An induction of labour. This is recommended content for every woman who is pregnant, particularly those getting close to the end of their pregnancy. Inductions aren’t rare and can represent a challenge for some women who feel blindsided by the significant change of plans.
Brigid Welcome everybody to Episode 9. And in today's episode we are going to talk about the day when your health care provider says to you. "Looks like we need an induction". This is a challenge for some women and sometimes it can feel like these statements seem to come straight out of the blue. So what we do in our grow my baby program is we talk about the four principles of pregnancy that rocks and we believe that they are when you're CALM, CONFIDENT, CLEVER and CONNECTED. So by the end of this episode we aim to help you with all of those principles so you can feel like you can breathe and then get on with having your baby.
Brigid [00:01:13] So we're going to talk about all the reasons you may need an induction. What happens in an induction and some of the common fears about induction. So Dr. Pat hello hello. Pat's got his phone on today people because he's got someone in labour as we speak so sorry about that if you hear the phone ringing and I don't seem to say something for a little while.
Patrick [00:01:41] Another good busy week so I'm really pleased that we're talking about induction of labour today because this is one of those things that can happen in pregnancy that can upset people's calm and can really be a significant change of plan for people and can seem to come on very suddenly. That's also not that rare. So I really think it's something that people should know about as a possibility well before it happens.
Brigid [00:02:10] Yeah absolutely. And that is about helping people feel confident when they come into the later stages of pregnancy. You know if they do get their health care provider saying to them you need an induction. They go " I know all about that".
Patrick [00:02:21] It's nice to already know what that means. Yeah. That it's nothing to be too afraid of.
Brigid [00:02:26] You're not blindsided.
Patrick [00:02:27] That's right. So let me tell you the story about a patient I've seen recently.
Patrick [00:02:32] So this is Sarah and it's her first baby and her pregnancy was absolutely textbook normal from start to finish well almost to finish, the normal tests normal growth. But then I saw her at thirty eight weeks and suddenly on the old fashion tape measure test where we measure from the pubic bone right up over the top of the tummy. She's only measuring 36 centimetres and that's a trigger to go and have an ultrasound to see why the growth is lagging at the end. And on the ultrasound I could see that there was a significantly reduced amount of water around the baby and yet she didn't give any history of the waters having broken. And the amount of water around the baby. Firstly most of the water around the baby at the end of a pregnancy is foetal urine. And so imagine if you and I had been in a car accident and we were in the intensive care unit one of the things they would be doing would be measuring our output as a measure of how well things were going for us and foetal urine output is a really good measure of how well things are going for the foetus. So if we've got a baby that stopped weeing enough and therefore there's less water around the baby and we can see that on ultrasound then we're a little bit concerned about that baby's well-being. So suddenly we've got a situation that's gone from normal to abnormal. And the answer for that baby, we can't put the water back. The answer is to get that baby out. So suddenly I'm saying to Sarah look last week it was fine this week it's not. That's why we're seeing you once a week. And what we now need to do is induce the labour to get the baby out before whatever's wrong with the baby gets worse. And suddenly she's gone from a plan of natural delivery at full term to this potential issue and recommendation for induction, and it can be a bit of a shock for people.
Brigid [00:04:28] So that's sort of one reason and you've picked that it's the baby's unwell but are there other reasons for having induction.
Patrick [00:04:35] Sure. I guess common reasons would be post dates. A little bit of debate in obstetrics circles about what that means. But most people most obstetric care providers have a figure in mind of what of what amounts to a pregnancy that's gone too long. And a common reason to be induced would be if the pregnancy was still going at 41 weeks or term plus 10 days or two and plus 14 days whatever that care provider's cut-off is.
Brigid [00:05:04] And do you have a preferred time yourself for post dates.
Patrick [00:05:08] Yes. I like everybody's baby to be up by about a week past the dates because of the use of first trimester ultrasound which is extremely accurate. We can be extremely confident of when the 40 weeks is up for every baby. And if you're still going at term plus seven days under my care then you need at least we need at least a plan and ideally around that seven day mark to have everybody up and going. Yes there's some small risks of continuing to go beyond term plus seven days and usually the risk of being induced is less than the risk of keeping on going.
Brigid [00:05:44] Yeah. And what about the mother.
