Induction of Labour, Guide and How to Have a Positive Experience

If you are offered induction of labour (IOL) it is helpful to explore the reason why and look at your individual circumstances to decide if this is the right choice for you and your baby. This piece will

• Discuss the common reasons for induction with reference to the supporting evidence.

• Consider ways to start labour prior to medical induction.

• Offer suggestions for a positive induction experience.

If you are told you need induction or you will be induced on a set date it may feel that you don’t have any options, this is not the case. Having an induction is always your choice although it may not be presented like this by your midwife or doctor. It is important to know that no one can force an intervention without consent.

Reasons Induction is Offered and the Supporting Research

Around 1/5 of pregnant women in the UK will have an induction, the more common reasons are considered below.

Postdates

Being ‘overdue’ is the most common reason that IOL is offered and the UK base their healthcare guidelines on the National Institute of Clinical Excellence (NICE) a summary of which can be found here. NICE suggest that induction is offered between 41 and 42 weeks of pregnancy so that the baby is born by 42 weeks, you can find the evidence to support this guideline here.

In summary, the research says that the rate of stillbirth is 0.4 per thousand for women who had induction prior to 42 weeks and 3 per thousand for those who went beyond 42 weeks of pregnancy. The data found no difference in the rate of birth by caesarean or forceps and ventouse (instrumental births) between the two groups. Consider these numbers, you may feel that it is a significant increase and a risk you would not feel happy to take OR you may think that the increase is small and would consider going beyond 42 weeks of pregnancy. This is a deeply personal decision and not a choice anyone else can or should make for you.

Maternal Age

In the UK you will be offered IOL if you are 40 years or more when your baby is born, this is because there is an increased chance of stillbirth if you are over 40 and go beyond 40 weeks of pregnancy. You can find the supporting research for this here. It is important to note that if you have had a previous baby your risk of stillbirth is lower and a summary of this data can be seen in the table below.

Stillbirth Rates for Women Giving Birth per 1000 Ongoing Pregnancies

Reddy, Ko et al, 2006 (Data taken 2001-2002 from US Birth Certificates)

IVF/ Articifical Reproductive Technology (ART) Pregnancies

There is no conclusive data or universal agreement if induction should be offered for ART pregnancies, so hospitals have varied guidelines some offering induction and some not. There is an increased risk for these pregnancies, but this is associated with maternal health factors (older age, obesity, uterine anomalies, multiple gestations etc) rather than the treatment itself.  You can read further research related to this here.

When deciding if IOL is right for you and your baby consider your individual circumstances and if you have other risk factors rather than simply the use of assisted conception.

Medical Reasons

If IOL is offered for medical reasons including diabetes, high blood pressure, pre-eclampsia or baby’s size you can ask to see the relevant research and data that these guidelines are based on. Looking at the numbers helps you make a balanced and informed decision.

It is interesting to note that NICE says in the absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic) although this does occur often in practice.

Pros and Cons for Induction

Weigh up the pros and cons for IOL by looking at your own individual circumstances. The decision may feel easy and obvious or a more difficult one to make.

Possible Pros

• IOL feels like the safest choice for your baby.

• You may be able to start the induction process as an outpatient or on the midwifery-led unit.

• You may feel ready to give birth.

Possible Cons

• It may take a couple of days to get labour started in the hospital leaving you tired and more likely to choose an epidural.

• Induced labour can feel more intense and less manageable than spontaneous labour (NICE).

• If you require a syntocinon drip to trigger regular surges you will need to be on the doctor-led unit and the birth pool will no longer be an option.

• The induction may fail in which case the baby will be born by caesarean.

• You may feel unready to give birth.

You can choose to accept, postpone by a day or two or decline the induction. NICE suggest that from 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice‑weekly cardiotocography (CTG) and ultrasound estimation of maximum amniotic pool depth.

Encourage Your Labour to Start before Induction

Trying to stay as relaxed as possible is important but many Mums become anxious as they go past their due date. Remember that the due date is just a 5-week due ‘window’ which stretches from 37-42 weeks.

If you a holding in pent up anxiety it can be helpful to feel the emotions deeply. Try to release them with a weepy movie and a good cry long. I have had many clients go into labour once they have allowed the feelings rather than suppressing them in their efforts to stay calm.

