A doula's guide to induction

This blog has been a long time coming. It’s been sitting in my drafts looking at me for quite some time. With induction being so common in our maternity system, I think it’s really important for you to know what it all means from the inside out. I have supported many inductions as a doula and I’ve sat alongside women and their partners as they go through each and every step. I’ve seen kind and gentle informed care and I’ve seen coercion, misinformation and protocols being more important than a woman’s experience…so let’s take a look at the process…from the very beginning…

What is an induction?

If your labour is to be induced, it means your body will be helped into labour using medical interventions rather then letting your body go into labour spontaneously.

Why might you be offered an induction?

There’s lots of reasons an induction may be offered…you’ve gone overdue, you’re over 40, there’s a medical need, you’re an IVF pregnancy, your baby is showing too small or too big on scans, your waters have broken already and labour hasn’t begun and the list goes on…

How do I know if induction is the right choice?

The decision to be induced is truly, the most important part of the process. Often missed out completely with women thinking that the induction isn’t a choice. Firstly, induction is ALWAYS a choice, even if the medical reasons are very real, everything to do with your body and your baby are your choice. It may not always be presented like a choice but it is.

So the most important thing you can do is take time with this decision.

What will help you make it? INFORMATION.

What have they told you is the reason for your induction?

There are some sweeping reasons why you would be induced such as maternal age, post dates (going overdue) and your baby’s size. This is where you have to really go and look at the evidence, the stats, and balance this with your own feelings. You are at your most intuitive in pregnancy especially towards the end as you prepare for your birth, if something doesn’t feel right to you, it needs to be explored, questioned, discussed until it does. Women who go into an induction feeling unsure means they haven’t been given enough information to make a balanced decision.

For excellent resources on induction decision making, please take a look at the following websites:

Sara Wickham, the renowned research midwife has lots of info here

As does the amazing Dr Rachel Reed from midwifethinking.com

For instance something that is more and more common at the moment is a ‘big’ baby. Firstly, let’s just say ‘bigger’ and not be sizest about these sweet babies. Secondly scans are inaccurate and the evidence suggests up to 15%. This is actually quite a lot…so if your baby is suggested to be 8lbs when it is born (and yes babies at only 8lbs are getting called big) means your baby could be over a pound bigger OR smaller. Your baby could be anything from 6lb 13oz to 9lb 2oz…that’s a big range and let’s come back to bodies being designed to birth babies whatever their size.

Another thing to know is you get to decide on a plan…they will offer you their suggestions but their suggestions will always be based, in most cases, on general care rather than each individual woman. If you need more support in making the decision, you could arrange to speak to a consultant obstetrician or the head of midwifery and have a deeper chat. However again in my experience there are pro choice medical professionals and their are pro protocol ones. So you might need to ask around who is best to see, ask local friends who they would recommend at your hospital or there are some great facebook support groups where you could get the low down on your local hospital such as the positive birth group and induction of labour in the UK.

If you do want to make a different plan to what they’ve suggested and you want to wait…you could wait a day, a week, an afternoon…if you and your baby are well, what’s the rush? What I always find hard to swallow is when I go in and support a woman, they’ve brought her in due to a specific risk, the mother is obviously worrying about that risk and then once she’s in, ticked off so to speak, she’s left…sometimes for hours just waiting for a room and then the induction process itself can take easily two or three days sometimes more and yet there was a perceived urgency to this decision?

So what if I do wait?

Always a good question to ask. You could wait anything from an hour to a week and you have the right to change your mind at any point. You can also refuse the induction all together and not want to put a date in at all. You can go in daily for extra monitoring of you and your baby. If your waters have gone and you want some more time, you can take your temperature and keep an eye on it at home as a raised temperature can be a sign of infection.

Why would I wait?

To give you and your baby more time to be ready to birth. Any amount of time gives your baby that chance to be closer to being ready to be born and your body more time to soften for birth and a chance for your own physiology to take over and perhaps spontaneous labour will happen.

But why would I wait if there are risks?

Firstly it’s important to be sure of the actual risk. A risk is often presented in relative terms rather than actual terms. For example, I found this article written by the Guardian, the headline is sensationalised, ‘children born after IVF are found to be nearly twice as likely to be born early, stillborn or die within 28 days of birth’. That sounds really scary right?! Then I read further into the article and found the actual risk…’Neonatal deaths rose from 0.3% in naturally conceived babies to 0.5% in IVF children’ which is a 0.2% difference…and the article also goes on to question the validity of the study. This is the thing about evidence, it can be exaggerated and misinterpreted and often changes year on year, I wrote more about this here. So it is really important to assess things for yourself. Evidence based birth is another great website for stats.

