Diverse birthing stories and breathing/ relaxation techniques https://www.amazon.co.uk/Pearls-Birth-Wisdom-Insights-Practices/dp/0993375189/
Concluding thoughts
Induction of labour (IoL) is an intervention to consider carefully. I want to make it clear that I am not against IoL because it can absolutely be the right choice in certain situations. However, each situation has to be taken individually and you need to weigh up all the consequences of that decision.
I hear from a lot of first-time parents that if they were in the situation again, of being recommended an induction for being overdue, they would decline it. This is because it led to a cascade of intervention. At the time, they wanted to meet their baby as soon as possible, but didn’t realise how the induction would make the labour much harder.
In Sara Wickham and Rachel Reed’s books on induction, you can read diverse stories of the experience of labour. Some of these are positive. From listening to thousands of mums over the 19 years of teaching, it seems that how ready your body is to go into labour makes a big difference. If you were a day away from starting labour, this will be quite a different experience than if you were three weeks away.
If you know someone who is planning on becoming pregnant, strongly encourage them to chart their cycle so that they know when they were likely to have conceived. This may give them the confidence to know if they have actually gone ‘over due’. For information on charting for fertility, this is an excellent website: https://www.tcoyf.com/
I hope that this article has given you some useful resources to learn more about the process of induction and enables you to make the right choice for you.
