Induction

What is it?

Induction means to start labour before it spontaneously occurs. Around 20 per cent of pregnancies are induced.

Why might it be recommended?

  • Multiple births
  • Gestational diabetes
  • High blood pressure in the mother
  • Pregnancy well past its due date
  • Slowed growth of the baby.


How is it done?

Vaginal prostaglandin gel

This is a hormonal gel which is applied to the cervix to encourage it to soften and open. It can take between six and 18 hours for the gel to take effect and trigger labour.

Dilators inserted into the cervix may also be used. This method of induction has the advantage of allowing you to remain free of a drip and the contractions tend not to be as painful as those that result from administration of oxytocin.

Augmentation

Contractions of the uterus during active labour generally take about 40 to 60 seconds, spaced two to five minutes apart. Sometimes, labour begins naturally but the contractions aren’t effective. A common medical intervention for a labour that’s progressing slowly is augmentation, which means certain techniques are used to speed it along.


These techniques include:

Amniotomy or breaking the waters .

The membrane holding the baby and amniotic fluid is punctured with an instrument inserted into the vagina and through the opened cervix. Labour usually begins around 12 hours after the procedure.

Pros

  • This allows the baby’s head to press directly against the cervix which causes uterine contractions. This process happens naturally during labour in most cases.

Cons

  • Causes labour to speed up and increase in intensity often making the contractions distressing which will interfere in the mother’s ability to cope leading to the use of drugs for pain relief. See ‘Understanding pain in labour’ for an explanation of the process behind this.
  • Creates a risk of infection. Due to this risk, labour has to begin within 24 hours. If this doesn’t occur then further methods of induction will be used although this may be avoided with careful observation.

Synthetic oxytocin drips .

This is a synthetic form of oxytocin given via an intravenous drip to stimulate contractions.

Pros

  • It speeds up labour and brings on stronger and hopefully more effective contractions

Cons

  • This often results in longer, stronger more painful contractions which reduce the mother’s ability to cope with the pain and may increase the need for pain relief. See ‘Understanding pain in labour’ to understand how this can affect the normal process of labour.
  • This needs to be given via a drip so the mother’s ability to move around is restricted, although this doesn’t make active birth impossible. If you find yourself in this situation, make sure that your IV tube is long enough to allow as much room to move as possible. You can also get a support person to follow you around with the drip.
  • Strong contractions may reduce blood flow to the uterus which can cause problems for the baby.
  • Even though strong painful contractions will probably be experienced, there may be little progress in the dilation of the cervix which may result in a caesarean.

Episiotomy

The area between the vagina and anus is called the perineum. Once the baby’s head starts to appear, the vagina may be cut. The rationalisation for episiotomy is that the perineum will tear if it can’t stretch enough. Some care givers believe that these naturally occurring tears can be difficult to stitch and may not heal very well.

It is thought that this clean cut is much easier to control and repair, tends to heal better than a tear, and is less traumatic to the underlying muscle and tissue. Research has shown that this is not necessarily true, there is evidence to suggest that episiotomies cause more tears than they prevent. If you think about it like a piece of fabric that it is snipped at the end along the grain, this is similar to what can happen when an episiotomy is performed in the common direction of vagina towards anus. These tears that result from episiotomies also tend to be deeper, take longer to heal, cause more pelvic floor problems, more sexual problems and lead to a higher rate of incontinence. Episiotomy has also been found to be more painful than a natural tear, cause significant blood loss for the mother and expose her to risk of infection.

Most hospitals have finally ditched the practice of routine episiotomy but they are often required if there have been any other interventions and are still used preventatively if the caregiver at the birth thinks there is a likelihood of tearing.

The world health organisation take on this issue is that episiotomy is indicated in 5-20% of cases and that systematic use of episiotomy is not justified.

In many cases, whether or not you have an episiotomy depends on where you are in the world, your socio-economic environment, whether you have an obstetrician or a midwife attending the birth and various other factors that have nothing to do with the size of your vagina or how well it can stretch.

