An Independent midwife’s guide to the realities of the third trimester induction epidemic and how to avoid induction where possible.

The sad reality right now is that conventional obstetric practices are not always based on the best available scientific evidence, or the best interests of the mother and so there is an ever-increasing list of reasons for induction of labour which are woven into hospital policy. And guess what, hospital policy is NOT the law, so it means diddly squat in terms of YOUR decision-making around your body and your baby.

The Third Trimester

Generally speaking, most women sail through their pregnancy and as the third trimester approaches the focus moves towards birth preparation.

During the third trimester your midwife may start to measure your tummy with a tape measure as a method of screening baby’s growth, and she will plot this onto a customised GROW chart which has been formulated based on your weight height, ethnicity and previous births. This is optional, and it’s your decision to have these measurements taken or not.

The measurement is plotted on a graph which has percentile lines, and to explain what these mean – A baby on the 50th percentile is right in the middle of the normal range: 50% of babies of this gestation are lighter, and 50% are heavier. A baby on the 10 th percentile weighs less than 90% of other babies of that age. A baby on the 90th percentile weights more than 90% of other babies that age.

These measurements are not an exact science as they measure the uterus and all its contents (it is like measuring a moving object in a water filled balloon) and can vary from midwife to midwife in terms of where the tape measure is placed on the abdomen, which is common when you see a different midwife each visit.

Base on this arbitrary measurement, if the growth plotted has changed significantly from the previous trajectory then the midwife will suggest a growth scan at the hospital and this is often where the induction cascade begins.

Induction -is it a one size fits all approach ?

Induction has become part of the one size fits all approach used by the NHS as an increasingly homogenised method of managing risk with little regard for the birthing woman and the impact that Induction might have on her birth experience.

In situations where there are REAL concerns about the wellbeing of mother & baby which are fact based with clear diagnostic evidence such as blood results or reduced placental blood flow demonstrated by Doppler measurements on scan, then women need to be given information calmly in order to be able to fully understand the situation and to be able to make clear informed decisions without feeling threatened. Scaring women into accepting tests or intervention is never acceptable, and the effects of this unkind and manipulative language can stay with women for a lifetime.

Accepting an induction of labour was made much more stressful for women during the Covid pandemic where women were separated from their partners sometimes for up to 5 days in an induction suite in hospital when the unit policy was that partners were “not allowed” in for support until labour was ‘established’.

This lead to profound stress as labour inductions can be uncomfortable and this is a time when cuddles and support from loved ones can really help you to release the hormones that make the situation more manageable.

Inductions have increased massively over the last 10 years, and now a least 1: 3 labours are induced. This is largely due to NHS risk aversion and is leading to many unnecessary inductions for sometimes spurious reasons. Here are some of the common scenarios:

“Large” Baby

Your midwife says baby is measuring larger than expected, and refers you to the hospital for a growth scan. The scan confirms baby’s weight has accelerated, so you are offered a glucose tolerance blood test to rule out gestational diabetes, which if confirmed and the diabetes is not well controlled, might lead to a larger baby.

Now you are in front of the doctor who mentions induction at 39 weeks, so that baby doesn’t grow ‘too much bigger’ to birth vaginally and mentions shoulder dystocia (difficulty in birthing baby’s shoulders) in all of it’s graphic detail.

All of this whilst omitting to give you facts around the very small incidence of some of the worst aspects, and bundling it all up into a horror story so that you feel compelled to agree to the induction, or are left so traumatised that you return home in deep distress whilst trying to process the discussion and deciding what to do next.

Tailing Growth

Your midwife says your abdominal measurement is below what she was expecting at 34 weeks, and an ultrasound scan confirms that baby is growing on the 10th centile of the GROW chart.

The midwife had previously plotted baby’s measurement on a slightly higher centile, so it appears that baby’s growth is tailing off.

(However, remember that abdominal measurements are not 100% accurate) so doctor suggests another scan in 2 weeks time, the liquor (amniotic fluid) around baby and the blood flow to the placenta are also checked and all measurements are normal.

The doctor brings up the question of induction and says it all depends on the scan results in a fortnight, so you spend the next fortnight anxious and unsettled.

Two weeks later, and the scan shows baby is still around the 10th centile, but growth might have just dipped a tiny bit (almost negligible on the centile chart) so the doctor suggests baby might be telling us that they are ready to be born. However, the liquor around baby and blood flow to the placenta are fine, and the sonographer tells you it was not easy to measure baby’s head accurately as it is down in the pelvis, so you doubt if the measurement was accurate. But, you are now feeling pressured into induction because the risk of stillbirth has been raised by the doctor.

Reduced fetal movements

You have had a textbook pregnancy and felt well throughout. You are 39 weeks pregnant and birth ready, and you are planning for a home birth or birth in a midwifery led unit. You believe that baby’s movements have slowed down today, so you contact the hospital assessment unit or triage, and you are invited in for a CTG (cardiotocograph) tracing of baby’s heartbeat.

The resultant computer trace is all normal, and you are reassured that baby is well, however the midwife tells you that it is hospital policy to offer induction at 39 weeks if baby’s movements have changed as baby might be telling us they are ready to be born. You are completely taken aback by this suggestion as it had never crossed your mind, you feel confused, scared and uncertain of what to do next.

This suggestion totally changes your birth landscape and accepting it will mean consultant led care in hospital, continuous fetal monitoring, and separation from your loved one for days whilst the induction process is happening, limited access to the birth pool and an unlikely pool birth, and as midwives know, an increased chance of caesarean birth due to failure of the process as your body was not ready to release your baby so early.