Patrick [00:05:46] Yes. So other reasons not all foetal reasons sometimes they're due to how the mother's going and the really common ones are those are diabetes and high blood pressure and preeclampsia. So there are conditions that if we look at pre-eclampsia for example if you get diagnosed with preeclampsia which is complicated high blood pressure and pregnancy then the treatment is to have the baby. Yeah. That's basically the only treatment. So if we're right out into a stage of the pregnancy where the baby would be expected to be healthy then the answer is to get on with it.
Patrick [00:06:21] And then we've got the people who the babies we're worried about or the situation called P prom which is premature pre Labour rupture of membranes where the waters have broken and we reach a point where the water is broken but Labour doesn't immediately come and we reach a point where we feel the baby's better out than in. Or another problem just called pre Labour rupture of membranes where the woman might be at full term the waters break naturally a big gush of water comes out but no labour is forthcoming within within about a day. And that's another reason to get on with it.
Brigid [00:06:55] And just while we're on that point if if somebody is like what is have broken they go pretty much straight to the hospital don't they they get monitored. Yes.
Patrick [00:07:03] Yes. It depends on the pregnancy itself and how many what the risk is and so forth. But in a low risk person the water's breaking on their own. It's not a it's not any sort of emergency. A nice low risk patient the waters break then we would typically see that woman at some stage that day to make sure all was well. But she doesn't necessarily need admission to the hospital she can go home again. Yeah right. Get on with the early stages of labour and come back when she's really cooking along.
Brigid [00:07:30] Yeah great. All right. Good to know. So what about this thing called soft induction or people wanting to do inductions because of either their needs or the hospital's needs.
Patrick [00:07:43] Yeah these are the ones that we try and steer clear off if possible. But you know sometimes there's special circumstances so things that we sometimes get asked are you know can I be induced because grandma is very sick and she wants to see the baby. Can I be induced because I want to have the baby on such and such a day for nonmedical reasons. And I guess most of those situations potentially bring in risks that we really didn't need to. And it might have been smarter to leave that leave that that pregnancy alone in the absence of any true indication to induce and one of the things that really comes down to is is how hard or easy do you think that person is going to be to induce. Yes. So for example a woman having her first baby who's 37 weeks pregnant and needs it needs induction for preeclampsia. Her cervix is probably going to be long and closed because the cervix thinks it's doing the right thing staying shut. And that that's going to be tricky. That induction will require a lot of work and may or may not end in vaginal birth whereas if you have someone who's had three vaginal births before and you examine them at 37 weeks in the cervix is three centimetres open and just sitting there soft and you can put some gloved fingers through the cervix and touch the baby's head. Yeah they're really good to go. They're good to go. That's right and that is. That's a different risk proposition altogether.
Brigid [00:09:09] Because it is about supporting the mother. So for example her her support system is not going to be there in a week's time or whatever it might be. I don't know. It's always something that as an obstetrician I imagine you're weighing up all the time.
Patrick [00:09:23] Yes. So so the answer is automatically no for a so-called soft induction the answer is maybe but to be honest with that patient we have to assess how easy that induction is going to be and give the patient that information. Yes. And so you know is this something you really want. Because it's going to be really hard.
Brigid [00:09:41] Yes. And of course there's on the flip side those women that definitely don't want to be induced. And if you go onto websites and forums and everything. There are so many people asking the same question all the time which is how can I bring my labour on naturally. Yes. And now if you're not following our Instagram we did a post on this. So stop the podcast right now and please go to Instagram and follow us. It's @grow_my_baby. Good hit follow. Come back. And so this post was on them all the methods that people used to naturally start labour. And there's lots of them there's you know people say that you have to hot curry and hot sex and bumping car rides and castor oil and you know wearing your best undies having acupuncture like Are any of these methods proven to work?
Patrick [00:10:28] Yeh no. So that's the problem is there's very little evidence that any of them actually work more than would be expected by chance alone. And I guess that's the problem with assessing an intervention like that. You and I could design a study where we looked at whether if we wore a blue hat would it bring on labour. And of course if if everyone in our study has 40 weeks pregnant which they would be. We don't want anyone else to come into labour. Then a certain number of the women are going to come into labour anyway, regardless of what they do. Then we will create that we will create the false impression that the blue hat was part of the effect. So if we look at interventions they are hard to assess because everyone's going to labour eventually but using the appropriate statistical techniques it's pretty clear that that the so-called folk induction methods they don't actually work. But the good news is they don't harm you either. Yeah. Yeah. So the ones that involve having you know hot chillies and so forth they can give you diarrhoea.
Brigid [00:11:29] Yeah. Which is really unpleasant during a a labour.
