Episode 181 - Induction of Labour Part 1
[0:00] 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 everybody to today's episode of the Great Birth Rebellion podcast.
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[3:57] the link is in the show notes. Today, I'm talking about the process and risks of induction of labor. When I started writing this podcast episode, it became obvious about four research papers in that there was no way I was going to be able to cover it all in an hour. So this is part one and next week is going to be part two. So this is a two-part episode on the risks of induction of labour which is telling in itself. I haven't included the reasons or benefits for induction of labour. That's because these two things can be incredibly varied and dependent on your personal circumstances and the reasoning for induction of labour is best discuss with your care provider. But we've also touched on the reasoning and the usual.
[4:40] I guess, excuses for induction of labor in some previous episodes. And I will link those in the show notes below so that you can go back. If this is a topic that interests you, you can go back to the previous episodes, but we've already spoken about induction of labor and revisit that content. Something that motivated me to make this episode is that often care providers are really good at giving you a lot of reasons as to why you should accept an induction of labor, if they believe that you should have one. But sometimes they're not so good at giving information that might discourage you from choosing an induction because typically people will just give you the information that they want you to have so that you make the decision they want you to make. So if your care provider is particularly invested in you choosing an induction, it's possible they will understate or not mention the risks of induction. And often they're inducing you because they believe that there are risk factors in your pregnancy that could be remedied by you having your baby but then they neglect to inform you that actually the intervention that they need to give you in order to stop you from being pregnant if you have your baby also carries some risks.
[5:52] So this choice of having an induction is about balancing the risks of staying pregnant while also balancing the risks of having the induction and then women when they understand those risks fully can make a decision about which risks they're willing to take and the chances that they're willing to take with either continuing their pregnancy or submitting themselves to a medical induction.
[6:15] So this episode is for you if you're a care provider keen to give women a more well-rounded amount of information about induction. And if you're a woman who's been recommended an induction, you might notice that your care provider focuses heavily on all the reasons that you should have one, but isn't as thorough on the possible risks of having an induction. So that's what I'll be covering today. And just to be clear, I'm not suggesting that you use this information to decline a recommended induction. I'm just offering you some information that you might find useful when balancing the risks and benefits of your options as you make your own decisions around induction of labour and if it's right for you and your circumstances. It's entirely possible that an induction offers you and your baby more benefits than risks, but it's also possible that it's the other way around and that the risks of inductions feel too high when you compare them to the benefits. So that's my motivation today. And I'm also motivated by the very real possibility that the person recommending an induction to you has not done the work to fully understand the risks of induction. So if that's you, I've done a bit of the legwork for you.
[7:31] And I understand that care providers are busy and they can't be fully across everything all the time. So hopefully this is enough information that you can pass this on to your clients. If you're a care provider who's recommending an induction for somebody, perhaps this is a resource that you could also offer them as part of that discussion. So let's get into it. I'm going to start by talking about what a medical induction is. I won't have time to talk about self-managed or at-home induction methods in this episode, but I'm sure I'll cover that in a future episode.
[8:02] That's a whole thing on itself. I'll talk about the process of how it's done and the possible additional interventions that are included in the process and then the compounding risks and complications associated with each of those. So every intervention also has an intended and unintended consequence and once you start layering interventions you start layering possible unintended consequences. Now all of the resources that I used to create this episode are in the resource folder. If you don't yet have access to the resource folder for this podcast, all you have to do is sign up to the mailing list for this podcast. It's in the show notes below and you'll get access to all of the resources from this and all previous episodes.
[8:45] So what is an induction of labor? It's the process of attempting to artificially start labour before the woman's body or the baby are ready because if they were ready the woman and her baby would have started labour already. So any induction that's done before the woman's body is finished with the pregnancy and before the baby has finished developing to its full term and sometimes the benefits of an induction will outweigh the risks of being pregnant. So for.
[9:19] When a woman has been diagnosed with preeclampsia, to decline an induction or birth by caesarean could be more danger than the induction or surgery itself. So I'm not denying that some inductions are necessary and beneficial, but induction means starting labor before the mom and baby are fully finished developing. So we have to consider the long-term risks of prematurely ending pregnancy. And we will speak about that in part two. But there are three steps involved in the medical induction process. So first is ripening the cervix. Second is breaking the amniotic sac or breaking your waters. Rupturing your membranes is another term midwives and obstetricians would use. And then there's the process of creating contractions. So we'll go through each of these in turn. And there are a lot of steps and stages within these things. And they're all done in hospital. Even if you have a private midwife and you were planning a home birth or a birth center birth, if you make a plan to have an induction, then you'll be in hospital. And gosh, I hope I don't need to be telling practitioners not to try medical induction methods at home, but maybe there is someone doing that. And if you are, after this episode, you might rethink that given the risks that are associated with medical induction processes. anyway.
[10:45] You will be in hospital and exposed to hospital policies, which will likely include the use of CTG fetal heart rate monitoring, continuous fetal heart rate monitoring throughout the process.
