I was nearly one of those induction statistics

ISSN 2516-5852 (Online)

AIMS Journal, 2023, Vol 35, No 4

Editor’s note: While Jo remembers her ‘nearly induction’ experience with fortitude and pragmatism - I love the way that she went shopping while she was waiting - her story is increasingly common and does not always end happily. It is a story that describes a sequence of events that not uncommonly leaves women feeling depressed, anxious and even traumatised by the mismatch between the sense of urgency that led to them agreeing to the (often unwanted) induction and the quality and timeliness of the care received (or not received) once that agreement was secured.

Colour photo of Jo Dagusten

By Jo Dagustun

Induction rate soaring. Maternity units short-staffed and unable to cope. Much talk of some inductions being unnecessary. How can we judge?

18, nearly 19 years ago, I was nearly one of those induction statistics. Would that have been an unnecessary induction? Here are my recollections and reflections. They may not be entirely accurate, but you will get the gist.

Wind back to 2005. I was pregnant, in the zone of term. Baby #2. First labour and birth straightforward, albeit 15 years previously, with a different partner.

Pool set up in the living room, ready for a go at a homebirth, to be attended by NHS midwives; maybe even a home waterbirth.

Monday: leaking amniotic fluid. Midwife came out to visit. This event took me into the PROM category. Induction advised within x hours. Was asked by the midwife to check in at my local hospital that evening, if contractions hadn’t started, to be admitted for induction.

An aside: I called a - midwife - friend. She suggested I go in. She’d had a bad outcome with a baby the previous week, I think she’d said. She was clearly nervous. (Never call a midwife?!)

No more buses, I announced, when I spoke to the midwife we spoke (on the phone?) that evening. Thinking I held a trump card.

And even if I come in, I haven’t agreed to an induction. (I’m not sure whether I spoke this sentence out loud.)

I wasn’t prepared to pay for a taxi. I didn’t see the rush. Argued the case for the following day. Midwife suggested I call 999 for transport (!) The transport argument blown away – my main defence - that’s what I did. Awkwardly. Yes, I said to the paramedic, that’s what I’ve been told to do, realising the ridiculousness of the situation as they sought to ascertain why they had been called out.

Now an inpatient. Monday night. Tuesday. Wednesday. Nothing. Nothing that resembled care, more like an adequate hotel stay. I had my own room. Probably not en suite, but I wasn’t fussed. Explored the local area a bit. Stacked up on magazines and snacks from the local Tesco Local. Chilled out. Seemed a bit silly, but what did I know?

No further offer of induction. I recall being told that they were too busy. How did the expiry of an x hour danger zone (was it 24 or 48 hours, I can’t recall) come to count for so little, I wondered?

But no problem. I was settled. I didn’t yearn for home. However, I felt that I was being treated well on the explicit staff assumption that I was yearning. I sensed that I had become ‘the disappointed home birth in room x'. Who’s going to argue with that?

I realised that I might/should be able to do something – some sort of active movement - to trigger the onset of labour, to avoid the impending induction procedure, which felt to me unnecessary. (Labour had been triggered with #1 whilst watching a comedy movie. I think this was relevant!) But the easy opportunity to keep mobile in my home environment was not available to me. No stairs. No cup of tea to make. No village walk to pass the time. (Nor the video player to put on a funny film.)

Wednesday night: a deep squat at the bedside seemed to do the trick. Contractions started. Yikes. Spontaneous onset of labour achieved. Okay, we’re ready to go …

(There’s also something to be told then about labouring on the antenatal unit; visiting restrictions; how and when partners get called back when we go into labour on the antenatal ward, but that’s another story.)

Thursday morning: a straightforward birth

Postnatal ward: why do so many babies here have broken arms, I wondered? Later to find out that what I saw was antibiotic treatment, not casts and slings … And that’s another issue, not for now.

So, some reflections, with the benefit of hindsight.

