Monday, 8 September 2014

Induction - Cascade - Caesarean Section



It's well known fact of modern childbirth: Inducing labour sets off a cascade of other interventions which often lead, with grim inevitability, to an emergency C section.

But is this actually true?

update, 1/10/14 - Since writing this post the NCT have updated their information on inductions and removed the section quoted below. More on this here.


 - Firstly, hat tip here to This Blog - I'm writing my own aimed at people who probably aren't regular readers of Scientific American (confession, I'm not either) and because I have one or two opinions ...



When I went overdue with MissE I dreaded being induced. I'd heard nothing but horror stories and  according to my NCT teacher it was basically entirely awful and unnecessary. It would also completely scupper my plans for a natural birth in a midwife led unit. But at the same time I was BLOODY MASSIVE. It was August, and hot, I was desperate to meet my baby and had had quite enough of being pregnant. So I agreed to booking an induction and did everything I could think of to make that booking unnecessary*. In the event I got my wish (although I still ended up going through much of the induction procedure after 24 pointless hours of contractions... but anyway)

41 weeks. Bloody Massive


So was I right to fear the induction? It seems the answer to that is no.

A recent study has shown that being induced doesn't increase the likelihood of having a caesarean. In fact women having a single baby, who are induced at term or when overdue are slightly LESS likely to have a C section than those who hang on for nature to do her thing. They are also (again, slightly) less likely to have a baby who dies or who needs to be admitted to intensive care.

This goes against so much other information - Can we really trust this new study?

We often see piles of scientific studies that contradict each other, one minute coffee causes cancer the next it cures it etc. etc. so how reliable is this one, given that it goes so strongly against the generally accepted view?

In this case the authors of the paper didn't set up their own experiment or trial. Instead they did what is known as a meta analysis. This is important because a meta analysis is far more reliable than most of the scientific studies that make it into the media. The authors took the data from 157 different trials and did some serious number crunching. Looking not just at the results of those trials but at their weaknesses too. For example, many of the individual trials were pretty small, meaning their results are less reliable than bigger studies. By putting all this information together they are able to overcome most of the errors and biases that inevitably influence the results of individual studies. We rarely find perfect answers in anything associated with biology, but a meta analysis is about as good as it gets.

So now what?

The differences seen are fairly small, they certainly don't warrant more or earlier inductions but they do call into question the generally accepted view of induction.

Here is what the NCT, the UKs largest parenting charity says about induction on it's website:

Induction of labour may set off a ‘cascade of intervention’, and before you know it you may be drawn into having drips, electronic monitoring, epidurals and all the trappings of a medically complicated, high-tech birth. If you go two weeks past your dates, you can ask to have regular checks on the baby rather than have your labour induced.  ...

 Other methods you may want to consider are acupuncture, hypnotherapy, reflexology and shiatsu. There is no clear evidence that these methods work, but they may be worth a try.

This was written before the recent study was published, but it is a good example of the prevailing view of induction. That it is something to be avoided, even when doctors recommend it and that it's better to go with completely unproven* (actually disproven may be better) and generally quite expensive alternative remedies, rather than risk the dreaded descent into a "high-tech" birth. 

Its strong stuff and something I absolutely went along with when I was pregnant. After all, the NCT are the foremost childbirth charity in the UK. We paid a LOT of money to attend a course given by one of their most senior teachers, who told us that everything she said was evidence based. It turns out that that evidence never existed. 

I sincerely hope that the NCT will now update it's website and ensure that it's instructors are giving accurate, evidence based information to expectant parents. Of course there are plenty of people who've had a bad experience of induction and many who ended up with a C-section but the same is true of others who held out for a natural birth and plenty who went into labour at about the right time anyway. Childbirth is unpredictable with or without a medical kickstart.



Looking pretty rough after 34 hours of labour and an emergency C section - but hey at least I wasn't induced!


This is a good news story 

The result of all this is that women are now better able to make an informed decision, and I for one am all for that.  Of course there are still plenty of other reasons why an individual may or may not want to be induced (having been through much of the procedure I entirely sympathise with both sides). Ultimately it will always be a complex and individual decision and the last say must go to the mother. Always. But we can now remove from the decision the fear of that dreaded cascade into the operating theatre. It's simply a bunch of unpleasant anecdotes.

 This study also has implications for the recent advice that all low risk mums should be advised to give birth at home or in a midwife only unit. In these settings induction is unlikely to be available and this may actually increase the number of caesareans. As I've written before we need to ensure that all birth places provide a good level of care. Women shouldn't be scared to have an induction because it means they'll loose the better standard of care often available in midwife units or at home births.

The NCT and others in a similar position of authority now need to get this message out there. Much is made about the problems of fear in childbirth and here is one less thing to be afraid of so let's shout that from the hills. Or at least on the NCT website!

SB
* For what it's worth I was so very desperate to get MissE out that I wasted a not inconsiderable sum on an acupuncture session in the hope of starting labour. I knew, really, that it wouldn't work but I wanted to do something, anything to avoid that induction. Oh and no, it didn't work and yes I am embarrassed I even tried.


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