Patrick [00:11:33] That's the problem. So it kind of might harm you because the evidence that that sort of diarrhoea actually brings on labour is very weak. But the evidence that diarrhoea is a horrible thing to have while you're labouring is very strong.
Brigid [00:11:46] Yeah because not only is it uncomfortable and unpleasant but it can also lead to dehydration and you know you're not your best self. If you've got diarrhoea in you are labouring. Yeah sure.
Patrick [00:11:55] And I just don't think that's that's anyone's dream labour.
Brigid [00:11:57] Right now well before I met you I had my first two children and I was late with both. So the first I went to 42 weeks and then the second I went to 42 weeks as well because I was trying to go into spontaneous labour. Why is it that some women just don't go into spontaneous labour?
Patrick [00:12:18] You'd think we would know this but we don't. We don't know enough about that. The triggers for labour are still a little bit of a mystery. We know that there's some of it's got to do with the foetus some with the mother and some with the placenta but nobody knows exactly the contributing percentage of all three of those things and we don't exactly know why Labour sometimes just doesn't come. Yeah the observations over the years, particularly with the use of of third trimester ultrasound which can look not just at foetal growth but foetal well-being is we know that the placenta's got a use by date and placental function will decline post dates. So there will be some people who just don't labour and are going to need some help to get into labour at a gestation that's safe.
Brigid [00:13:06] I do remember looking at my placenta after Dempsey's birth and thinking yeah that looks old and tired. I mean as a layperson I could tell that it had really done its job.
Patrick [00:13:16] Yeah. So they get a little bit fibrotic, a bit a bit tough. They get to be a bit smaller and they get full of calcium. And sometimes we'll send those placentas off to pathology to ask the pathologist if there's anything else in there that might give us more information about what happened to that placenta and then we might get to use that information for the next time to say to that patient look maybe you're prone to some sort of abnormal placental development and we might give different recommendations.
Brigid [00:13:43] Wow. Okay. And why is 40 weeks. Sort of like the magic number. You know why do we always say you must deliver by whatever time. Why can't we just wait? Apart from the placenta. Are there other issues with waiting.
Patrick [00:13:56] Well the idea that the human gestation was 40 weeks long is just was just an observation that if you graph when most natural labours happen that's when they happen. But the really interesting thing is that we've just always kind of assumed that that was necessarily desirable and some really interesting studies have been done in the last couple of years where they miraculously managed to randomize women to be induced at 39 weeks if there was nothing wrong with them. So I think this is one of the most interesting clinical studies in obstetrics done in my career. Mostly because they somehow managed to get healthy women to agree to be randomized - open an envelope and say No - Yes you're gonna be induced at 39 weeks or no you can wait for spontaneous labour at term. And so there was one interesting aspect is what a good job they did finding those volunteers. But the second interesting aspect is the results which are really very very very interesting in that they showed something quite unexpected was that to be induced at 39 weeks is a lot less harmful than a lot of people thought in terms of the caesarean section risk.
Brigid [00:15:03] I know this study you're talking about like it was a lot of women was like six thousand women or something that yeah it's something that yeah.
Patrick [00:15:10] It's something that we've looked at in the grow my baby program because we don't want Well we're trying to help people not be afraid of an intervention like this. Yeah. So are we ready to get 39 workers to volunteer to be induced. I don't think so. I think the study would need to be replicated. Yes. And also more numbers larger.
Brigid [00:15:30] Yes even a six thousand is a very big sample size. But yes.
Patrick [00:15:35] It's a great start but with 100,000 the statistical power that the result is real is increased. So we look at. So are we ready to get 39 weekers to say you're better off being induced. Absolutely not. But if you're 39 weeks and you need to be induced for problem X Y Z do you have much to fear from that? Not really. It's perhaps no one's idea of a dream birth it's not how we wanted it to go but the study that's that particular study that we're talking about showed that the induced group had a smaller risk of caesarean section than the group were left alone.
Brigid [00:16:11] Yeah. Which is kind of earth shattering really isn't it.
Patrick [00:16:15] Well it's a little counterintuitive. And it's not what what some providers of obstetric information tell people but it's there in black and white.
Brigid [00:16:26] And also the other thing about going overdue. Like so 41 42 weeks is of course your baby is getting bigger all the time and there's been a lot of media lately about pelvic floor injury. Yes. And you know for me that that is a new thing for me to understand that the obstetrician or the health care providers making that decision based on the mother's health as much as baby's health. Yeah.