It certainly feels that I should have just stayed put at home, with guidance to check my temperature regularly and report in if I noticed an issue. The risk, as I understood it to have been, was infection with the potential of severe consequences for me or the baby, so why did my place in the induction queue involve me being put at increased risk of a hospital acquired infection?[1] I could have gone in when called.

I don’t know whether I’d have made it through labour at home, so a transfer might have been necessary in any case.

I don’t feel I will ever know whether the staff and I were taking an unacceptable risk in (as I understood it) not following the induction protocol, due to lack of capacity (rooms/ staff, I’m not sure) to deliver it.

Given the delay in induction ‘treatment’, I feel that I took up space on the antenatal ward for no benefit to anyone, but at a cost to me. The cost was in the potential for this environment to reduce my ability to sleep well, to eat well, and to mobilise well. This might have affected my chances of going into spontaneous labour, I’m not sure.

I’ve also heard talk of a difference between fore water and hind water leaks. That the amniotic sac might reseal.[2] I hope we know more now, and with that knowledge shared, more accurately understand our options.

I hope that things have changed. That I’d be encouraged to stay at home, to be trusted to take my temperature to check for infection. To call for help if needed. I now wonder: was the inpatient-located induction queue really all about the lack of trust in the service user to look out for ourselves? How hard can it be to take your temperature regularly?

I don’t know the cost of my 48 hour inpatient stay for the system.[3]

The opportunity cost[4] must be very high now, with the rates of induction having risen. I hear of new areas in some maternity hospitals now: the induction suites. All needing to be staffed and maintained, inpatients fed and ‘cared for’. We’ve got a new specialist midwife role too: the induction manager or somesuch. That all costs, and takes away from resources that could be spent elsewhere.

I wonder how many women, like me, go into spontaneous labour whilst they’re in the queue for the reason of PROM. (Why are so many labours induced nowadays? Perhaps the PROM route is a small minority?) And how many of us are induced just before a healthy straightforward spontaneous onset would have anyway occurred.

Lots of questions, but one thing I’m sure of: I could so easily have been just another induction statistic.

Author Bio: Jo Dagustun, mum of four, has been an AIMS Volunteer since 2017. Jo is a geographer and civil servant by background, and wrote a PhD on women's birth experiences (Learning to birth, mastering the social practice of birth: conceptualising women as skilful and knowledgeable agents). As well as working with others to understand and improve maternity services in the UK, Jo enjoys tutoring on The Brilliant Club's free to access Scholars Programme and spending time by the sea.

[1] Guest JF, Keating T, Gould D, Wigglesworth N. Modelling the annual NHS costs and outcomes attributable to healthcare-associated infections in England. BMJ Open. 2020 Jan 22;10(1):e033367. doi: 10.1136/bmjopen-2019-033367. PMID: 31974088; PMCID: PMC7045184.

[2] Editor’s note: A single episode of leaking fluid is sometimes attributed to a small tear higher up in the sac of membranes that has resealed. www.ncbi.nlm.nih.gov/pmc/articles/PMC7311775

It is now advised that women do NOT allow any vaginal examinations (either with a speculum or with fingers) if they know their waters have gone, because this increases the risk of infection. If it is not certain if the waters have gone, a short wait will make things clear because if they have gone, the leaking will continue - so it is still a good idea to decline even where there is uncertainty. https://wisdom.nhs.wales/health-board-guidelines/swansea-bay-maternity-file/pre-labour-spontaneous-rupture-of-membranes-at-term-management-2-swansea-bay-maternity-guideline-2021-pdf

[3] Editor’s note - at today’s prices a hospital bed is about £350 per night, www.theaccessgroup.com/en-gb/blog/hsc-virtual-wards-funding-and-costs

[4] Editor’s note: Opportunity cost refers to what you have to give up to buy what you want in terms of other goods or services. In Jo’s example, money spent on increasing rates of induction and on induction suites, cannot now be spent on providing more midwife-led units or more one-to-one care.

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