And if there is a true medical need for your baby to come out now, is induction the right way to go about it? If your baby is genuinely in need of a swift exit, induction is not without risks and is your baby going to cope with it? Could a caesarean be a safer choice? Induction is so often portrayed as a safe option but it presents risks too. One of the underestimated side affects of an induction is that the mother and the baby miss out on the natural physiology and hormonal cycle of labour which aid bonding, breastfeeding and recovery. Labour is such an intricate and complex dance for the mother and the baby, what natural processes are being stunted with an induction? I’ve heard midwives tell women that syntocinon, the drip given to induce contractions is the same as your own oxytocin. How can a synthetic drug be the same as a woman’s body producing her own oxytocin through labour?

And I get it, you’re now probably thinking, ‘how can I challenge medical professionals?’ Well you can because they are offering you a service, a service you pay for and it is not a one sided decision. Birth in the main, is not a medical event. It is a naturally occurring bodily function which has become over medicalised through time.

So it’s becoming more and more common for women to be induced for example for ‘big’ babies and then when they’re born and they are not big at all, no one is held accountable for the fact this mother has been induced unnecessarily. The NICE guidelines clearly state that if a bigger baby is the only reason, an induction should not be offered. Sadly, this is not what is happening though.

So as you can see, MOST of the decision making is done before you even go in for your induction.

Now you’ve made your decision, and you’re going in to hospital to begin the process…

What will induction look like?

The waiting

The first thing you’ll probably have to do is wait. I’ve not supported an induction yet where there wasn’t some waiting around. Once I waited 8 hours with a Mum before we even got a space to wait…that’s unusual but not unheard of. So for all the pressure and urgency of an induction having to wait for everything can feel unsettling. Expecting this helps and writing your own rules a bit here, really helps. If they’ve given you a set time to come in, great. If you’ve called up and they’ve said come in, you might want to take your time depending on the situation. Don’t feel rushed because most likely you’ll be waiting when you get there. Have a nice breakfast first, or check in and then pop home, go for a walk…you are not a prisoner. I’ve had Mums pop home to see other children during inductions, take long walks in the surrounding parks, if you’re just hanging around, you can make it work for you. Some couples have been known to pop to a restaurant for dinner and a glass of wine ;)

Pessaries

Inductions themselves are also often long. Much longer than a standard labour because your body is not coming from a ready to birth place. It’s got to get ready and this can take a while. The first thing you’ll usually be offered in hospital is a propess or a pessary (you’ve probably had sweeps already by this point or declined them- more info on sweeps here).

A propess is like a small tampon which is inserted into the vagina to ripen the cervix using prostaglandins (the same hormone found in sperm) and it can be left in for up to 24 hours. Some trusts let you go home with this one (interesting that it isn’t consistent between trusts) so it’s worth asking if you can have this as an outpatient. A propess gives your body time to ripen your cervix and some women will move into a normal labour from this. They will begin to dilate and have contractions. More detailed info on propess and pessaries here.

If the propess doesn’t work they may offer you between 2-4 rounds of a pessary which stays in for 6 hours, imagine a giant paracetamol tablet which is inserted into the vagina. This means you will gain more time for your body to get ready but you’ll also have more internal examinations which is something to consider especially if your waters have gone.

This probably sounds like a long time to wait just to get going. However this can be great for your body and your baby to bring them closer to birth in a gentler way. Treat it like a hotel stay with your partner, rest and read and chat and snack and make it a special time just the two of you.

So what’s next?

You will likely have been in the hospital a day or two and in most cases you’ll be on the antenatal ward in a bay and by this point craving your own space. It can be hard for some women to let labour take hold in such a public place.

The idea of the propess and pessary is to ripen your cervix so it will begin to dilate to at least 2cm so they can break your waters. If you are checked and are at least 2cm, this will be their next suggestion. ‘I can get you your own room now and we can break your waters.’ This is something to again consider. You may have heard of the BRAINS acronym for making positive birth choices but I find it too complicated especially if a birthing woman is trying to get into labour land and out of her thinking brain. So I just say have a CHAT.

CH - CHOICES? What are they at this point?

A - ASK questions - if your choices aren’t clear or you feel unsure, keep questioning it.

T - take your TIME - in most cases there is no rush to make this decision, ask for some time and privacy to talk things through. Pausing when big decisions are being made can make such a difference to how you feel about your birth.

So why wouldn’t you want to break your waters?

The waters being broken is speeding things up before your body is ready. The waters are your baby’s cushion and yours against the strength of contractions and infection protection for you both. Lots of women report contractions were far more intense once the waters had gone. Also if baby’s position supports waters breaking naturally, i.e. the baby is ready and in the right position to break them, you may be rushing a baby who isn’t in the correct position which could affect your labour and needing assistance later on.

So why would you break the waters?

