Induction and preventing stillbirth

 

I started off writing an Induction booklet but then I began reflecting on being induced for going over due dates and the concern about the increased risk of stillbirth. For me, the risks are far from clear and induction for being ‘overdue’ and without a medical reason divides me – it hurts my heart and my head.

My head tells me that if a baby isn’t ready to be born yet, why force it? Let’s just wait because he might just need a bit more time to develop, to grow and to get into a better position for birth. Some babies will be ready at 37 weeks, while others won’t be ready until 42 weeks, or even after that.

My head tells me that inductions can be tough on women and on babies and they can increase the need for interventions and caesareans. But my heart tells me that most of us would go through any birth to be able to have our baby, safe in our arms.

My head tells me that 550 women would need to be induced to prevent one stillbirth. But my heart screams that if induction can save one baby, then isn’t it worth doing?

If a baby dies in late pregnancy, parents will be offered an earlier induction with their next pregnancy – a welcomed intervention that can also leave parents wishing this was offered for their lost baby, who may still be alive had induction been offered to them then.

 

What are the facts?

In the UK, 1 baby in 200 will be stillborn and this percentage has remained largely unchanged in 20 years.

Common causes include complications with the placenta function or with the umbilical cord, infections and congenital defects.

Risk factors also include obesity, smoking/drug taking, being over 35, epilepsy, high blood pressure, diabetes and expecting more than one baby.

The cause of one third of stillbirths is unknown.

One third of stillbirths occur at full term.

Each year, 500 stillbirths take place during labour.

The risks of stillbirth at full term

The Royal College of Obstetricians and Gynaecologists (RCOG) states that:

1 in 3,000 babies at 37 weeks

3 in 3,000 babies at 42 weeks

6 in 3,000 babies over 42 weeks

 

The risk may seem minimal but that is of no comfort at all to someone whose baby has died, someone whose baby might still be alive if they had been induced.

Offering an earlier induction can seem like the solution but when should it be offered – from 37 weeks, at 40 weeks? And what about the risks of induction?

 

 

Another study – The Prospective Risk of Unexplained Stillbirth in Singleton Pregnancies At Term – which was published by the British Medical Journal, found that the risks of stillbirth are:

35 weeks is 1:500 babies
36 weeks is 1:556 babies
37 weeks is 1:645 babies
38 weeks is 1:730 babies
39 weeks is 1:840 babies
40 weeks is 1:926 babies
41 weeks is 1:826 babies
42 weeks is 1:769 babies
43 weeks is 1:633 babies

This study looked at routinely inducing labour at 38 weeks but it concluded that this would lead to a high incidence of caesarean sections, as well as a small risk of breathing problems in babies.

 

 

Being Induced

It isn’t simply a case of kickstarting labour. Induction can be about encouraging a woman’s body and baby to do something it isn’t quite ready for yet. If labour is imminent, induction can work well and women can have really positive births but induced labour can be tough going, both physically and emotionally.

 

Belly Belly describes it beautifully: Normal, natural labour involves a magnificent ‘dance’ of hormones released by mother and baby, which work together to get the process going and established. Not only do you need the labour hormone, oxytocin, to be circulating in your body, but your uterus also needs oxytocin receptors to be activated, something that only happens once labour is established, which takes time. Because your body may not be ready for labour, high amounts of artificial oxytocin may be needed to get labour going. And that in itself poses a risk to you and your baby, something that is often conveniently left out by your carer. 

 

Induction can also carry risks which include…

An increased chance of needing more pain relief, interventions or a caesarean
An over-stimulated uterus
Cord prolapse
Fetal distress
Babies can need more care and observations when they are born

 

 

What is being done?

The sad reality is that not all babies can be saved but if the number of stillborn babies can be prevented, then that must be a priority. The 35/39 study is aiming to reduce the risk of stillbirth in women aged over 35 and SANDS is calling for more antenatal checks and scans in the third trimester, to pick up any problems with the umbilical cord and to check placenta function. 

 

The NICE guidelines currently state that there needs to be a medical reason for induction, so maternal request on its own may not be enough. So, if you are pregnant, what can you do?

 

Be aware of your baby’s movements – if you notice any change at all, if you experience something out of the ordinary, if you feel ill or if you just feel that something isn’t quite right – get checked out. Never think you are wasting anyone’s time. According to Count The Kicks, 50% of mothers who have lost a baby to stillbirth reported a decline in their baby’s movements a few days before their baby died.

 

Count The Kicks also encourages you to get checked out by your midwife or at your local pregnancy assessment unit…

If you notice a change in your baby’s normal movement pattern
If you have any itching or a rash
If you have a temperature or fever
If you have any pain including headaches
If your vision becomes blurred or you see colours or patches
If your hands or feet become swollen or painful
If you have any fluid loss or bleeding
If you have pain passing urine
If you have a “bad feeling” or feel uneasy in any way

 

 

So why am I so divided? I don’t like the idea of induction without a medical reason, it is something I wanted to avoid when I was pregnant with each of my three children. While induction could reduce the number of stillbirths, it also holds the potential to create different hazards and traumas for women. But I also know the pain and trauma of losing a baby and if that pain, trauma and grief can be prevented for other parents, are changes needed?

Do expectant parents need better information about being induced and about staying pregnant beyond due dates so they can make more informed choices about induction or waiting for labour to start naturally?

If parents are to be given more options of induction there needs to be better support – private rooms and being able to stay together as a couple are important, as is being able to stay mobile, to have one to one midwifery care, to be able to use water and to be able to relax and breathe to stay calm and in control. With better support and a better birthing environment, induction could be more of a positive experience, with increased birth satisfaction.

And birth satisfaction is an important issue which shouldn’t be under-estimated – while most women would go through any birth experience to be able to have a healthy baby, birth can sometimes cause trauma which can be hard to live with and which can have long lasting effects for a woman and her partner.

It’s a complicated issue, which causes huge emotion and argument and I don’t think there will be an answer that suits every woman. Even if early induction was offered, I suspect many women would prefer to wait for nature to take its course but maybe the important issue is that it needs to be on offer?

Sources of Information:

RCOG
NICE
BMJ
Count The Kicks
SANDS
35/39 study

 

About Janine 568 Articles
I am an antenatal teacher, doula, baby massage instructor, postnatal educator, life coach, writer, mum, wife, friend and, sometimes, just me. As an experienced and qualified practitioner, I specialise in pregnancy, birth and early parenting - my aim is to listen, inform, support and reassure when needed. I have worked with parents since 2002 and I set up Birth, Baby & Family in 2011 to provide good information, a different perspective and links to the best products and services for families. I set up the Birth, Baby & Family Centre in 2014 to provide a welcoming, friendly and supportive space for parents across Tyneside.