What we need to know about the physiological onset of labour and the option of induction: three books to inform and inspire

Complete list of book reviews on the AIMS website

AIMS Journal, 2021, Vol 34, No 1

Reviewed for AIMS by Gail Werkmeister

Originally I worked as a research scientist, ironically in obstetrics, then I became an NCT antenatal educator and I have worked with parents and students for over 30 years. I have been a representative of the ‘users’ of the maternity services on labour ward forums, Maternity Service Liaison Committees (MSLCs) and national guideline groups. I agreed to write these reviews because I am genuinely shocked to meet an ever increasing number of healthy ‘low risk’ pregnant women who are suddenly, in the last few weeks of their pregnancy, facing induction and who feel overwhelmed and disempowered by decisions that they often feel are being made for them.

In my experience as an antenatal practitioner, I see these pregnant women planning for straightforward births and then being induced, often at 38 weeks. This early term induction may well result in long labour with a ‘cascade’ of interventions including assisted birth and caesarean birth. I have witnessed the longer term effects of this on the mental health of these women and their birth partners, such as postnatal depression and birth trauma. From reading the three books below and talking with my peers, I know I am not alone in this observation.

Here I must emphasise that I, along with the authors below, recognise that induction of labour can be vital for the safety, health and wellbeing of a pregnant woman and her baby. I know that the experience of induction, as with any birth intervention, can also be positive and empowering if the pregnant woman feels she has been well supported and has played an active part in the decision-making process.

All three books provide a massive amount of both evidence-based and practical information. They also contain wisdom and advice on making decisions that are relevant to each woman in her own specific situation. They show that the use of generalised guidelines and protocols, applied to all women, does not result in good care because all women and babies are different and should be treated on an individual basis. The authors suggest women need ‘personalised care’, ‘woman-centred care’, ‘continuity of care’ and I agree. Each book is written in a unique style which will appeal to different readers and they are aimed not only at pregnant women and their supporters but to all healthcare professionals involved in their births.

‘The AIMS Guide to Induction of Labour’ Principal Author: Dr Nadia Higson AIMS 2020 ISBN-13 ‏ : ‎ 978-1874413493 218 pages £8 Buy this book here

Principal author Nadia Higson is a scientist and educator. I feel that she brings her knowledge and skills particularly as an antenatal educator (with the insight this gives her), to plan the layout of the book with a clear and practical structure. The research base is impressive and the layout is visually pleasing too with simple and clear diagrams and graphs when they are helpful. This is not necessarily meant to be a book you would read from start to finish, but a handbook that a pregnant person, supporter or educator might dip into to find the information most relevant to them at that moment in time.

Higson begins with a very clear and informative chapter on generic guidelines and what is meant by evidence-based information (including its limitations), and on how to have discussions with doctors and midwives to make informed decisions. Here she aims to enable pregnant women to gain confidence in their right to decide how they birth their babies and suggests the questions they may need to ask to achieve this aim.

This is followed by a chapter on the reasons induction might be offered. Each topic subsection explores in depth the evidence for the given reason for induction, for example ‘Length of pregnancy’ it is then followed by a short ‘Summary’ of that evidence and then a section titled ‘Things to consider’ which suggests questions a woman might ask herself about her own feelings and instincts. Also, what she might want to explore with doctors and midwives, and how she feels about the risks and benefits for herself and her situation.

The third chapter covers in detail the stages in the induction process, encouraging women to consider all possibilities. A subsection ‘What may help an induction to work?’ describes ways to make the process more successful and empowering. There is a visually helpful flow chart of the process showing decision points where a woman and her birth supporters could assess how she is feeling before moving on to the next step or not!

In addition this handbook has the thoughtful inclusion of a glossary, which I am sure will be a useful jargon buster for many.

‘Why Induction Matters’ Author: Dr Rachel Reed Cover illustration: Sam Kalda Pinter & Martin 2018 ISBN-13 ‏ : ‎ 978-1780666006 176 pages RRP: £8.99 Buy this book on Amazon

Rachel Reed is a midwife, academic, writer, blogger and presenter who has worked in the UK and is now based in Australia. In her PhD she explored women’s experiences of birth and midwifery practice during birth. She states that it’s not necessarily the type of birth a woman has but the sense of empowerment from it that matters. A woman in labour needs to feel that her decisions and wishes have been respected, she needs ‘woman-centred’ care.

I was impressed by Reed’s first chapter which gave an insightful analysis about how decisions are made. This included the roles and responsibilities of healthcare professionals to give unbiased information, and the writing and uptake of NICE and other clinical guidelines. She notes that these guidelines can include ‘expert consensus’ (of the guideline group) where evidence is not conclusive or is of poor quality.

