Dr Samina Dornan, consultant OBGYN and fetal medicine specialist at King’s College Hospital London, Dubai, gives you the lowdown on induction in the UAE and the questions you should ask your healthcare team:
1. What is an induction and how common are they in the UAE?
Most women will go into natural spontaneous labour by 42 weeks. However, sometimes labour needs to be started artificially; this is called ‘induced labour’. In most cases, an expectant mother’s waters will break naturally and she progresses into a physiological birth. However, sometimes it’s advised to induce labour to avoid a pregnancy lasting longer than 42 weeks, or if a woman’s waters break but labour doesn’t start. In both cases. the baby’s health may be compromised if no action taken. In recent decades, more and more pregnant women around the world have undergone induction of labour (IOL) to deliver their babies. In the absence of official data, it is difficult to say what the exact statistics of IOL are in the UAE. In well-resourced countries, up to 25 percent of all deliveries at full term now involve induction. In developing countries, the rates are generally lower, though there are exceptions where there are higher numbers.
2. When would induction be needed?
The most common reason for induction is to avoid a prolonged pregnancy. Midwives or obstetricians may discuss this with the mother at her 38-week antenatal appointment. If they are offered an induction for this reason, the details of the induction (when and where it takes place) are determined based on the patient’s preferences and the location of the facilities available in their area. Patients may also be offered an induction if they are more than 34 weeks pregnant and their waters break prematurely, but labour has not started on its own after 24 hours. Other factors that may suggest the need of an induction include: if there is concern that the baby is smaller than expected; if the baby is not moving well on a repeated basis; or if there is a specific health concern, such as gestational diabetes, or high blood pressure in the mother, or a specific problem found in the baby, concerning the baby’s heart or anything else serious. However, induction of labour should not be offered if it is solely based on the baby being larger than expected.
3. What is the Bishop Score?
If the mother and her midwife or obstetrician decide the labour should be started artificially, the baby’s heartbeat should be checked using sensors attached to the patient’s abdomen beforehand. The midwife and obstetrician should also examine the patient’s cervix. At that stage, the doctor then calculates the Bishop Score, which is a measurement that assesses the position of the cervix, the cervical consistency, length and dilatation, as well as how high up in the pelvis the baby’s head is sitting.
4. What does induction involve?
During induction of labour, the mother is given medications that simulate the effect of the hormones that naturally trigger labour. These drugs are called prostaglandins. These prostaglandins are inserted into the mother’s birth canal, in the form of a gel, tablet or pessary. The mother’s cervix is then re-examined after six hours, if they have had a tablet or gel, or after 24 hours if they have had a pessary.The baby’s heartbeat is checked when contractions begin and will be checked at regular intervals, normally using a hand-held doppler device. If the mother goes home after they have been given prostaglandins as a tablet or gel, they should contact their obstetrician or midwife after six hours if contractions haven’t started, or when regular contractions start. Amniotomy is another method of induction, in which healthcare professionals artificially break the waters. Amniotomy should not be conducted, unless the mother’s obstetrician or midwife thinks there may be specific problems likely to occur with using prostaglandins
5. How safe are inductions? Are they more painful?
Induced labour may be more painful than spontaneous labours but not always. Mothers should be offered support and appropriate pain relief, as different people have a different pain threshold. Pain relief discussions should take place regardless of whether the labour has been induced or not. Furthermore, patients should be encouraged to use their own coping strategies for pain relief for as long as they can and so desire. Labouring in water often provides good pain relief. The uptake of an epidural, which is an anaesthesia in the patient’s back is highly popular in women’s first labour, which can often be quite prolonged and sometimes very uncomfortable. However, every labour is different and each woman should choose whatever she needs to help her work with the pain of labour. Most importantly, she should have the confidence that she can do it and never feel that she is a failure if she requires more pain relief than was planned.
6. Does induction increase the chance of an emergency C-section?
The straight answer is no. As far as induction of labour (IOL) and caesarean section are associated, there is increasingly reliable evidence stating that, at 39 weeks of gestation, maternal complications rates following IOL are similar to those in a spontaneous labour group. Similarly, when looking at neonatal outcomes, comparable findings can be found. However, if the mother doesn’t go into labour after attempted induction, her midwife or obstetrician will discuss this with her, and check her and the baby. Depending on the patient’s wishes and circumstances, they may offer her another dose of prostaglandins. In some circumstances, she may be offered a Caesarean section at this stage. It may be acceptable to schedule labour induction as long as seven days before the patient’s due date and this does not increase the risk of emergency C-Section. Additionally, there is now more robust evidence showing that IOL at the patient’s due date actually reduces the risk of complications affecting both mother and baby, and indeed the rate of emergency C-Sections.
7. What would your advice be to mums worried about induction?
Your midwife or obstetrician should explain why you are being offered an induction. They should also talk with you about the risks and benefits, explain the alternatives and encourage you to look at various sources of information. They should talk to you about when, where and how labour can be induced and about how pain relief options may vary, depending on where you are induced, and the options if inducing your labour doesn’t work. You should be given plenty of time to discuss induction with your partner, or family, before making a decision and your healthcare professionals should support you in whatever decision you make. If you choose not to go ahead with induction, your midwife or obstetrician will discuss your other care options with you.
I also advise women to ask the following questions to their health care team when discussing IOL.
- Why am I being offered induction?
- What are the benefits?
- What are the risks (to me or my baby), and how likely are they?
- Can I be induced at home?
- How is an induced labour different from a spontaneous labour?
- What pain relief is available and when can I have it?
- What happens if I choose not to be induced?
Lastly, I would like to urge women to discuss everything in detail with their healthcare team, as knowledge will empower them and help them enjoy the journey.