Patrick [00:16:51] So this is where it gets really tricky. There's not a lot of data out there, not a lot of good quality data out there that suggests that for example if you're induced when your baby gets to three and a half kilos, is that better than your pelvic floor than if you laboured naturally at term and the baby got to 3.9 kilos? That work hasn't been done and you can see it would be complicated to make a fair analysis. But one of the things that we sometimes do when we're looking at a woman carrying a very big baby is we might say, Well how old is this woman? How stretchy are her tissues? Is this her first baby or her fifth? How many babies does she want? And make a much more nuanced and complex assessment of the potential pelvic floor outcome for that woman from having that baby vaginally.
Brigid [00:17:44] We might have to cover pelvic floor injury in another podcast. Oh it's a whole podcast outcast. Yeah. Yeah. So on that note. So I've picked up something on one of the forums which was worth reading out I think so it says this the first poster said "with a long weekend coming up the hospital would prefer to do an induction now to suit the staff. But I would prefer to wait to see the baby. I'd rather have a natural start to labour than be induced I'm currently 40 plus one" and then "one of the respondents said if there's no risk to the baby then you don't have to have one. Sometimes it's just a convenience to them. I know with public hospitals they will let you go 40 plus 10 days as they try and avoid induction because of the higher chances of emergency C-section. I've read a lot of obstetricians push for inductions. I don't know why but they do."
Patrick [00:18:35] Yeah well I guess this is this is a legitimate fear that people have that somehow the advice that they might be getting is due to other factors that they're not being told about. And sometimes my patients ask me about this and my simple answer is I didn't get into obstetrics for my convenience. It's it's not it's not a convenient job it's a job where you know I think of all my colleagues or the people who taught me over the years these are people who really dedicated their life day and night to the care of women and the and the pursuit of better outcomes for women and babies. So I think this mythical idea of the golfing obstetrician who wants your baby out so you can get on the golf course, I don't I I've actually never seen that that hasn't existed somewhere someplace maybe. I think that the lesson from that discussion is that if someone private obstetrician, public birthing unit is proposing that you be induced then there are some serious questions that you should be asking that team why are you advising that? What will it look like? How will it go? Do I need just the jelly? Do I need my waters broken? Do I need a drip? Do I need an epidural? And that's all part of it. And then the big question which we should all ask our health care providers is what will happen to me if I don't do that? Yeah. Yeah. So that's not just for obstetrics, if I've got gallstones get my gallbladder out and you might say well okay I don't like the sound of surgery, if I don't have my gallbladder and these are information that modern health care providers should be happy to give.
Brigid [00:20:10] Yeah and I'm going to actually put in a little plug for our program here because in the grow my baby program we have how you ask all these questions. We have it in a nice sort of templated form so you kind of know how to put that within even your birth plan because it's knowing the right questions to ask to elicit the responses that are going to help you make a really informed decision. Yeah yeah that's best for you, best for your baby. So. Talked a lot about sort of the theoretical part of inductions But practically what actually happens when you have an induction.
Patrick [00:20:42] You're right. So getting down to actually what does it actually involve. Yeah I guess once we've made our assessment recommended to the patient that induction is a good idea explained alternatives and so forth. Let's say we're all agreed that getting on with it is the right thing to do. It starts with an internal examination and it might be actually the first vaginal examination that the woman's needed in the whole pregnancy we don't tend to do vaginal examinations unless there's a question that needs answering and feeling the cervix gives us the answer. So there's something called a bishop score where we feel the cervix and assess the cervix for how firm it is, how long it is, in general how ready to go it is and a cervix that's very very ready to go gets a high score and a cervix that's shut and long and closed and still thinks it's supposed to be staying closed has a low score. And the score is useful because it can tell us really what's the best way to get that woman into labour.
Brigid [00:21:43] And as a patient. And am I within my rights to ask what that score is.
Patrick [00:21:47] Yes all this is your body, your information. Yes. And it's not rocket science it's just a simple score for hardness, a simple score for length, the simple score for dilated, somewhere between 0 and 2 add up the score. For example a woman a woman with a cervix that was long and closed and not ready to go, would get perhaps advised to have a some prostaglandin jelly which is a gel product that goes into the vagina by a little syringe and it's absorbed into the cervix overnight and it can turn that hard long closed cervix into one that's softer and squishy and much more able for us to get through that cervix and break the waters.
Brigid [00:22:28] Is that also the tape?