Sometimes it doesn’t feel like a choice but it is and sometimes women need to move things along. There could be a good medical reason or it could be the mother’s preference. They may already be exhausted and that has to be taken into account during a long induction process. Balancing what you can tolerate, energy levels and mental wellbeing is just as important.

But having your waters broken to get a room is not a reason. This is a form of coercion and you don’t have to agree to it. You may have to wait for a room but you do not have to have your waters broken to proceed.

You can give your body more time first or you may be happy to go ahead. But it is your choice.

Augmentation of labour

After your waters may or may not have been broken, and you’ve had all the pessaries, things may have got going and you are on your way to meet your baby. If things are not moving along, a drip will likely be offered to speed things up. A syntocinon drip is artificial oxytocin to help your uterus contract. Your body will respond quite quickly to the drip usually within the first hour or so and you’ll have 3-4 contractions in ten minutes. They’ll be long and strong from the get go. There is a lot of fear around drips and the pain of contractions that comes with it. However you can get on top of drip contractions. Because they have a predictable pattern and a consistent strength you can use this to your advantage and find a rhythm that works for you.

If you have a drip, you will have to have a cannula in your hand to administer the syntocinon and any fluids you might need, as well as being there if you do need to go to theatre for any reason. So decide which hand you want it in, usually based on if you’re right handed have it in the left. Cannula’s can be quite sore and can get in the way post birth too as they’re reluctant to take it out for the first few hours in case you need any meds, so bare this in mind. If it is really sore ask them to redo it, which might help and post birth, keep reminding them if you need it removed sooner as it won’t be a priority but it can make a big difference to you.

You can also make a decision how long you want to labour in this way for. Maybe you want to set a time limit for yourself like, ‘I’m happy to give this 4 or 6 or 12 hours and then I’m going to decide to have a caesarean’. I think it’s important before entering into an induction with potentially lots of interventions how far you want to go and making this decision with a calm mind ahead of time can help. Is a vaginal birth important to you? How do you feel about an assisted birth? How do you feel about a caesarean birth? For you and your birth partner to know what’s important to you ahead of time can help during moments of big decision making when you might be more tired and emotional. You don’t have to see it through to the end and have all the interventions in between. YOU get to call it. I’ve had women decide not to proceed with augmentation and go straight to a c birth. YOU get to decide. For some going all in is what they want to do.

Obviously all of this depends on yours and your baby’s wellness throughout and sometimes things change and there may be a moment when it is clear what needs to happen and your baby needs to come out. Even in this moment though, everything should be clear to you. Everything should be being explained and you should be agreeing to the next steps from a place of complete understanding that it is in fact absolutely necessary and why. An emergency caesarean birth is classed as an emergency whether the baby needs to be out in 5 minutes or anything up to 24 hours. So it’s worth knowing the level of emergency too. If your baby has some time, you have time to decide how you would like your caesarean to happen, and there is usually at least a little time. Would you like music, skin to skin at birth, delayed cord clamping, a slow and gentle birthing of the baby if possible? This link discusses gentle c birth in more detail here.

Pain relief options during induction

Once your induction is happening, there are many comfort measures and options available to you.

Before you enter a labour room

So while you’re hanging out on the antenatal ward waiting for things to start, what can you do to help?

The most essential hormone to labour is oxytocin. The hormone of love, sex and birth. If you’ve now made the decision to be induced, the best thing you can do is go with it. Bring as much of your own oxytocin to the birth. Bring positivity and gratitude that you’re on your way to meet your baby. Have a giggle with your partner, cuddle, maybe they can give you a massage, a foot rub, read you relaxation scripts, when my best friend was being induced we watched Love Island because that made her happy…if you’re feeling calm and at ease, your oxytocin will build which will help your body work with the induction.

Lavender is a calming essential oil, eye masks and ear plugs are great to block out the noise on the ward, do your best to create your own bubble.

A tens machine can be invaluable through a long induction, it can help you when other options aren’t available and it’s in your control, pressing the boost button as you need it gives you the power to soothe yourself.

Gas & air - Using entonox can be an option if you need something more. Some women feel queezy when they first puff on it but that feeling often wears off and can be a great pain reliever, most women describe it as feeling a bit drunk.

Pethidine - An injection in the thigh to offer a high strength pain medication. Pethidine is an opiate and does transfer to the baby so is not recommended later in labour as the baby may be drowsy for birth. Pethidine usually gives a Mum the chance to rest, lasting a couple of hours, it can be enough to take the edge off, lie down and doze. You can have a couple of doses roughly 4 hours apart. Some women do not feel very well on pethidine or don’t like the feeling of it at all so it is something to think about.

On the labour ward

Epidural - Inserted into the spine, an epidural numbs the body to offer often total pain relief. Most women still feel the sensations of the contractions but not the pain. It usually covers the area of contractions, the middle of your body, but some women have less feeling in their legs too. An epidural will allow you to rest and sleep which can feel very welcome after hours of labour. Sometimes the body really needs that rest to continue and give yourself the energy to bring your baby here.