[10:59] And it's usually done at intervals, which are determined by the hospital. We've got lots of episodes on CTGs. If you need more information on that, again, they are tagged in the show notes. And it's likely that they'll want to do things like CTG before and after each procedure and they'll check your maternal observations like blood pressure and temperature and all kinds of things.
[11:21] So the process can become quite drawn out and delayed as a result of hospital processes and everything that goes along. Every time they do an intervention they also want to monitor something and assess something so take a snack bag this is my first top tip take a snack bag with enough food and water for the day and something to do to pass the time so maybe a good book or plan to have a nap or some knitting or crochet or something whatever you do when you're sitting around waiting for things so we'll kick off with step one ripening the cervix so your cervix is the opening to your uterus if you imagine it a little bit like a balloon the knot that's tied at the end would represent your cervix and it's the part of your body that stays closed all the way through your pregnancy to keep your baby in and then it opens and dilates during labor to let your baby out and during pregnancy it's longer firmer and closed and as you get closer to labor it becomes shorter, softer and opener.
[12:29] More open. So ripening your cervix is the very first step of the induction process. But if it's not urgent, you'll only be invited to have your cervix ripened if there's time to plan something like this. So that's for things like scheduled inductions where you and your baby are actually well. And this is more like a prophylactic or policy-based induction. Some hospitals have policies where if you're over 35 or if you've had IVF or gestational diabetes diagnoses or whatever it is, the other big reason is that if you're over 41 weeks pregnant, so post-dates pregnancies, then you're actually well. This is a prophylactic induction, sort of non-medically indicated induction. It's a theoretical induction. And so for these scheduled inductions, when you and your baby are actually well, then you have time to go through this process of cervical ripening. If it was an emergency, they would likely skip this part. So the top two reasons that we have here in Australia for inductions, non-medically indicated inductions, is the diagnosis of gestational diabetes and post-dates pregnancies. And in these circumstances there's very little immediate danger and an induction is planned slowly to suit the timeline of the hospital.
[13:58] So they will schedule it in for whatever suits their hospital calendar and ask you to come in the day before your scheduled induction. So I would suggest attending this first appointment the day before your scheduled induction with the support of someone that you know and love and who can support you. It's also best not to bring your children home. Because this part is quite invasive and it can be uncomfortable and painful and it will require your attention and it isn't something that little people would enjoy being a part of. Because when you get there, they will want to put two fingers inside of your vagina to give access to your cervix because they want to assess for readiness and its rightness to respond to the next stages of induction. So they will give your cervix what's called a Bishop score and describe your cervix as favorable or not favorable for the next two steps in the induction process. So if your cervix is unfavorable, then they will recommend that you have cervical ripening.
[15:05] Now, vaginal examinations are no one's cup of tea. We all grit and bear them. Most women are not welcoming of a medical vaginal exam, but we'll submit to it for a purpose. So any midwives or obstetricians listening, just know that we don't really want these vaginal examinations, but women are doing it because it's part of the process. So just go easy, be gentle and human about it. To you, it's just everyday job. To women, it's a big deal. But before we talk cervical ripening or cervical ripening, this thing with the Bishop score, now it measures a few things about your cervix and its position and then it gives you a score. And this score determines which interventions you will get next. Just that score, that Bishop score, is your ticket or not to a slew of interventions and a night in hospital before induction. So I just want to stop on this for a minute and tease it out a little bit.
[16:15] So the Bishop score is obtained using information that's gathered through the vaginal examination and the practitioner will reach high up into your vagina to your cervix to gather the information. So this Bishop score is all based on what the clinician feels and what they're measuring with their fingers and it's not checked by anyone else. So if you want to go deeper into the actual scoring process of how they allocate a score and all of the detail. There is a very detailed article in the resource folder about Bishop scoring, but just be aware that the Bishop score is a subjective measure. It's not set in stone and the results are completely dependent on the biases and the skills of a care provider.
[17:00] And if your Bishop score is considered low, so in some settings, they'll say it's low. If it's under five or others are under eight,
[17:10] it just depends on the hospital and which process they're using. Then if it's low, you'll be subject to the process of cervical ripening, which is what we're going to talk about in a minute. If your Bishop score is high and your cervix is deemed favorable for the next step in the induction process, which is breaking your waters, your amniotic sac, then you will likely be able to skip this cervical ripening step because you've already, your body's already done it, your cervix is ripe. So first though, what are the risks of this first step of obtaining the Bishop score? Midwives are going, what do you mean risks of obtaining a Bishop score? Well, here we go. I mean, they might not be perceived as risk to you, but these are the possible consequences or unintended consequences. So a vaginal or cervical exam like this, like what is used to gain a Bishop score, this is actually experienced as it can be uncomfortable or painful and women are not offered pain relief. They're expected to just grin and bear it and that's what we expect as midwives and we tell them this might be uncomfortable.