Patrick [00:22:29] Yes it comes in a few different forms. So there's a gel that goes in or there's a tape which is another system whereby you can put the drug up to the cervix but if you run into problems you can pull the tape in it comes out. Whereas the gels kind of stuck there. And there are a few different ways to do that you can inflate a balloon a rubber balloon inside the cervix and use literal physical pressure from the balloon to stretch the cervix open.
Brigid [00:22:58] Is that also called a Foley's catheter?
Patrick [00:23:00] Well Foley catheters are the ones that go in the in the bladder. And you blow the balloon up so the catheter stays in the bladder and doesn't fall out. And in the early days of this technique of using a balloon to dilate the cervix they did actually use the same thing. But now we have fancier ones. They have two balloons and one gets inflated on the inside the cervix and one on the vagina side and they sort of squeeze the cervix in the middle and and overnight the cervix will open from from direct pressure whereas the prostaglandin and jelly does it as a drug.
Brigid [00:23:32] And are either comfortable or uncomfortable like what do I experienced when that's happening.
Patrick [00:23:37] You get some little contractions, especially from the prostaglandin gel. A little bit off it's absorbed into the uterus and some contractions which we call prostin pains come on overnight and they're like little little contractions and sometimes the baby will actually respond to those contractions in a way that can be seen on a foetal heart rate trace. So we tend to do all of this in the hospital.
Brigid [00:24:03] Oh yes. So you've come in and this process starts in the hospital and you stay in what overnight?
Patrick [00:24:07] Yes you stay until a baby comes.
Brigid [00:24:09] Okay. Okay. This is the steam train.
Patrick [00:24:12] I take few days but this is all best done in the hospital.
Patrick [00:24:16] So by contrast we might have another patient who comes in at full term, induced for high blood pressure for example, and on that vaginal examination the cervix is already good to go. Yes. She doesn't need the gel because the cervix is already soft and maybe if she's had a baby or two before the cervix is not only soft it's a little bit open it doesn't mean she's in labour. It just means it's sitting about one to two centimetres open and you can just put a gloved finger through the cervix and touch that baby's head already. Well that woman's only going to need to have her waters broke to get into labour. So we do that with a little hook that rolls onto the end of your finger, break the waters and because your water comes out and we get that woman up and walking around and pretty soon she'll be in labour.
Brigid [00:24:58] You know I've read and heard other friends say you know one day they went and the midwife or their health care provider has said that they're dilated about one or two centimetres but then the next time they have a vaginal examination they've been said to have a closed cervix. Is that what's happened that you can have an open cervix and it closed or it was just error in the first place.
Patrick [00:25:19] A mistake by the first person presumably.
Patrick [00:25:21] Yeah so once it's opening there's there's no going back. It go backwards. Yeah okay.
Patrick [00:25:25] So there are differences of opinion but in my experience that's typically for example an inexperienced care provider does a vaginal exam. And comes up with some findings and they might present those findings to the rest of the team at the morning handover and the rest of the team, perhaps more experienced people might know that doesn't sound quite right. That woman's re-examined and sure enough she those findings were wrong.
Brigid [00:25:49] Okay all right so we've had the ARM, it's called isn't it? The artificial rupture of membrane. Yeah.
Patrick [00:25:56] That's where health care provider breaks the waters. Rather than breaking by themselves. Yeah. Yeah.
Brigid [00:26:02] And what else happens what from there.
Patrick [00:26:04] Well if we get to the point of the induction where the waters are broken but there's still no labour then usually a syntocinon infusion would be started up and that's the drip in your hand that makes the contractions come back.
Brigid [00:26:16] Yep and that's called some other names isn't it? What other terms are there for that.
Patrick [00:26:20] People call it the drip and synto. There are there are some other drugs used around the world but the drug we use here in Australia is is called Syntocinon, it so it's a synthetic version of the natural labouring hormone.
Brigid [00:26:33] Yep. And in the States it's called, in case anyone's listening to us from the States, it's pitocin.
Patrick [00:26:40] Yeah and basically it's the same thing it's just a it's a synthetic form of natural labouring hormone and we were running a trickle to start with and increase the dose until the woman is contracting strongly, regularly and in a way that gets the cervix to open up.
Brigid [00:26:59] And there's a bit of confusion out there isn't there between induction and augmentation with syntocinon.
Patrick [00:27:05] Yeah I think this is actually important for people to understand that syntocinon infusion has got two important uses, and they're not the same thing. To use syntocinon to induce means exactly that you might have someone who's not in labour, who you break their waters, put up the syntocinon drip with the intention of getting them from not in labour to into labour.