In Australia the episiotomy rate varies greatly from hospital to hospital. In some private hospitals in the areas of higher socio economic advantage the episiotomy rate is close to 40%, the lowest rate in Australia is 4% at a smaller country hospital.

More episiotomies are performed in private hospitals than public; virtually none are performed during home births.

Avoiding episiotomies

There are many things you can do which will reduce the risk of perineal tearing or the need for episiotomy.

  • Firstly, ensure that your entire birth team knows your position on episiotomy. Let them know in what circumstances if any you are prepared to accept an episiotomy, if you would prefer a tear to an episiotomy, ensure everyone knows it before the birth.
  • Your choice of care giver in childbirth seems to make a huge difference to your risk of perineal tearing and episiotomy. People who choose an obstetrician to manage the birth have the greatest risk of perineal trauma. A birth attended by midwives only reduces the risk considerably and those women that choose to have a doula have a much smaller chance of having any difficulties in childbirth.
  • Ask your birth attendant to use everything possible to support the perineum during second stage. This may involve applying warm compresses or perineal massage during labour.
  • During second stage, ensure that your perineum is relaxed, if you feel yourself holding any tension there, let it go. You could assign this task to a support person. Have them remind you to release any tension in the perineum during the rest periods between contractions.
  • Consider a water birth, the warm water helps the perineum to relax and takes away the need for an episiotomy.
  • There are also two things you can do during your pregnancy which will help to preserve your perineum (as well as your bowel control and your sex life)

Perineal massage

Researchers at Laval University in Quebec found in a study of 1,034 women, that the rate of giving birth without tearing was 61 percent higher in those who used perineal massage than those who did not.

Any amount of time you devote to this will be time well spent, but my recommendation is to spend 5-10 minutes a day from 34 weeks onwards.

Jojoba is a great oil to use ( you will find this in our shop ) as is sweet almond oil or even the plain old olive oil you have in your kitchen.

How to do it

Put some oil on your fingers and a little just inside the vagina. Place your thumbs about 2 cm inside the vagina and press down towards the rectum for 2 minutes , until the area becomes numb, and then breathe slowly and deeply while you try to relax the muscles in this area. Then gently massage back and forth along the sides of your vagina, moving your hands in a u-shaped motion for three minutes. Relax and repeat.

Of course you can have a partner do it for you if you prefer, it is something Dad can do to help prepare your body for the birth. Many Dads would love this job.

Kegel exercises

During pregnancy, Kegel exercises strengthen and tone the pelvic floor muscles, which eases childbirth. After birth, they restore vaginal integrity, and improve sexual performance and satisfaction. Arnold Kegel, an American obstetrician-gynecologist, developed “Kegel” exercises more than fifty years ago to strengthen the pubovisceral muscles of the pelvic floor. These muscles surround the vagina.

How to do it

Contract and relax the muscles in quick succession for 10 seconds, then rest for 10 seconds. Next contract and hold the pelvic floor muscles for 10 seconds then rest for 10 seconds. Repeat the routine as many times as you can until you can’t do it anymore.

These are the muscles you use to stop the flow of urine, so this is a good test if you are concerned you aren’t doing it properly. You can also place a finger in the vagina and squeeze it. Do at least 25 repetitions at various times throughout the day, gradually increasing the total number to 100-150.

 

Consider a water birth

Medical pain relief options

The aim of drug free birthing is to bring your baby into the world in the healthiest possible way, giving you both the best possible chance of getting off to a good start with breastfeeding and recovering from the birth quickly. There appears to be a commonly held belief that advocates for natural childbirth use scare tactics and make women feel weak or inadequate if they are unable to achieve a natural childbirth.

I want to assure people that I don’t make any judgements what so ever on anyone who chooses to use pain relief medication during childbirth. Birth is an incredibly intense experience both physically and mentally and sometimes all the planning, self education and support in the world are not enough to get you through it.

As with everything to do with health, I think it is important for people to weigh up the benefits of each method with its risks and to make a truly informed decision before choosing to take those options. Some parents find it helpful to make a list of their own thoughts on each method, pros on one side, cons on the other and deciding together what they are comfortable with before the birth.