Things to consider with an epidural is you’ll have less feeling for pushing, you’ll most likely be on your back with monitors on and this may lead to further interventions such as an assisted birth. You will also need to have a catheter put in as you won’t have the feeling you need to go to the loo and you’re not allowed off the bed as you’ll be unsteady on your feet. More on epidurals here.

Assisted birth

So sometimes during birth, Mum and baby need some help. With an induction birth being much more disturbed and managed than a spontaneous birth, your body does have to work harder. It’s got to try and keep it’s flow even when it’s being interrupted. With this in mind, baby’s position, having an epidural, among other factors, a suggestion might be made to offer assistance. Your baby might be showing signs of distress such as a dipped heart rate (which can also be a normal part of the pushing stage as baby is compressed through the vagina) and with your agreement this intervention feels necessary. Sometimes assistance can be provided in the birthing room and sometimes you need to go to theatre, it will depend on the medical need of both of you, where it happens.

A kiwi cup birth

A kiwi cup is the gentlest form of assistance. A bit like a small plunger the suction cup is placed on the baby’s head and offers that extra pull to help get baby earthside.

A ventouse birth

A ventouse is another form of suction cup with a bit more force. A ventouse and a kiwi can only be used when your baby is already low enough in the pelvis i.e. you’ve already done most of the work and you’re almost there…if baby is too high, they wouldn’t be an option.

A forceps birth

A forceps birth using metal forceps placed around the baby’s head to pull the baby out. Forceps are less gentle on the Mum because they have to be inserted in to the vagina whereas a kiwi cup and a ventouse are placed on the baby’s head. You will have an anaesthetic for this.

If your baby does have an assisted birth, it is worth seeing a cranial osteopath to release any added tension which may have occurred during the birth. This link explains a little more about it.

A caesarean birth

You may decide you don’t want an induction or you want to stop your induction at some point and move to a caesarean birth. Again all your choice. A caesarean birth is also major surgery cutting through layers of your abdomen to birth your baby. The recovery will likely be longer than in a vaginal birth and will likely impact your birth decisions for next time if you’re hoping to have more children. However a c birth is birth. You’re bringing your baby earthside and into your arms and that is birth.

You are a brave and beautiful mama however you birth.

Something that women worry about with caesarean birth is that the baby is missing out on passing through Mum’s vagina and getting her micro-biome and what’s called seeding of good bacteria. Something you can do is either place a sterile gauze in your vagina and wipe over your baby afterwards or simply lots of skin to skin and kissing is a great way to build that back up.

After birth

Some massage therapists are qualified in scar work now to help release pain and tension from a c birth scar and support healing in the body. If you do experience a long or painful recovery, get checked for an infection and if all is ok, this kind of massage might be useful to you.

Antibiotics are quite common place too with assisted and c births so again before you go in, decide how you feel about these. They may be very necessary or they may be for a ‘just in case’ approach. I’ve had quite a few parents not want to administer them but feel pressure to do so. It’s important to remember that this is your baby and you get to make the decisions. You should never feel coerced or forced into a decision about your body or your baby and if you do, ask to speak to someone else with a gentler approach. If you or your baby do have antibiotics, you can take a good probiotic to rebuild your gut bacteria which your baby will benefit from in your breastmilk and there are also baby probiotics too.

If you need some help processing your induction birth afterwards, please reach out to someone…you could debrief with your hospital if they have a birth reflections service, you could find a birth trauma rewind practitioner here, you could talk it through with a trusted friend, midwife or doula, seek a therapist or counsellor, and Make Birth Better have some great resources too.

This may all seem like a lot to process and think about before your birth and a big responsibility, be gentle with yourself, it can really help to be in a relaxed state to make these decisions. Find a way to ground yourself whether it’s through breathing, walking, talking, moving, resting, crying, find a way back to you and then think about it all. It’s very hard to think in an anxious state so find your centre first so you can hear yourself.

‘Birth matters…It is the way we all begin our lives outside of our source, our mothers’ bodies. It’s the means in which we enter and feel our first impression of the wider world. For each mother it is an event that shakes and shapes her to her innermost core. Women’s perceptions about their bodies and their babies’ capabilities will be deeply influenced by the care they receive around the time of birth.’ Ina May Gaskin, Midwife & Author

Sometimes birth takes us on a different path. Sometimes the journey isn’t what we thought but getting informed, taking your time and following your instincts can still bring you a beautifully positive birth experience.

Sending tonnes of doula love for what’s ahead.

Jen

x

A birth & postnatal doula working in Surrey and London

www.theminimalistdoula.com

- earthside postnatal online course out now -