[18:19] So that is a side effect to a medical vaginal exam. There is also a risk of what we call iatrogenic or medically caused rupture of membranes or breaking of the amniotic sac.
[18:34] Which, I mean, everyone's going, yeah, cool, that's what we want. We want to break borders. We want to start labour.
[18:41] But if you break a woman's waters by accident during an internal vaginal exam, then this puts the woman on the clock. So if she doesn't go into labour within a certain number of hours, depending on the policy of your hospital, there's going to be pressure on her to get things started, in inverted commas. It shortens the amount of time until it's expected that the woman will go into labour or else she might be offered antibiotics which is another medicine and it has its own risk factors.
[19:14] Or they might try and speed up the induction schedule which maybe if the woman's cervix wasn't favourable could impact the success of that induction process and if the waters are broken, now that woman has lost the option of mechanical cervical ripening. So if her Bishop score is low and she was going to be receiving some kind of, prostaglandin gel or pessary or a mechanical way of ripening her cervix, that option is now off the table to her because having ruptured membranes is a contraindication for this first process. So it's not a small risk factor. It actually does change the trajectory of a woman's induction process and the amount of time that she'll be offered by that hospital to get her labor going and have her baby. The other thing that might happen to you after this procedure is that you may experience bleeding from your vagina, which is most likely going to be coming from your cervix, but it can be concerning to a woman who has been pregnant and not expecting to bleed. And it may also mean more medical monitoring and assessment if the volume is large.
[20:26] The other consequence is that when you interact with the cervix in this way, in a way that is required you to get a Bishop score, then it can also have the consequence of the woman getting uterine contractions. Again, this might be a welcome addition to the process for some women, but perhaps they're unprepared for the contractions that they're going to feel and the discomfort they're going to feel. This is why I recommend having somebody with you to support you and love you. You might start getting contractions. It could feel uncomfortable in your vagina. You might start getting cramps.
[20:59] So have a plan for some comfort measures. Hospitals aren't particularly comfortable places. The chairs are uncomfortable. You can't just lie down wherever you want. There's not really a lot of soft furnishings. And if you're in pain or getting early labor cramping, you want to have some comfort measures. So even potentially a nice soft pillow, a heat pack, a TENS machine, things that you're planning to use in early labor anyway, just have them packed in preparation in case this early induction process actually starts you off with some pre-labor activity. Now, this next risk factor is not something that you will see on a medical list of complications from a late pregnancy cervical examination. And this is the risk of inadvertently being given what's called a stretch and sweep. We actually have a whole episode on the podcast on this, episode 46. So I won't go into too much detail about this as an intervention, but it's essentially a cervical massage and manipulation of the cervix. And it's an induction technique. It's something that's used to try and put women into labor. And sometimes midwives use it to help women avoid the process of an actual induction, but it's a procedure.
[22:18] So your care provider is actually expected to get your full and informed permission in order to perform one. But some practitioners will take it upon themselves to give you a stretch and sweep, disguising it within the Bishop's score procedure without your consent or your knowledge. And sometimes they don't even realize they're doing the wrong thing and they'll say, ah, I just gave you a stretch and sweep while I was in there. And you know, the midwife or obstetrician thinks they're doing you a favor or they might do it and not tell you at all. So if you're a clinician listening to this and you think that you're doing women a favor by doing this, please know that anytime you perform a medical procedure without consent, it's medical assault. So stop it. Have some respect for the women's bodies. And anytime you want to do something, give them all the information and get their permission instead of going ahead and doing it, assuming that you're doing what's best for them. So it's an unconsented medical procedure. So you have to inform the woman first and ask them.
[23:22] So women, if you are listening and you want a stretch and sweep, you may want one. And that's completely fine. By all means, go ahead and ask the clinician to give you one. You know, while you're in there doing the Bishop score, I would actually love a stretch and sweep. But if you don't want one, I would suggest that you say ahead of time and clearly that while you agree to the Bishop's score assessment, that you decline a stretch and sweep and tell them not to do one while you're there. Sometimes this can become routine practice for some clinicians. They just do it as part of their routine and they've forgotten to ask for consent.
[23:59] So to understand stretch and sweep in detail, go listen to episode 46. It's considered a fairly low-risk procedure and the potential benefits are interpreted by most to outweigh the risks. But the possible risks are similar to those of the cervical examination, which include pain, accidental rupture of membranes, bleeding, and the commencement of contractions before you're ready to comfortably manage those. So of course some of these consequences might be considered ideal if you're scheduled for an induction anyway, but I'm just here to give you as much information as possible to help you set your expectations as close to what your experience might be so that you can make decisions about what you want to do with that. In addition to this vaginal examination that you've just had for the Bishop score, potentially the one for your stretch and sweep, throughout the process of induction, you will be given a number of vaginal examinations. How many exactly? It's hard to say. But each time they want to assess your cervix, which is at least three cervical exams to determine the favourability of your cervix prior to attempting to break your water. So there would be one for the Bishop score, possibly one for the stretch and sweep if you want one, and then a second to insert the medicine or apparatus that they're going to use for cervical ripening. And then again, to assess the effectiveness of this after a period of time.
