A Critical Eye On Induction Of Labour

Midwife Ingrid Groenewald lives in Cannon Rocks in the Eastern Cape. She is also a wife, and a mom to three children. Ingrid says, ‘As an independent midwife, I see low-risk women throughout their pregnancies, do home- and water-births, and run healthy mom and baby clinics in our area. I am also a perinatal educator, who loves to interact with pregnant couples during their antenatal education sessions, and an IBCLC (International Board Certified Lactation Consultant). My passion is to educate, help and support breastfeeding mothers, as I do believe that most women can breastfeed with the right knowledge, support and care.’

After examining the evidence on inductions, midwives cannot continue to keep quiet about the real risks associated with this often-unnecessary procedure, says Ingrid Groenewald.

I get to meet many expectant couples in my work as a private midwife and as I teach antenatal classes. Over the years, the one thing that really stands out for me is how often pregnant women are told that they have to be induced – for whatever reason. Many just accept this, without even pausing to question this intervention. Many of these women also then end up having a caesarean birth and/or experiencing negative feelings regarding their birth. When I talk to these mothers afterwards, it often feels to me as if they’ve never even considered that the reason for their bad birthing experience or caesarean birth might have been the induction to begin with.

This is the reason that midwives, antenatal educators, and any other health professionals working with pregnant women, need to keep educating and empowering women. We need to help them understand that this is their pregnancy, their birthing experience, their baby, and while some interventions are called for in particular situations, these decisions should always be based on evidence-based practice.

A Common Yet Drastic Procedure

Let’s start at the beginning and look critically at inductions. An induction of labour is the stimulation of uterine contractions prior to the onset of spontaneous labour. It is a very common procedure but it has also been described as ‘one of the most drastic ways of intervening in the natural process of pregnancy and childbirth’. The WHO estimates that 25% of all women in developed countries now have their labours induced. This is a two- to four-fold increase within the last three decades.

Though the procedure is common, this does not mean it is not problematic. As midwives, and considering the evidence, we all know that childbirth is a physiologically natural process, best left completely alone, not to be interfered with. Independent midwives see this time and time again: women who birth where they feel safe, surrounded by the people they’ve chosen to be there, women whose labour is not interfered with at all, birth really well. They often describe their labours and births as happy. Sadly, this is not how women who’ve been induced commonly experience their labours.

Ultimately, labour induction is a drastic form of interference. The uterus is stimulated with medication in such a way that it starts having contractions prior to the onset of labour. Because of this interference, other interventions can easily snowball.

The Real Risks

Some common problems inductions can cause are:

  • Hyper-stimulation of the uterus
  • Fetal distress
  • Slow progress of labour
  • Very painful labour
  • Postpartum haemorrhage
  • Failed inductions
  • Higher incidence of caesarean birth
  • Negative feelings for the mother regarding the birth
  • Postnatal depression (the use of syntocinon is now being linked to PND)
  • Death (studies have also indicated that induction can result in the death of about 1 in 10 000 women, caused by amniotic fluid embolism (AFE); research shows that 50%–70% of AFE is ‘associated’ with induction)

Why Induce?

Historically, labour inductions were performed only in situations where the mother and/or baby had pathological conditions that put them at risk, such as pre-eclampsia, intrauterine growth restrictions, and diabetes. Routine inductions were also only considered 14 days after the due date, at 42 weeks gestation.

In the last decades, however, it has become increasingly popular to have labour induced earlier, sometimes even before 40 weeks gestation. Reasons include the availability of cervical ripening medications, a general increased use of intervention in childbirth, and an increase in the request from pregnant women to ‘end’ the pregnancy. Nowadays, many women request the intervention, mistakenly believing that it is an ‘easy way out’ or preferring to schedule their birth. The list of reasons some practitioners give for what they say are ‘necessary’ inductions can seem to go on and on too and inductions are even performed based on non-evidence-based beliefs, such as:

  • Baby is ‘full term’ from 38 weeks gestation and can be born safely
  • Pregnancy immediately becomes increasingly dangerous for the baby after the 40-week mark
  • Baby might be ‘too big’ for a natural birth

What Does The Evidence Say?