Patrick [00:27:25] That same drug in a drip form is also used for people who are already in labour but it's going too slow.
Brigid [00:27:32] Yeah everything sort of ground to a halt and you need to kick start again.
Patrick [00:27:35] Yeah. So that's called augmentation and it's a different topic for a different day.
Brigid [00:27:39] Yeah. All right. We'll put that on the list too. All right so lots of people and me included. You know your line up and you have your stretch and sweep is that also part of this induction.
Patrick [00:27:48] Yes, stretch and sweep is a form of sort of lower intervention induction typically used for post dates patients.
Patrick [00:27:56] And that's where you have an internal examination and the examiners finger goes through the cervix and sweeps around and a little bit of an arc to stretch the cervix a little bit and also to strip some of the membranes off the interior aspect of the of the cervix. And it can help bring you into labour without the need for hospital admissions and drugs and intravenous drips. It works a lot more than the folk remedies but not as much as the more drastic interventions.
Brigid [00:28:27] Yeah I know our listeners can't see me but all of a sudden I'm sitting in my arms crossed.
Patrick [00:28:32] I'll just relax again. Yeah yeah yeah. You look like men sitting around discussing vasectomy. Yeah.
Patrick [00:28:39] So the problem with stretch and sweep, it is not only it doesn't always work but it's not, it's not 100 percent the low risk intervention that it's often made out to be. There's certainly a risk of introducing infection by doing a stretch and sweep and I've definitely seen that. This is not this is not infection from the outside world. It's just pushing vaginal bacteria into the up into the cervix where they don't belong. Yes you put a lot of people into labour that way but once in a while you could introduce a significant infection by doing that and I think with stretch and sweeps that that's a risk that probably needs to be openly discussed.
Brigid [00:29:21] So pat I've heard you talk a lot about gentle induction. What is that?
Patrick [00:29:26] Well a gentle induction is just a term that that I use. What I mean by that when I use it is that if we're going to for example get somebody into labour with prostaglandin jelly then you have to factor in enough time for it to work. So the prostaglandin jelly, which is what I use on an unfavourable cervix, It comes in one milligram and two milligram doses and if someone's having their first baby and the cervix is very unfavourable to start with, then they might need.
Brigid [00:29:53] You mean closed and long. Yeah.
Patrick [00:29:55] Then while they might be three or four milligrams to get the job done you can only give it every six hours. So what I mean by that is I often say to people if we want your baby to be out for whatever reason by term plus seven we might have start the whole process a term plus 5, so we don't back ourselves into a corner and get unduly rushed because if we give ourselves time over a couple of days it will work.
Brigid [00:30:17] Yeah. So those women that sort of say "oh my God, It's taken me three days to get into labour or whatever you know I've had some friends saying "oh I don't know why it's taking so long", it's because you're trying to make it gentle and calmer or you're gonna be trying to give them the best chance of having a Natural birth.
Patrick [00:30:35] That's right. And if we think of the natural process then a non induced labour at rarely comes for the first baby it really comes as a thunderclap where you suddenly, bang you are straight into good labour. It evolves. And in fact that the processes of labour are actually going on for weeks or even months before the woman comes officially into labour. Yeah slight changes in the cervix, slight changes in the uterus, even a slow building amount of contractions within the uterus and a lot of people consider labour to be the crescendo at the end of a long process rather than a totally separate thing. Yeah.
Brigid [00:31:11] And that is a good way to sort of mentally prepare too isn't it.
Patrick [00:31:14] Well I think if you're being induced and that and you have an understanding of the natural process then you might say why a safe induction might take a couple of days. Yeah.
Brigid [00:31:22] And why is it do you think that some women are fearful or actually objected to induction?
Patrick [00:31:27] I think that it's quite legitimate to be fearful or upset if an induction is proposed. Especially in the woman who quite rightly believed that she was having a perfectly normal pregnancy and then suddenly, big surprise I went saw the doctor he wasn't happy and now here we are. So the key to it is I think communication and part of good communication what we're getting at through the Grow My Baby program is if you know a bit more then it's less scary if that happens to you. But women will worry about this situation not only because it's a change from the expected but also because they're worried about the risks of being induced for them in the baby and also what happens if we don't work.