[25:27] And then again, they'll re-enter your vagina when they attempt to break your ward, it's.
[25:33] And what we know is that with each vaginal examination that practitioners do, this increases the chances of the woman getting an infection in their uterus. So given that your labor hasn't even started yet and you've likely had three to four vaginal examinations, consider that with this number of entries into your vagina, your risk of infection is also increasing.
[25:58] And these examinations will also continue through your labour and be performed two to four hourly if you're having a medical induction, depending on the circumstances. And from research for women in labour, and some hospital policies also state this, that from five examinations upwards, we're exponentially increasing the risks for women that they'll develop an infection in their uterus. And some hospitals will even offer prophylactic antibiotics in response to this. So if they see that you had a number of vaginal examinations, they might offer you antibiotics as a preventative strategy to avoid infection. So that's not a low risk, having an infection in your uterus and need antibiotics to fix it. Some medical practitioners might think that, but for a woman, that is a big ideal to enter your parenting journey on medication with an infection.
[26:52] Not small, that's big. Okay, so we aren't even up to the actual procedure of ripening your cervix yet. We've only just discussed the assessment process that precedes it and we've already come up against some risks to consider. So now, if your assessment showed that your cervix is favourable for induction, you'll probably be invited to come back the next day when they'll break your waters for the next stage of induction. So sometimes if they happen to have room or they have time, they might even offer you a spot on the spot and say, actually, your cervix is favorable. Would you like to start your induction now? So that's up to you with regards to what you want to do with that. You could go home and come back the next day or whatever you want to do. But if your cervix is not favorable, meaning that they can't access the amniotic sac to break your waters because your cervix is closed shut and it's firm because you're not ready to have your baby yet then they will offer to ripen your cervix to try and change your bishop score to soften and open your cervix so that they have enough room to get through to break the waters so whatever happens from now know that you'll be staying in hospital until your baby is born however long that takes.
[28:11] And just know that an induction of labor is by no means faster than physiological labor Bye-bye. So don't go in assuming that it's a quick process and you'll go from one stage to the next. And there's just a lot of waiting around and checks and measures. And depending on how your body responds to the induction process, you're likely to be having an overnight stay in hospital and often that is alone without your family members in most cases. So prepare what you need to prepare at home for childcare or whatever happens at your house. So the final medications that you need to actually start your contractions, which is kind of the third stage of an induction of labour, they're usually not administered overnight or for non-urgent inductions. Hospitals prefer to do non-urgent inductions in the daylight hours when they are staffed and resourced and where their resources are at peak and their staff numbers are at peak. So cervical ripening. There are multiple medical ways of doing this and each are different and have different consequences. Each have different level of effectiveness and risk to each other.
[29:24] But unfortunately, you might not have a choice as to which one is used depending on the hospital that you're at or your particular risk factors.
[29:34] So we'll work through that. Some hospitals have different resources. They might choose a cheaper product over a more expensive one, and they just only have access to one thing for induction sometimes. So I'll explain them to you so you can confidently understand the options and ask your care provider which cervical ripening method or medicines that they are going to use or whatever they use at that particular hospital. Then you'll know what you're in for. These methods for cervical ripening can be divided into two basic categories with options within each. So there's mechanical ripening, and this is done with either what's called a balloon catheter. It's got one or two balloons on it, or sometimes you might see it written as a Foley's catheter. And then there's the pharmaceutical ripening option where they will use an artificial.
[30:26] Prostaglandin, which is something that your body produces actually in the process of ripening your cervix during physiological part of preparing for labour. But they've kind of tried to mimic this with artificial prostaglandin.
[30:40] And sometimes it's kind of a pessary or tape with a little string attached to it or a gel or a cream, or this can also be admitted orally, but that's a kind of more new way, but we will talk about it. Both of these methods are tapping into the fact that prostaglandin production by your body or externally applied artificial prostaglandins are in part responsible for your cervix ripening. And the process is far more complex than that, but that's the process that these interventions are aiming to simulate.
[31:13] So mechanical ripening with the balloon, these might be chosen for some women depending on their personal circumstances or your preferences. And this involves, again, vaginal examination, and it involves passing a flexible plastic rubbery tube through your cervix. It looks like a urinary catheter. The tube is about sort of five millimeters wide. So if I had to have a guess, and they can be one or two balloons at the end. And they fill those up 30 to 60 mils full of sterile fluid that they use to inflate the balloons that are in your cervix. So basically, they put past the tube into your cervix, inflate the balloon. So it's doing what you think. It's kind of stretching your cervix open. and the idea is that it creates pressure and it forces your cervix to open by mechanical force because it's a mechanical item. So if you experience...