Sweeps

You will be offered a sweep by the midwife at some point after 40 weeks of pregnancy, you can learn more about sweeps and consider if you want one by watching this video. Sweeps can work if your body is already starting to change ready for labour and your cervix has softened moved forward and opened. Data suggests that sweeps work 50% of the time although you may need 2 or 3 over a few days.

NICE says that currently, available evidence does not support the following for induction of labour: herbal supplements, acupuncture, homoeopathy, castor oil, hot baths, enemas, sexual intercourse. However, some of my clients have had success with the following methods.

Acupuncture

Starting once-weekly treatment from 34-36 weeks of pregnancy to encourage the cervix to ripen and open. This can be combined with full body massage for maximum relaxation.

Nipple Stimulation

Stimulating your nipples by hand or with a breast pump releases oxytocin and there is some evidence that suggests this can increase the chance of spontaneous labour by up to 30%. These studies were based on mums doing this for at least an hour a day for 5 days.

Dates

There is limited evidence to suggest that eating 6 dates a day from 34 weeks of pregnancy reduced the chance of needing our labour augmented with the oxytocin drip.

Movement

If your hips will allow it, go for a vigorous long walk each day to encourage the baby’s head to put pressure onto the cervix to stretch and open it.

Baby’s Position

Sometimes labour does not start or starts and stops because your baby isn’t in an optimal position eg back to back/ posterior. You can learn more about this and encourage them into a better position by taking my online course Align Your Baby.

Reflexology/ Massage/ Deep Relaxation with Audio Tracks/ Orgasm

Any complementary therapy or activity which encourages a feeling of wellness, calm and oxytocin release may be beneficial. Plan your days to include things that you find deeply relaxing.

You can watch me talk more about other ways of encouraging labour to start here.

I Have Accepted Induction, How Do I Have a Positive Experience?

If you go into IOL feeling very anxious and that it is not your decision this can increase your adrenaline output and reduce your birthing hormones, potentially making the induction process longer and more challenging.  

Once you know you are going in for an induction, mindset and a little preparation is key for a positive experience. You can watch a video explaining the process of induction here. It is important to make peace with your decision even if you feel it isn’t your ideal situation and as labour will be starting in a more medical setting you need to lay on your relaxation techniques extra thick. The following suggestions can be helpful.

1. Write some mantras for a positive induction. Use these throughout the days in the lead up to induction and throughout the birth.

2. Read some positive induction stories here.

3. Set up your environment in the hospital with home comforts; pillows, aromatherapy, photos etc.

4. Listen to the hypnobirthing tracks before induction and during the early stages in the hospital to tap into your state of deep relaxation. Headphones and an eye mask can help you block out the hospital environment and travel inwards.

5. Use slow breathing to relax whenever needed.

6. Take yourself off for walks and lunch or dinner if you need a break from the hospital environment, the process can take a couple of days so it is good to have a change of scene if possible.

7. Gentle nipple stimulation to boost oxytocin! Kissing, cuddling and massage can all get the hormones flowing.

8. Focus on your gorgeous baby, holding them in your arms and taking them home, boost those loving feelings to help your body go into labour.

9. Visualise your cervix softening and opening.

10. Once you start the induction process in the hospital remember, you can still decline anything at any time if it does not feel right. If you are not sure about something ask lot’s of questions and for half an hour or an hour to consider it, so you don’t feel pressured or rushed into decision making on the spot.

Although it may not feel like it, it is possible to stop the induction process and move to a caesarean if this is the right choice for you and your baby at any time.

Birth Bag Checklist

I am a BIG believer in LESS is definitely MORE when it comes to your hospital bag. These are the ‘can’t live without’ essentials, and you’ll be glad you took them with you.

Think about it as though you are packing for a short holiday, we are always tempted to pack more than we need so don't pack items unless you use in your everyday life!

FOR BABY

• Baby vests x4 and baby grows (with legs and arms) x4 this may seem like a lot, but you’ll be surprised how many they go through!!