Brigid [00:32:12] And there is so much around. I mean we still hear it don't we. This whole cascade of intervention don't let the the ball start rolling on induction because it will then lead to this and this and this and you'll end up with a Caesarean section. But I think you know that study that we just talked about. That's just one of many studies to show that there actually isn't any correlation between being induced and ending up with a Caesarean section.
Patrick [00:32:35] The simple answer is no there's not but one of the problems is that the group of women who are having an induction are not the broader obstetric population. There should be a reason why they're being induced and therefore they might actually be more accurately seen as as a subset a different group and you would think that it wouldn't actually be that surprising if some of the women who were being induced. For example, you're getting induced because there's no water around the baby. Then the contractions start and suddenly the baby doesn't like the contractions because there's no water to buffer that and that baby gets into foetal distress. So it's actually not that surprising that a woman being induced for that particular problem, that that baby may not be happy in strong labour. Overall though the studies suggest we actually don't have that much to fear from induction. Part of it I think is communication because if we say to the to the patient very clearly here's why we're doing it. Here's what happens if we don't do it here's what might happen if we don't do it and here's how it might unfold. In my experience the worst reactions from patients are the complete out of out of the blue supply surprises where there's a couple if you give me this advice is the first I've heard of it whereas in the doctor's mind he's been thinking about that all along.
Patrick [00:34:00] He just hasn't shared that with passion.
Brigid [00:34:03] Yeah I remember feeling too when I wasn't going to spontaneous labour. I really felt kind of cross it myself like I felt that my body was not doing what I was made to do and that this natural process I was failing this at this natural process. I think that's a common fear that a lot of women have as well. And I think that that sort of changes how we have our objective decision making process around being advised that we need induction.
Patrick [00:34:32] Absolutely. So you know in an ordinary month if I've got a few patients needing induction there'll be some people of the yes doctor whatever you recommend. And then there'll be some people who are resistant to that for exactly that reason. And that's a reality that we need to deal with. And there will be some people who feel who you know who walk away from an induced labour or a Caesarean section and say oh yeah that's how it panned out, no dramas and there'll be some people who feel let down by the system or that they've let themselves down by not labouring you know open quotes "well" yeah.
Patrick [00:35:11] And this is you know this is part of the complexity of the job.
Brigid [00:35:14] And it is complex and I think that's because you know people will say things like oh you know don't don't do anything just let the baby come naturally and a baby will come when it's ready. But we now know that that is only part of the story. The other part of the story is how well is that baby. How well is that mother.
Patrick [00:35:47] Yes. So again I think there's kind of two sets of advice there. There's a group of women who who are perfectly normal and are probably well advised to let their pregnancy take its course have a routine surveillance blood pressure and so forth. Listen to the foetal heart and to allow that baby to come when it's ready. There are another group of patients who have sort of whose whose clinical course has deviated from that. And those those are the people we've got to discuss and say look you know this is not going according to plan. And here are the risks involved in me intervening. And here are the risks if you choose not to take up that that intervention. Yes. And yes it's nobody's ideal labour to be induced running a synto drip with an epidural in in the hospital but it may ultimately be a smartest decision.
Brigid [00:36:38] And by the way that you have a vaginal birth although Absolutely.
Patrick [00:36:42] So that's a another complexity is that we talk about induction often as if it's the fast track to a caesarean section but in fact it may actually increase your chances of having a vaginal birth by intervening when an abnormality is in the early stages. So if we choose not to be induced, come back a week later and whatever the problem is is much worse then we try and do it a higher chance of caesarean section. Yeah or we might have run into a problem where there's not only no water around the baby but now the baby showing other signs of being sick. No labour at all straight to caesarean section. So there are some times when the judicious use of induction can actually increase someone's chances of having a natural birth. Yeah. And this is part of that so-called art of obstetrics comes with experience.
Brigid [00:37:33] And so you know we've talked a little bit in smatterings through this podcast about the risks of induction. So could we just talk about them in one sort of nice little neat package. What would you tell your patients the risks involved in induction?
Patrick [00:37:48] I tend to sort of work out what what how I think the induction what it needs to consist of. So the jelly the risks involved in having prostataglandin jelly, for example, is that it will put a small number of women into into sudden and strong labour which may or may not be a problem but it can do that even though it's really only designed to soften the cervix and occasionally that sudden and strong labour is too strong for the baby. And you might have to resort to immediate caesarean section which is why the induction is done the hospital. Yes. And the other thing the prostaglandin jelly might do is not work.