[32:12] Some complications with this, it's easy to deflate and remove. So like this is a reversible option. So for some women who have the risk factor, there are some women who more likely, for example, for their uterus to respond to this cervical ripening process by suddenly getting lots and lots and too many contractions. It's called hyperstimulation or overstimulation of the uterus. And this can put women at risk of uterine rupture. And these risk factors will be discussed later in the episode. But women who have risk factors that might predispose them to overstimulation or uterine rupture are likely to be offered mechanical cervical ripening options over the pharmaceutical ones because they're easier to reverse. Prostaglandins will leave you more predisposed to those kinds of risk factors, but the mechanical ripening ones work a bit differently.
[33:08] So the balloon that they inflate, it then stays in place for 6 to 12 hours. And the idea is that, again, it applies that pressure to your cervix, forcing it to open. And within this process, it also produces an inflammatory response and prostaglandin
[33:24] release, which is part of the usual cervical ripening process. So a balloon catheter is like a prolonged stretch and sweep. And if your cervix responds to the balloon it will fall out as your cervix ripens or softens and starts opening usually falls out around four to five centimeters possibly and you'll have also a big rubber tube hanging out of your vagina because the balloon is going to be in there and the tube's attached to the balloon and it's taped to your leg and you'll ask to be remained in hospital for the next steps of your induction again all through this process they'll be You're monitoring your baby with a CTG monitor and all kinds of things. This all just takes a while.
[34:09] The next option is the pharmaceutical ripening, and it's done with manufactured prostaglandins. And the trading names for these medications are, And the application process might be different. So ask your care provider for the patient information leaflet or the medication insert that's in the packet, whichever option that they're going to be offering you. And then take some time to just read the medication insert of the medicine that they want to give you that they're going to use to ripen your cervix. So that you can fully understand the possible risks of the medication that they are considering offering you. So if you want to search these ahead of time, you can search for the active ingredients and they are usually Dinoprostone or Prostaglandin E2. And some of the product names include Servadil, Dinoprost or Prostin E2. So I went ahead and hunted down the inserts for you of all three of those products.
[35:11] And also the oral misoprostol, the oral medication that they can offer you instead. And you can have a look at them. They're in the resource folder. Again, you can get access to that if you sign up to the mailing list. So you can read those ahead of time. You can ask the hospital which medication they'll be using or take them with you. And then when they tell you which one, you can read them. But I'll read directly from them as the side effects are listed on the medication information sheet because essentially the risks come from the medication. So the vaginally inserted prostaglandins suggest not using them if you've had any kind of surgery on your uterus and the balloon catheter is the alternative and preferred option. So if you've had any surgery, investigative surgery, laparoscopic surgery, caesarean section, any surgery on your cervix or uterus, it's not recommended that the gels or the creams or the pessaries, the prostaglandin pessaries, they're not as safe.
[36:09] As the use of the mechanical methods. So don't use it if you've had that. The first medication is something that the hospital's called Servadil and it's a pessary with a string on it so it can be removed and the creams and gels are harder to remove. So if you no longer want or need them in there or if there's a complication like overstimulation of your uterus, then you can easily pull out the pessary options the creams and gels are harder to reverse so I've just taken out a little section it's section 4.4 for cervidil which is the one with the little string on it and it says special warnings and precautions for use.
[36:55] This product is for hospital use only. It says Servadil should be administered only by a trained obstetrical personnel in a hospital setting with appropriate obstetrical units and facilities for continuous fetal and uterine monitoring. And that's because there are risks associated with this medicine and side effects that need to be monitored and responded to. That's why they're recommending this. So the condition, this is the next thing they're saying, the condition of the cervix should be assessed carefully. So this is the Bishop score before Cervodil is used. Don't just put it in there without first checking the cervix. Use caution with patients with a Bishop score of eight or more. So what it's saying is if the cervix is already ripe, don't use this. This medicine is not recommended for that in this circumstance. So they're saying a Bishop's score of 8 or less indicates appropriate use of Cervidil. After insertion, uterine activity, fetal condition and progression of cervical dilation and effacement must be monitored carefully and regularly by qualified healthcare personnel. If there is any suggestion of maternal or fetal complications or of adverse effects occur, the pessary or the vaginal insert should be removed.
[38:15] Uterine rupture has been reported in association with the use of cervidil, mainly in patients with contraindications. Therefore, cervidil should not be administered to patients with a history of previous cesarean section or uterine surgery, given the potential risk for uterine rupture and associated complications. If uterine contractions are prolonged or excessive, so if you have hyper-stimulated the uterus, There is a possibility of uterine hypertonus or rupture and the vaginal insert should be removed immediately. As with other uterotonic medicines, so any medicines that cause uterine contractions, the possibility of uterine rupture should be considered in the presence of excessive uterine activity or unusual uterine pain. It also said that prostaglandins, which is what cervidil is.
[39:09] Potentiate or add to the uterotonic effect of uterotonic medicines. So cervidil must be removed at least 30 minutes before administration of other medicines that will cause contractions. So that's artificial oxytocin. So the main risk factor here with the prostaglandins is hyperstimulation of the uterus.