• Hat for the first 4 hours after birth and for the journey home

• Cotton blanket

• Cotton wool to gently clean Baby’s bottom with warm water

• Going home clothes, these will vary depending on the season but will include a thicker layer to go on top of the baby grow

• Nappies, a small pack

• Muslin squares x2 for mopping up milky dribbles spills etc

• Socks or booties x1

• Car seat, you will need this to go home but your birth partner may be ale to bring it in after your baby is born

FOR MUM

During Labour and Birth

• Hospital notes with birth plan stapled to the front

• Snacks (nuts, energy balls, dark chocolate, bananas, cereal bars or anything you fancy!)

• Drinks (isotonic or coconut water is great)

• Clary sage and lavender essential oil. Clary sage can increase your surges, so this is good if your labour is slow or surges are far apart/ mild. Lavender is excellent for relaxation. Add 3 drops of essential oil to a tissue and sniff OR to one tablespoon of base oil like almond, sunflower or coconut, and rub this onto your tummy and back

• Other massage oil for labour

• A nightdress or long Tshirt/ vest x2 (in case it gets dirty and you’d like to stay fresh) to wear during early labour. Many Mums will prefer to be naked in strong labour

• Lip balm, your lips gets very dry especially if you use gas and air

• Hairbands

• TENS machine, good to help Mums cope in early and strong labour, you can rent or buy one

• A pillow with your own patterned cover on so it doesn’t get absorbed by the hospital, there is often a strange shortage

• Something to play music on a like phone or Ipad with mini speakers/ headphones

• Reusable bottle of water with a straw in it. Keeping hydrated definitely helps your labour and a straw helps you drink more easily

• A flannel, it feels so lovely to have your face wiped with warm or cool water

• Water spray for your face

  After Birth

• Soft pyjamas with an open front for breastfeeding (shirt style)

• Slippers or flip flops

• Bathrobe or dressing gown

• Thick sanitary pads, your bleeding after birth is heavier than a period for 24 hours

• Disposable knickers (1-2 sizes bigger than normal) or old soft large knickers, x5 pairs. You’ll get through more than you think

• Going home clothes that are soft and stretchy. It’s common to be a bit sore and tender after birth, so the softer the better

• A breastfeeding-friendly bra if you plan to breastfeed/ soft supportive bra if you don’t

• Hairbrush

• Toothbrush/ toothpaste, hand sanitiser, deodorant, shampoo, soap and face cream to make you feel fresh

• Eye mask/ earplugs

• Small portable touch light for the night (tap to turn on and off), good for feeding in the night at home as well

• Paracetamol

  FOR BIRTH PARTNER

• Plenty of food and snacks for during birth and after

• Drinks!

• Wallet with change for the parking and vending machine

• Phone with useful numbers stored (midwife/ hospital)

• Long phone charger

• A change of clothes

• Plastic bag for dirty clothes

You can download a FREE shareable PDF of this piece here.

A Free Guide to Mental Health in Pregnancy and Postpartum

Becoming a mother is one of the most significant transitions in a woman’s life. Not only is there the physical growth and birth of the baby, but there is a parallel emotional journey towards motherhood.

The way a woman experiences her pregnancy is individual to her. We all come to pregnancy with our own important personal histories. You may have been through many cycles of fertility treatment; you may not want children; you may have conceived in a blended cultural family; you may have experienced a previous pregnancy loss; you may have conceived straight away and are ecstatic; you may be recently bereaved; you may have experienced birth trauma; you may have become pregnant at the same time as your best friend… this is by no means a complete list, but highlights how each and every woman will be experiencing and living her pregnancy differently.

Most women experience changes in their mood and relationships during pregnancy. This is to be expected as it is a huge life-changing time. For most, these feelings come and go, and may feel momentarily overwhelming, but you are able to continue living your life as you would like. For some, however, these feelings and emotions can be all-consuming, and they hinder every-day life. A pre-existing mental health diagnosis can sometimes be an indication of maternal mental health challenges in pregnancy or with a new baby, although not always.

Please know, that the behaviours and thoughts I list below are not to be used to diagnose, these are for personal reference only. The list is not exhaustive, and there may be symptoms and behaviours not mentioned. If you are concerned about yourself or a loved one, please speak to a professional.

Ante/Postnatal Anxiety – anxiety can heighten during pregnancy. This can feel like restlessness; running thoughts; heart thumping; sweaty palms; panic; breathlessness; hypervigilance; insomnia; exhaustion.