Post-dates

You reach 40 weeks and your midwife offers you a sweep, which is a routine suggestion at term with NHS care.

40 weeks is baby’s ‘expected’ date of birth also known as Term, but this is based on out of date science, and it is more accurate to suggest a ‘due period’ from 37 weeks to around 42 weeks (or even longer if you wish).

The sweep at 40 weeks is a form of induction, so think very carefully about accepting this.

At 41 weeks your midwife again offers you a sweep, and again you can decline this and wait for nature to take its course. Your midwife also tells you that she is going to ring the hospital and book you in for an induction at 41 weeks and 5 days so that baby is born by 42 weeks.

Accepting this date fills you with fear and dread, and you start watching the clock. As the days go by, your adrenaline starts to increase, which can put the blocks on labour starting.

The older mother

First time mothers over 40, or even sometimes in late thirties, get “offered” an early induction of labour at 39 weeks and this is often raised at the very first appointment with the consultant at 16 weeks of pregnancy (and can significantly burden a woman for the remainder of her pregnancy).

This is mostly quoted as being due to the risk of stillbirth increases in older mothers.

To quote the Royal College Of Obstetricians and Gynaecologists:

“The incidence of stillbirth at term in women is low. It is higher in women of advanced maternal age. At 39–40 weeks of gestation this equates to 2 in 1000 for women over 40 years of age compared to 1 in 1000 for women less than 35 years old.”

This means that the risk of stillbirth is still very small. It might still not be an acceptable risk for you. But it does make sense to balance those risks against those of the induction process, so that you can make a truly informed decision. Read a real-life Positive Birth Story from Susan who felt pressured to be induced, she was aged 40 and covid lockdown restrictions had just started.

The induction ‘pressure cooker’

The suggestion of induction of labour is influenced by doctors’ fears of getting sued, and hence the discomfort many women report as they describe how they felt pressured and coerced into agreeing with the decision to be induced with the doctor telling them that if they disagreed then they would be acting ‘out of policy ‘and would have to take personal responsibility for any poor outcome.

These conversations are deeply stressful and unsettling for a woman and seriously destabilise her emotional calm and wellbeing in the last few weeks of her pregnancy

Some of the language used by midwives and medical staff to coerce a woman into induction are quite frankly horrendous, and pretty formulaic too eg if there is a suspected larger baby the discussion heads down the route of baby getting stuck, fractured collar bones, and bad perineal tearing. If the pregnancy is ‘post dates’ the discussion is around the placenta becoming less efficient and not supplying enough nutrition for growth any longer, which can lead to poor outcomes.

In reality the risks are much smaller and much less frequent than is being portrayed and so it is crucial that you ALWAYS ask what the actual risk is in terms of numbers as this could hugely impact your decision.

We must also fiercely protect one of the fundamental tenets of medical ethics: respect for autonomy.

Autonomous individuals act intentionally, with understanding, and without controlling influences.

How to avoid induction and say no

Everything offered during pregnancy, birth, and the postnatal period is OPTIONAL. That said, saying no can feel very scary.

Importantly you can’t make decisions based on fear and the possibility of what might happen

NEVER EVER agree to an induction on the spot however hard the person offering is pushing you. This is a MASSIVE decision and needs to be considered very carefully indeed, once you have reviewed the facts, and sought a second opinion if necessary.

When you’re faced with a discussion that is slowly filling you with fear, and being asked to agree to something before you fully understand the implications, it’s just WRONG.

Do not agree to ANYTHING until you have looked at the alternative course of action and weighed up what is best for you and baby.

You NEVER have to give a reason for your decisions, but if you’re feeling stuck, these might help when you are feeling pressured by a doctor to make a decision.

• I want some time to think about that.
• We have thought about this and decided against it.
• I want to discuss with my birth partner first.
• I don’t want to.
• I’ve made the informed decision to…

Write a few notes, come out of the meeting and do your research on the options.

Let the doctor know that you will be back in touch when you have done your own research and reach out to a birth advocate to discuss alternatives before you make a decision.

The AIMS charity in London are great at providing research to help with decision-making, as are the consultant midwives in hospitals.(contact them via hospital switchboard).

The best way to prepare for difficult discussions around induction is to… FIND YOUR POWER!

Find your Power through great Preparation

I can teach you more about how to protect yourself from coercion around induction, and avoid induction of your labour in my complete hypnobirthing and newborn course or you can book an ‘empower hour’ with me so we can make a plan and organise your birth preferences.

This is so very important because many of my clients have described how sitting in front of a consultant is intimidating and how vulnerable they feel.

When talking about options for a course of action based on scan findings the discussion rarely feels balanced.

The doctor, who in doing what they BELIEVE is best for you and your baby, can start to use coercive or frightening language to steer you around to their way of thinking.

Time and time again women tell me they felt vulnerable and flustered and agreed to what was suggested because the doctor was the expert. This led to an induction that was prolonged uncomfortable and in retrospect probably unnecessary.

Keep in mind that the decision to induce is rarely an emergency. You have time to think it through. Feel it out. You have time to ask questions. If you do need an induction, you’ll know you made an educated choice.

As women are increasingly exercising their power, choice and control and are beginning to request ‘out of policy’ management for the birth of their baby, the Royal College of Midwives have produced a new guideline which informs NHS staff around how to communicate without coercion, thus ensuring informed choice and a balanced discussion which will ensure a safe birth but ALSO a better birth experience for the mother.

These are not mutually exclusive and should be a basic human right.

Stand up for the birth you want on your terms, you only get to birth this baby once, so make it a birth you want to remember rather than one you want to forget.