[39:30] And that is occurring if you start getting uterine contractions, like contractions in your uterus, from the medications, and they are very painful. They last for longer than two minutes each. Or if you're getting five contractions or more within a 10-minute period, then your uterus is hyper-stimulated.
[39:49] So you need to be reporting this to the care providers. And one big issue that when they reflect back with women on their experience of induction, one of the big problems is that care providers seem not always, some do not say everybody not always take seriously women's reports of what's happening to them and women have experienced situations where they are actually in danger and no one is taking it seriously so if you are feeling that your contractions are too long lasting longer than two minutes each or if you're getting more than five in a 10 minute period it's possible that your uterus is hyper stimulated and you're at risk of rupture and your baby is at risk of hypoxia or low oxygen because there's not enough of a break in the contraction pattern for the baby to re-oxygenate.
[40:42] So during spontaneous or non-induced labor each contraction does naturally reduce oxygen to the baby because there's reduced blood flow through the placenta and to the baby while the uterus is contracting. So this is a normal and physiological process in labor and babies are designed to be able to tolerate that type of stress during a contraction in physiological labour. And then during the rest between contractions, the blood supply is re-established. It clears away some of the lactic acid that's built up during the contraction. And the baby re-oxygenates, ready for the next contraction. So this is normal and babies can cope with that. What they aren't designed to cope with is extended periods of de-oxygenization in the case of hyperstimulation. stimulation. So if the contraction is abnormally long and is cutting off oxygen supply for an extended period of time, and this is happening very frequently, and the gap is not enough for the baby to recover, then the baby becomes hypoxic, has low oxygen, and is in danger of being damaged.
[42:00] So if you head to the CTG episodes that I did with Kirsten Small, particularly episode 114, you'll have heard that induction of labor is one of the only times that maybe fetal heart rate monitoring has a place because induction puts babies at increased risk of cerebral palsy and hypoxic brain injuries. And CTG use seems to reduce that somewhat, not that it has any magical powers, but maybe we can identify it earlier than if you're not using ctg so it by no means prevents it and it doesn't bring those levels back down to non-induction levels but babies are at more risk of hypoxic injury during an induction than they are from natural physiological labor so that's one of the risks of the prostaglandin applications the pharmacological option of cervical ripening is this risk of hyperstimulation. Now there's another product, it's the cream version of Cervidil. Sometimes they call it Prostin, depends on what brand the hospital's using.
[43:14] And its medication insert gives special warnings and precautions for use. So Prostin E2 vaginal gel should not be used simultaneously with other oxytocics, however they may be used in sequence, so one after the other. This Prostin-2 vaginal gel is an intravaginal product. It is not to be used intracervically, so they don't insert it into your cervix. It says intracervical placement, even, you know, accidental or, you know, on purpose, intracervical placement of dinoprostone gel may result in inadvertent disruption and subsequent embolization of antigenic tissue. So this is what they call an amniotic fluid embolism so the prostan gel there's a warning on this pack that it could cause amniotic fluid embolism and I have midwife friends who have seen this happen again it is rare amniotic fluid embolism in a well healthy women who was induced using prostan gel and having a amniotic fluid embolism usually results in maternal death unless you get very rapid medical assistance and even then there's no certainty.
[44:40] So prostant E2 vaginal gel for labour induction should be used in caution with patients with, there's a whole list of medical conditions that they've listed, women who are aged over 35, those with actual complications in their pregnancy. Oh, it says, and those with a gestational age over 40 weeks have been shown to have an increased risk of postpartum disseminated intravascular coagulation. So for those who don't know what disseminated intravascular coagulation is, it's basically a malfunction in your clotting factors. Some women will just bleed a lot more. Others will get blood clots. So it's an emergency. But what they've said in this insert is that if you're of gestation over 40 weeks, then it's been shown that there's an increased risk of DIC, this disseminated intravascular coagulation, postpartum. So the risk isn't even immediate. It's after you've had your baby. It says, in addition, these factors may further increase the risk associated with labour induction. Therefore, in these women, use of prostitin E2 vaginal gel should be undertaken with caution. Measures should be applied to detect as soon as possible an evolving fibrinolysis, which is changes in your clotting capacity in the immediate postpartum period. So this risk continues into your postpartum time. The risk of having had an induction doesn't stop once you've had your baby.
[46:08] So it says caution is advised when Prostin E2 vaginal gel is applied in the presence of ruptured membranes, which is what I mentioned earlier. There is a theoretical risk of increased absorption. And because of this, there's a risk of increased uterine hypertonicity or that overstimulation that we spoke about. It says this gel should only be used under the supervision of qualified medical personnel in obstetric units with facilities for fetal and maternal monitoring and operative delivery. So basically, they want to know that there's an operating theater available. If something goes wrong, they can race you out for an emergency cesarean section.