Ante/Postnatal Depression – can feel like a heavy dampening of everything; a lack of joy and excitement; some describe feeling empty and no variation in mood; struggling to sleep, sheer exhaustion; no motivation.

Ante/Postnatal Obsessive and compulsive behaviours and thought patterns (OCD). Thoughts that can feel overwhelming, intrusive and terrifying. Obsessively counting kicks/movement. Fear of baby dying. Compulsively cleaning, disinfecting, bathing.

Postnatal maternal OCD can sometimes present as relentless thoughts around the terror of harming your baby. Although you know you will never act upon these thoughts, they can be so chilling and abhorrent, and flood your mind. Please know these thoughts are common, and your baby is safe.

Birth Trauma – is when you were or perceived that you or your baby were under threat of death or serious injury. Re-experiencing the trauma through flashbacks, intrusive thoughts and nightmares; being hypervigilant, especially around the baby; feel guilt around the birth, or feelings of depression.

Postpartum Psychosis – is a rare, but treatable medical emergency. It can present in many different ways but is often accompanied by hallucinations, delusions and mania. It can appear suddenly and can change from moment to moment. If you suspect yourself or a loved one of experience postpartum psychosis, please read the APP website and call a healthcare professional immediately.

Although I have listed some of the occasions when mental health is strained, please know that for many women, the experience of becoming a mother is positive and fulfilling.

However, if you are struggling, there are some things you can do to help alleviate this.

• Speak to your midwife or GP.

• Speak to your friends.

• Join ante/postnatal classes.

• Gentle exercise (especially outdoors).

• Try and carve out some alone time, or social time – whichever is most comforting to you.

• Care for your body.

• Journal or note your thoughts down in a way that feels right to you. Sometimes telling someone else feels too much, and by writing you are telling yourself, and this can be surprisingly effective.

An incredibly uplifting and hopeful thought to hold on to is that with help and support, most perinatal mental health challenges are temporary.

 Some really useful websites:

• Mental Health Support Through Pregnancy and after Birth  

• Making Birth Better

• Birth Trauma Association

• Maternal OCD

• Postnatal Depression Awareness & Support   

• Mothers for Mothers

• Counselling Directory

• Stillbirth and Neonatal Death Society  

• Fertility Network UK

You can find a FREE shareable PDF of this and many other resources HERE.

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Elisha Nunhofer is a person-centred psychotherapist who specialises in maternal mental health. She has extensive experience of working with clients who are exploring the possibility of having children; going through fertility treatment; have experienced all forms of pregnancy loss and termination; ante and postnatal depression and anxiety; adoption and surrogacy.

She sees clients via video call or in-person in East Sussex. For more information, please visit her website.

A Free Guide to Having a Doula

To doula or not to doula…that is the question!

Ever heard of a doula? Wondered what one is, what they do and how they can help? Is it all witchcraft and incense? Hopefully, I can dispel a few myths here!

What is a doula?
A doula supports women and those that birth through pregnancy, birth and the postnatal period. How do we do that…. well, to start with we are non-judgemental and incredibly open in our approach. We appreciate that everyone makes decisions that are right for them at any given moment and our aim is to make sure that you feel fully informed and supported to make the choices that suit you.

We can help by signposting good evidenced-based research (no opinions, judgement or advice here, we want you to explore what feels right for YOU) and by exploring the emotional and practical needs a doula can bring, it means we will respond to the individual needs of each pregnant person…with the idea that you feel confident and empowered, and that any gaps in knowledge, care, understanding or communication is bridged.

You can read more about the role of the doula here and this is a great source of evidence-based information.

Are we just for the mother to be/birthing person?
No! As doulas we often support the partner, whoever that may be, so they too are informed and relaxed. By offering continuity of care, we build relationships with whoever needs that support so that when the day of birth arrives, everyone is as positive and included as they can be.

Are we clinical and can we give medical advice?
In short, no. We are not medics but fully appreciate there are roles we all play when supporting birthing women/people… although we have different roles, doulas keep the needs of those they support, at the forefront of their minds always. We want that oxytocin flowing so work hard to make your birth space as calm as possible!

Are there statistics to show the benefits of having a doula?
Yes! There is evidence to show that having a doula can:

• Reduce risk of caesarean birth.

• Reduce risk of instrumental birth.

• Reduce need for painkillers or epidural during birth.

• Reduce risk of induction of labour.