See ‘Understanding pain in childbirth’ for evidence based information on the hormonal flow of labour, how to encourage it and how fear of pain can get in the way.

See ‘Natural Therapies in Childbirth’ for natural alternatives which while they wont take the pain away, will help you to tolerate the pain and get on with the job.

There are three main medical pain relief options in Australia .

Nitrous oxide

This is often called laughing gas and is mixed with oxygen and given to the mother through a facemask. The gas takes a few seconds to work, so it is important to breathe from the mask as soon as a contraction starts. Nitrous oxide doesn’t stop the pain entirely, but takes the ‘edge’ off the intensity of each contraction.

The pros

  • The mother has direct control – you can hold the mask yourself and take deep breaths whenever you feel the need.
  • This drug doesn’t interfere with contractions
  • Nitrous oxide doesn’t linger in either the woman’s or baby’s body

The Cons

  • It can cause nausea and vomiting.
  • It can cause confusion and disorientation.
  • Some mothers experience claustrophobic sensations from the facemask.
  • Nitrous oxide doesn’t offer any pain relief at all for around one third of women.
  • It can interfere with the normal hormonal interplay of labour, the effects of this are variable depending on the women, for some it can interrupt the rhythm of normal labour.


Pethidine

Pethidine is a strong sedative (related to morphine and heroin), usually given by intramuscular injection into the buttock. It may also be given with a drip. The effects of pethidine can last anywhere from two to four hours. Pethidine can make you feel sick, so anti-nausea medications are usually given at the same time.

The pros

  • Pethidine usually provides pain relief
  • It may allow the mother to rest or even sleep a little, this can help labour to continue in a normal way

The cons

  • The baby gets a dose of the drug through the umbilical cord and may experience respiratory depression, may be sleepy at birth and be unable to feed. It may also be more difficult to settle even for days after the birth
  • Pethidine can cause giddiness and nausea.
  • Hallucinations, disorientation and altered perception are common side effects.
  • It is common for the mothers breathing to slow down which means that she will also have to have oxygen from a face mask, limiting her ability to move around freely, leading to problems of its own
  • Some women don’t get any pain relief from it.
  • Pethidine is present in breast milk in significant doses for many hours after the birth
  • Some babies can have a reaction to the drug and may need immediate intensive care.
  • Even babies who can feed following the birth may have a depressed rooting reflex which can cause attachment problems at the breast and could mean the beginning of a difficult breastfeeding experience.

Epidural anaesthesia

Anaesthetic is injected in the back into the lining of the spinal cord, which makes the mother feel numb from the waist down. This option provides pain relief for vaginal delivery, or allows the mother to stay awake and alert during the baby’s birth by caesarean section. Since an epidural may cause the mother’s blood pressure to drop, it is not recommended for women with low blood pressure or for those who have a bleeding placenta.

Pros

  • It provides reliable pain relief
  • It allows for pain free emergency measures if they become necessary such as caesarean, episiotomy, forceps or vantouse assisted deliveries.

Cons

  • If the anaesthesia isn’t injected into the correct spot, only one side of the body is numbed – this requires a subsequent injection.
  • Sometimes the anaesthetist can miss the mark completely, meaning no pain relief
  • An anaesthetist is not always available when you want one
  • The lack of sensation in the lower body means a urinary catheter must be inserted in many cases.
  • Epidurals can lengthen the duration of labour in many cases.
  • The odds of requiring an emergency caesarean are substantially increased.
  • The chances of requiring a delivery assisted by forceps or vantouse in greatly increased, this also increases the risk of episiotomy or perineal tearing.
  • You can’t feel the contractions so you don’t know when to push, which means the baby may have to be delivered by forceps or vacuum cup, or by caesarean section. Some caregivers will turn the level of anaesthetic down to allow an upright birth position and sensation of contractions but since you no longer have you own natural pain killers it can be much more difficult to tolerate.
  • Around one per cent of women experience severe headache or migraine following the procedure.
  • Around one in 550 women experience ongoing patches of numbness on the back near the injection site.