[46:47] I may be over-exaggerating the risk here, but this is just what I'm reading off the insert, the medication insert. So it is recommended that during induction of labour with Prostin E2 vaginal gel, that continuous monitoring of uterine activity and fetal heart rate is employed. As with other oxytocin agents, the possibility of uterine rupture should be considered in the presence of excessive uterine activity or unusual uterine pain. And again, there's a warning against not using this for women who have a Bishop's score above.
[47:21] They go on to say that there are other adverse effects and it says that the following medical events have been seen in patients treated with Prostin E2 vaginal gel for induction of labour. And this is the first time any of the medication inserts actually gave a percentage. So altered fetal heart rate patterns diagnosed as fetal distress. So they've said that Prostin E2 vaginal gel, there's a risk that it will alter your baby's fetal heart rate pattern and this will be diagnosed as fetal distress 10.3% of the time. That's the number that they've put in their insert.
[47:59] That means one in 10 babies for women who've received this gel to ripen their cervix, this prostitute gel, one in 10 will be diagnosed as being in fetal distress. It also says stillbirths have been reported. So that's the first stat that these brochures have offered us and it's saying that stillbirths from this medicine have been reported and that in 10.3 percent of babies exposed to this medicine they will be diagnosed with fetal distress one in 10 chance of distress for your baby and for those women who have been induced for post-date pregnancies because your chance of stillbirth is going up so what we know is that women are induced for post dates because their care providers are concerned that their risk of stillbirth is going up it's not untrue in your 40th week there's about a six in ten thousand chance of stillbirth and that rises to about twelve in ten thousand the following week of your pregnancy.
[49:08] But what they're saying is, is that stillbirths have been reported in response to the use of this medication. So we need to start measuring the risks of stillbirth or the chance of stillbirth as a result of induction of labor versus the risks of stillbirth by just staying pregnant. And what they're saying is babies have been stillborn as a result of this and that maybe they wouldn't have been stillborn if they didn't get induced, and the same argument could be made if a woman did get induced maybe she wouldn't have stillbirth so these are decisions that women have to weigh up but we know that as you get further on in pregnancy there's a slight increase in the risk of stillbirth but as you submit to an induction of labour that introduces the risk of stillbirth. So again, the other adverse effects that they talk about is the hypercontractility or hypostimulation of the uterus. They also again talk about the blood clotting issue postpartum. And interestingly, the.
[50:20] They mention here in this insert, it says, in post-marketing surveillance, so after the release of the product, an increased risk of postpartum disseminated intravascular coagulation, so this is the clotting or bleeding disorder that I talked about, has been described in patients whose labor was induced by pharmacological means, including by the use of dinoprostone. The frequency of this adverse event, however, appears to be rare. It says it happens in less than one per 1,000 labours. But guess what else occurs in around one in 10,000 pregnancies in the 41st week? And that's stillbirth. That's the reason why many women are induced because when you get into that 41st week, the risk of stillbirth increases approximately to one in 1,000 births. So really here what they're saying is there's a less than one in 1,000 labour stat where postnatally the mother is going to either lose the capacity to properly clot or control her blood clotting.
[51:30] So we're really trading one risk for another in this circumstance, except with this particular circumstance, we're shifting the risk from the baby onto the mother.
[51:40] And the insert says that other medical events which have been observed are postpartum hemorrhage, uterine rupture, postoperative infection, vaginal irritation, feeling warm in the vagina, amniotic fluid embolism, a deadly consequence, nausea, vomiting, diarrhea and fever, back pain, or hypersensitivity reactions, such as an anaphylactic reaction, anaphylactic shock.
[52:04] All right, that's all I'm going to say about the applications to the cervix in order to ripen it. The next pharmacological option that's part of your induction to ripen your cervix is newer. It's a less common option, but it seems to be an option that reduces the hyperstimulation risk and the uterine rupture risk that's associated with postaglandins that are applied directly to the cervix. And this is a oral, so you take a tablet of, it's misoprostol, it's oral prostaglandin, and some of the research suggests that this could remedy some of the risks of hypostimulation. But again, I've pulled a quote from the insert, and it said, a major adverse effect of the obstetrical use of Cytotec, which is the name of this particular medication, is the hyperstimulation of the uterus, which may progress to uterine tetany with marked impairment of uroplacental blood flow.
[53:04] Which is what I spoke about, about how a prolonged contraction reduces blood flow to the baby and to the placenta. It can lead to uterine rupture.
[53:16] And they've mentioned that it could require surgical repair or hysterectomy or an amniotic fluid embolism. You're at risk of pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia, which is a low heart rate for the baby, which is a sign of fetal distress, and fetal and maternal death have been reported. There may be an increased risk of uterine rupture, meconium passage of the baby, meconium stained amniotic fluid and caesarean section due to uterine stimulation with the use of higher doses. The risk of uterine rupture increases with advanced gestational ages and with prior uterine surgery including caesarean section if you've had more than three babies and we'll talk about the risk of uterine rupture for induction of labour that's associated with more babies.