Patrick [00:38:19] You might get to the maximum five milligram dose and it just hasn't done the trick since Towson on the risks involved in using syntocinon is this if we accidentally use too much. So if you think about the way the labouring uterus works during the contraction, there's no oxygen getting across the placenta. The oxygen gets across during the relaxation. Okay. And if you use too much syntocinon and there isn't a long enough relaxation between contractions. Baby doesn't get enough oxygen so using too much syntocinon is called uterine hyper stimulation and it's a real risk which is why we use syntocinon carefully, start low and go slow. Use a little bit and slowly increase it. And it's why we do a continuous foetal heartbeat trust in a patient on syntocinon because if the baby's not getting enough oxygen that will show on the trace.
Brigid [00:39:16] And it's not just that you're bothering me labouring mother. No no no no.
Patrick [00:39:21] That's not just sit there for the machine to be loud and irritating it's because that's the information we've got from the baby that the baby's coping. And if the Foetal heart rate trace shows that the baby is not getting enough oxygen then we can turn the syntocinon off, let the baby regroup, start again on a lower dose.
Brigid [00:39:38] And do you find that another risk is that you're more likely to require or request for an epidural.
Patrick [00:39:45] The answer to that is probably yes. And it's led to a common belief that the contractions from syntocinon are worse than the contractions the natural contractions are not a hundred per cent sure that's true. It's my view that all contractions are painful and they all suck and that the ones from syntocinon probably just come faster.
Brigid [00:40:07] Yeah. And you don't have a reprieve. You know you don't have the time that you can regroup yourself because it's coming a bit harder and fast.
Patrick [00:40:14] Well they shouldn't be coming faster, like closer together. That's that's bad for the baby. But you don't they don't build up over such a long time. Oh I see what you mean yet. If you break your waters at home at 3:00 in the morning and you might start getting the first little contraction at 10 a.m. You may not be in proper huffing and puffing labour until 10:00 p.m. But if we give someone syntocinon. Because we want them to be in labour will want to see huffing and puffing within a couple of hours. Yeah. So you don't get enough of a chance to get used to it. And so is the pain worse maybe. Does it come faster. Yes. Yeah right. Yeah. In a shorter period of time. Yes the onset is faster. Yeah. And I think in that situation it's not at all uncommon for people to say this is too much and probably push the epidural button sooner than they might have otherwise. Upside to doing that epidural really works and it allows us to push hard on this syntocinon infusion without having to worry about how much pain it's causing. Yeah and that's one of those scenarios where the whole thing may actually help with the overall caesarean section rate because if we've got a big enough problem such that we were inducing in the first place you're not doing this for no reason then to go that hard may be quite appropriate.
Brigid [00:41:26] Yeah and I think that is really important to just hang on to. There is a reason why getting induced and there's a reason why this is the path for your labour. Yes. All right. So for women who perhaps again on the flip side going I want to be induced. They're there at the doctor's office and or wherever the hospital and they're begging to be induced because they're concerned that their baby is too large or they're worried about tearing or whatever and they come away and they say but they won't give me one. What do you think in that situation you would do.
Patrick [00:41:58] I think getting to the heart of the patient's concern is the key to that. So exactly what is troubling that patient. So if that woman's fears that the baby is too big or I don't want my pregnancy to go this long because I've lost a baby in the past or something like that. Those are legitimate concerns and they need discussion. Patient may well be correct about that. If despite completely normal progress then you've got someone who still wants to be induced that may well represent some other underlying fear that you haven't got the bottom of you and you may be out to unearth that and settle that person's anxiety in a way other than an unnecessary induction.
Brigid [00:42:37] Yes. Yeah. So it's all about if our listeners are there and they're in that situation it's finding someone that they can have that conversation with.
Patrick [00:42:46] So we go pretty well in the private sector with that because by the time one of my women is a woman my care is labouring. I've met her and her partner maybe 14 15 times and we've established that level of rapport. In public hospital system that can be difficult. You may not know the people who are looking after you in the labour but it's often a team effort. And there's various people from the midwives, junior doctors, senior doctors, specialists in training, even students who might be involved in your care. And sometimes we might find that if one particular caregiver and the patient are clashing somebody else might be able to have a more productive conversation.
Brigid [00:43:29] And you can request to have a conversation with somebody else. So women this is what we're trying to get at. You just have to be you speak up and stand up for yourself and and really just say look this is not a conducive conversation is there somebody else that I can have a conversation with. I think that's really important. All right. I hope this has helped you feel the full bottle on what to do if you've been told you are going to be induced.
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