Reed explains that decision-making isn’t simply about looking at the statistics but how our own personal beliefs, cultural norms and intuition all play their part. This chapter culminates in a guided ‘Decision-making framework’. This consists of pertinent questions applied to the individual, which, when answered, align with the BRAIN, B (benefits) R (risks) A (alternatives) I(intuition) N (now/nothing) acronym decision-making tool.

In my opinion, a definite strength of this book is that Reed shares, as another form of ‘lived’ evidence, several women’s very different experiences of induction, weaving their accounts effectively throughout her narrative. I know from my own experiences as an antenatal educator that birth stories are very powerful and can influence women’s decisions and help them to feel more confident in their own bodies when approaching the birth of their babies.

The following chapters of her book are fascinating and focus in great detail on the complications of pregnancy such as pre-existing and gestational diabetes. Another focuses on the variations of pregnancy such as pregnancy length and advanced maternal age. The pros and cons of induction of labour in these scenarios is forensically examined. Although mostly to dip into, the information in these chapters will be incredibly useful for women who want to have detailed knowledge of their condition.

As in the AIMS book, this is followed by chapters on the mechanisms of spontaneous labour compared to medical induction. There is also a comparatively well-researched overview of the effectiveness of alternative and complementary methods of induction which I know many pregnant women would be interested in reading.

The book ends on a positive note with a framework for creating a birth plan to maximise a positive experience both for the woman and her baby. Reed states her wish that ‘every woman regardless of how she gives birth, steps into motherhood feeling strong and empowered, knowing that she is the expert when it comes to her body and her baby’.

‘In Your Own Time’ Author: Dr Sara Wickham Cover design: Sam Aalam ‎Birthmoon Creations 2021 ISBN-13 ‏ : ‎ 978-1914465024 203 pages RRP: £10 Buy this book on Amazon

Sara Wickham is a well-known and respected authority on birth matters. She is a midwife, author, blogger, speaker and researcher who thinks ‘out of the box’. Her book is ‘for anyone questioning the value of routine induction or concerned about rising induction rates’. It is a passionate criticism of the current status quo in UK maternity services with an induction rate around 34% of all births. This represents a peak in the medicalisation of childbirth that in real terms means one in three pregnant women are being induced.

Unlike the other two books, Wickham does not describe the induction process in detail or the pros and cons of this intervention, but she looks at the bigger picture. She draws a narrative arc stretching from the history of the ‘due date’, tracing the first documented length of pregnancy to Aristotle in Roman times, when women counted the length of pregnancy and birth in ten lunar months, up to our current practice of estimating due dates using ultrasound.

She suggests that the evidence shows that ‘normality’ is a range of a month and that the due date as calculated by Naegele’s rule is approximately in the middle of it. However, referring to induction after their due date ‘Women do not turn into pumpkins overnight’. She discusses the advantages to both mother and baby of ‘the waiting days’. Briefly, she argues that babies are born when they are physiologically ready and, if forced to be born before this point, there are disadvantages and possible long term repercussions. She states that there is a span of several weeks during which, at some point, each individual baby will attain optimal physiological readiness and, as midwives have long thought, it’s not useful to have a fixed point due date.

This being the latest of the three books, there is an excellent chapter on the new NICE Guideline Inducing Labour 2021. Wickham has several concerns about this guidance, for example the recommendation to discuss induction and caesarean birth with women in early pregnancy. This could undermine women’s confidence in their body’s ability to give birth spontaneously. She is also concerned about moving a suggested cervical sweep from 40 to 39 weeks and suggesting induction at 41 weeks as opposed to 41-42 weeks in the 2008 guideline.

Why does this all matter? Wickham makes the point throughout her book that there are medium and long term effects of induction on the health of mothers and babies. We know that induction can often lead to a ‘cascade of intervention’ and the concomitant risks attached to these further interventions might outweigh the often relatively small but very serious risk of stillbirth that the induction is meant to prevent. Pregnant women must have all the pros and cons to weigh up their decisions.

This is a powerful book. Wickam states that there are no simple answers to high induction rates because ‘it’s complicated’. However she does have some suggestions, such as working together to change the culture and conversation around pregnancy and birth. This book is aimed at everyone involved in maternity services: doctors, midwives, educators, pregnant people and their birth supporters. We all need to keep learning, questioning, and most of all listening to women, while, as Wickham writes, “...not forgetting to look up at the moon now and again, just as our ancestors might have done, and wonder at the miracle that is birth and the fact that, in most cases, if we leave well alone, it happens at the right time.”

Author Bio: Gail Werkmeister is an NCT Senior Antenatal Practitioner and Assessor, and a past President of the NCT (2005-2010)