• Shorten labour.

• Increase parental satisfaction with the birth experience.

• Increase the likelihood of initiating breastfeeding.

• Increase the likelihood of successfully establishing breastfeeding and breastfeeding at six weeks.

• Lower incidence of depressive symptomology.

• Improve equity and provide culturally responsive care

(Brigstocke S. MIDIRS Midwifery Digest, vol 24, no 2, 2014, pp157-160)

The best doula for you?
Chat to a few! See who you connect with... when the rapport flows and you know you could chat about anything with ease…you’re on the right track!

You can download a FREE PDF of this piece and many other useful resources HERE.

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Sam is a married mum of two, has a cat, dog & bearded dragon & has lived in Essex all her life.

After training in 2008 with Nurturing Birth she dipped her toe further into the birth world (also attending the training & facilitating for Mindful Doulas) and went on to explore mental wellbeing, Birth Trauma (3 step rewind technique), infant massage, hypnobirthing and many other workshops and study days that caught her eye! Finding community, supporting those who need it and embracing who you are is at the heart of Sam’s drive and is why you’ll find her as ‘the unapologetic doula’ on social media!

She’s been a doula mentor for seven years and at the end of 2019 was overjoyed to be asked to join the Nurturing Birth team where she has branched out to facilitate the new doula courses 😊

Contact Sam via email – samshepp4@yahoo.com or call 07793970367 for a free chat on how a doula can benefit you, or check out the links on this guide for her FB page, more info and reviews/testimonials.

What I've Learnt... From A Tale of Two Tears

Preparing for the birth of our first child in 2013, I was utterly convinced we had it sussed. I expected to breathe my baby down in my bedroom, upright, giving my tissues time to expand, gravity supporting my open pelvis etc.

I knew if there was a real emergency, I would have an unplanned C-section, but I never considered any outcome in the middle.

When I started bleeding with each surge, 12 hours in, we transferred into hospital during transition. I’d been coping brilliantly, feeling supported, enjoying it even.

When we left for the hospital, all of that changed. I was treated as an inconvenience, a nuisance, a first time mum who had been foolish enough to imagine she could do it at home. 

Unidentified people removed my clothes and cannulated me without discussion or consent. The consultant told me I would need an epidural as the pain would now hit me all in one go- I remember her laughing as she said it, mocking my optimism about managing without one.

For almost 5 hours, I came under the most enormous pressure to get the baby out promptly, despite there being no indication that either of us was struggling medically. I withstood threats of a caesarean, of stirrups, of episiotomy, and in the end, unsupported and exhausted, forced my baby out of my vagina all in one go, after much straining and screaming.

Unsurprisingly, I sustained a 3a tear, which I waited 5 hours to go to theatre to have repaired. There, people spoke about their weekend plans as if I wasn’t there, and dismissed my anxiety about feeling SO cold.

Every instance of pain, every feeling of weakness, every trip to the hospital for the following 6 months, I felt not just the tear, but the trauma of the way I’d been treated. Undermined, disrespect, unnecessarily injuring myself to try and maintain some autonomy over my body.

Fast forward 3 years, to the beautiful home water birth of my second baby. It was the most incredible experience of my life, birthing on my own terms, confidently boundaried, and wonderfully supported by 2 fantastic midwives. They were WITH ME, in every sense.

This enormous baby, with his fist upon his head, emerged slowly and gently from my upright body. And I sustained another 3a tear.

Don’t get me wrong- I’d have loved not to have torn. But I can honestly say, I wasn’t traumatised by it, even upset by it (beyond the inconvenience of going in). Everyone I encountered was compassionate, reassuring, nurturing. 

I had very little pain beyond the initial recovery, and any time it smarted, I felt reminded of my capacity- how powerful I’d felt, how empowered and supported I was to bring the human I’d grown into the world as I chose. 

The way we feel about birth isn’t simply about what happens- on paper, my 2 experiences were broadly the same outcome. We are limitless in both our strength and vulnerability in birth. The way that vulnerability is met carries forward with us into motherhood- can we expect to be belittled, mocked, disregarded? Or respected, held, accepted? 

My experience tells me that our best route to more positive births and confident parenting experiences is to focus on how women want to feel, and how we can achieve that- through realistic education, through advocacy and kindness.