[54:10] We'll talk about that in part two. That's it for medication insert information for now and I will just say that either one of these first steps whether you choose to be to have your cervix ripened by mechanical means, pharmacological means, orally by application to your cervix, either one of these first steps may not be fully effective and if not they'll offer you the opportunity to do it all again and wait again and see what happens. Or the other alternative is that just the process of ripening your cervix or the stretch and sweep was enough alone to be effective to put you in your labour. In which case, you might not need the next steps in the labour induction process. And then your risks from being induced are reduced because you've reduced the amount of interventions.
[55:05] So, we are still at step one of your induction of labour. and by the end of this you're probably 12 to 18 hours into this process. If the cervix ripening worked then you're ready to move on to have your waters broken. If your cervix ripening worked so well that you actually went into labour that's amazing too or maybe it wasn't as effective as you hoped and they want to repeat the whole process again. Either way you're probably now 12 to 18 hours into this process and you've had a night in hospital and you've had your own observations checked repeatedly to check for blood pressure issues, infection, etc. You've had a number of CTGs to check on your baby, a growing number of vaginal examinations. You may have also had a restless night in early labor and be getting some vaginal and cervical discomfort. And overnight you're doing much of this alone on the antenatal ward because they will admit you to hospital but they won't take you to the birth unit. They're going to take you to a ward. So you'll be waiting to be admitted to the birth unit the following day to start the next steps in your induction.
[56:25] So when you go in, be prepared with the supplies to possibly be in early labour overnight, which is usually only with the support of the antenatal ward staff. And sometimes midwives work on the antenatal ward because they're not really particularly interested in working with birth. And usually overnight, it's low staff numbers. So it's not like you're going to be getting hands-on care all through the night. I hope so. I hope there's amazing midwives out there who can do that. But it's not usually what the antenatal ward's set up for. So this can be a lonely and uncomfortable time because the antenatal ward is not really equipped for labour comfort like a birth unit might be. And you haven't got any visitors or supporters overnight. So at the risk of going too deep with this rabbit hole and exhausting you with any more doom and gloom.
[57:21] This is the conclusion of part one of the risks of induction of labor. And in the next episode, episode 134, we'll pick up at the labor ward where you're preparing for your amniotic sac to be broken, for your waters to be broken, to continue with the second step of your labor induction. And then onto administration of artificial oxytocin to get your contractions started if they haven't already gosh wouldn't that be amazing if you went in thinking you were going to have all these induction steps but the first one worked to put you into labor and just know that you also have options within these three steps for example.
[58:04] I've had clients who have realized that potentially they have a medical need for an induction, but having had a previous negative experience, have picked and chosen different parts of the induction process that they would be willing to accept and parts that they weren't willing to accept. So I've had clients who had favorable cervix and were willing to have their waters broken, but not willing to do anything else. I did have a client who said, I'll have my waters broken and then I'm going to wait 12 to 18 hours. If I haven't gone into labor, I want a cesarean section. That felt right to her. I've had clients who said, I'll have my cervix ripened and my waters broken, but I will not have artificial oxytocin. And they were keen to wait and see what happened and they did things like combine other sort of less medical induction options like walking the hallways and clary sage and acupressure and all these things that they added and then declined the oxytocin.
[59:08] Or some women might skip the first two steps and say, I just want to go straight to oxytocin. Obviously, those decisions are made in conjunction with the staff at the hospital and what they're willing to accept and provide. But just know that there's some flexibility within this process, depending on your personal circumstance. And those are the nuances that we will cover in part two. But while you wait for next week's episode, I want to let you know about something that is on offer to further extend your knowledge in this area. And other areas of rebellious maternity care. As I was writing this episode, I thought, oh, if only people could hear the talks that were at the conference because they speak to this topic and issue. Some of them do. Others, you know, speak about the broader circumstances in maternity care. But this episode has inspired me to want to open up these recordings to everyone, to the public, to watch them and learn from our incredible speakers, many of whom expand on this topic of induction oxytocin and much more honestly every speaker at the conference could have keynoted the conference by the quality so we had kirsten small hannah darlin hazel keetel sarah buckley i myself spoke dr stew fishbane we had liz noonham cheryl cidery ria dempsey.
[1:00:32] Jane Hardwick-Colleens, oh, and Athena Hammond was amazing. We had the Jacquemus team there talking about care for Indigenous women up in Top End. All right. So anyway, what I'm trying to say is there are recordings from the Convergence of Rebellious Midwives that I would love to give you all access to. So if that sounds interesting to you, if you want to expand your knowledge and actually hear other wise and rebellious experts speak on this topic, just have a look on the link in the show notes and it'll take you to the place
[1:01:07] where all the recordings are and you can keep growing your knowledge from there. Other than that, I will see you in the next episode of the Great Birth Rebellion podcast where we will continue with part two of the risks of induction of labor. To get access to the resources for each podcast episode, join the mailing list at MelanieTheMidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at TheGreatBirthRebellion.com follow me Mel @MelanieTheMidwife on socials and the show @TheGreatBirthRebellion all the details are in the show notes.
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