In 2018, a systematic review was done by the University of Copenhagen in Denmark, looking at the effect of induction of low-risk women prior to being post-term, where term is 40+ 0–6 gestational weeks, late term is 41+ 0–6 gestational weeks and post-term is only after 42 complete weeks gestation.

Induction at late term (41+ 0–6) compared to post-term (42+ 0–6) was associated with:

  • An overall increase of caesarean birth
  • An increase in caesarean birth due to failure to progress
  • Chorioamnionitis
  • Labour dystocia
  • Precipitate labour
  • Uterine rupture
  • Decreased risk of oligohydramnios
  • Decreased risk of meconium-stained fluid

No differences were seen in:

  • Postpartum haemorrhage
  • Shoulder dystocia
  • Meconium aspiration
  • Five-minute Apgar score <7
  • Admission to the NICU

What About Stillbirths?

Stillbirth is such a potentially devastating event that once this is mentioned as a possibility to women, they immediately feel that induction of labour is their only option to keep their baby safe.

But let’s look at the actual numbers. Current risk factors for stillbirths are:

  • At 37 gestational weeks, there is a 0,21% chance per 1000 births of having a stillbirth
  • At 38 weeks, the risk is at 0,27% per 1000 births
  • At 39 weeks, it’s at 0.35% per 1000 birth
  • At 40 weeks, it’s at 0.42% per 1000 births
  • At 41 weeks, it’s at 0.61% per 1000 births
  • And at 42 weeks it goes up to 1.08% per 1000 births

Thus, the risk of a stillbirth does gradually increase with gestational age, and increases even more rapidly after 42 weeks. Some researchers have found that elective induction at 41 to 42 weeks may decrease the risk of stillbirth or newborn death. It is, however, thought that there would need to be as many as 328 to 410 elective inductions at 41 weeks in order to prevent one stillbirth or newborn death.

This fact, together with all the other potential adverse effects of inductions, should be brought into consideration. Any conversation about elective induction should take into account the mother’s preferences, personal birth history, risk factors for stillbirth, chances of a successful induction (how ‘ripe’ the cervix is), as well as alternatives.

Other Ways To Induce Labour

If the mother and baby are examined regularly, a healthy pregnancy can be allowed to continue to 42 weeks and beyond. Other ways to bring on labour include:

  • Frequent sexual intercourse, as sperm contain natural prostaglandins
  • Orgasms to stimulate the uterus to contract, which might bring on labour
  • Eating spicy foods
  • Eating 60–80g of dates a day
  • Cervical stretch and sweep
  • Reflexology
  • Acupuncture

A Risky Routine

If we look at the facts critically, it is clear that labour induction can be risky. Induction prior to post-term has shown few beneficial outcomes and several adverse outcomes, and according to the WHO, any medical intervention should only be done if the benefit of the procedure outweighs the potential harm.

That is why Danish researchers adopted the policy of awaiting spontaneous onset of labour until post-term (42+ gestational weeks). They thus do not support routine induction of labour of low-risk women as their data showed that 70% of all pregnant women will go into spontaneous labour by 42 weeks gestation.

Should we then not follow suit and keep our mothers’ (and babies’) best interests at heart? Considering the evidence, as midwives, we should keep mothers and babies safe from harm by speaking up about practices that are not medically necessary.

  • Cohain, JS, 2018. ‘More Evidence to Avoid Hospital Birth: A Critique of the Results of the ARRIVE Study’, Midwifery Today
  • Deckker, R, 2017, ‘Evidence on: Due dates’. Available: https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/
  • Dekker, R, 2018, ‘Evidence on: The ARRIVE trial’. Available: https://evidencebasedbirth.com/wp-content/uploads/2018/11/The-ARRIVE-Trial-Handout.pdf
  • Knight, M, 2012, ‘Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations’, BMC Pregnancy Childbirth, 12:7
  • Rydahl, E, et al, 2018, ‘Effects of induction of labor prior to post-term in low-risk pregnancies: a systematic review’. Available: https://www.ncbi.nlm.nih.gov/pubmed/30299344

This article was originally published in Sensitive Midwifery Magazine in 2019.