Induction of labour: better early than never?

A recent European Perinatal Health Report (December 2008), authored by Dr Miriam Gatt and Dr Neville Calleja of the Department of Health Information and Research, highlighted the fact that Malta has an apparently high rate of induced births.

“Malta reports a low rate of spontaneous onset of labour (47.6% of total births) and a high rate of  induced labour (37.9% of total births).”

According to the report, thisrate is comparable to Northern Ireland, but higher than the EU average.

Public health specialist Dr Julian Mamo said that although doctors only induce labour when there is a medical reason to do so, he agreed that we have higher rates of induced birth than our European counterparts.

“As there is no apparent reason for the higher rates of intervention, it is something merits further research.,” he said.

By way of contrast, Dr Mamo pointed towards our very low rates of infant mortality – much lower than those of African countries as well as Eastern Europe.

Our infant mortality rates are comparable to other European countries, but the rate of intervention seem to be much higher.

There is broad disagreement on why the rate of intervention is so high, with the Malta Union of Midwives and Nurses blaming the trend squarely on obstetric paediatricians.

President of the College of Obstetrics and Gynaecology, Professor Mark Brincat, has denied allegations that doctors are unnecessarily inducing labour, saying that the MUMN has launched on a media campaign that was not initiated by the patients.

“If a patient satisfaction survey was carried out the results would show that the services offered at Mater Dei Hospital are second to none. It is noteworthy that the well-being of the mother and their babies has steadily improved and ranks one of the best in Europe.”

The MUMN threatened industrial action last week if the Health Division did not intervene in the unnecessary inductions being carried out at Mater Dei Hospital, which at times was as high as 15 scheduled inductions in one day and did not account for emergencies. The MUMN claimed that this was putting unnecessary pressure on doctors, midwives and nurses who were delivering babies in rooms not designated to be delivery suites putting both the mother and baby at risk.

Why induce labour?

Although most labour occurs naturally in some instances it is medically advised for a mother-to-be to give nature a helping hand and to be artificially induced.

An expecting mother may induced for a number of reasons. The most common reason for a woman to be induced is if natural labour does not occur past 41 weeks of pregnancy.

Research has shown that extending pregnancy beyond 42 weeks increases the chances of stillbirth and early neonatal death. In the UK perinatal mortality rate (which includes stillbirths and early neonatal death) doubles after week 42 and trebles after week 43. The underlying problem is that the placenta starts to show signs of ageing after 42 weeks and stops working as well as it used to, slowing the passage of nutrients from mother to foetus. 

Another reason for inducing labour is if the waters have broken, yet labour has not started. Although women usually go into labour within 24 hours, if this does not occur there is an inherent risk that the baby will contract a bacterial infection.

Women suffering from diabetes, heart disease and bleeding during pregnancy and other complications such as hypertension and preeclampsia, which causes high blood pressure, headaches and severe fluid retention will have an induction scheduled so that the mother can receive treatment as soon as they baby is born.

A doctor may also decide to induce labour if the baby is in any form of distress, not receiving sufficient oxygen or nutrients if the pregnancy is close to term.

Induced labour leads to higher risk of emergency Caesarean delivery for a number of reasons. If the baby does not progress through the birth canal, then the baby will be delivered by c-section. If the cervix was not ripe enough when labour was induced then labour will not progress well enough for a natural birth. Long labour resulting from lack of progress if labour is induced too early may cause distress to the baby, which will then have to be delivered by Caesarean.

How does induction occur?

A number of options are available to induce labour. Some women respond relatively quickly to being induced while others may need to have the procedure repeated for a number of days before labour begins.

Normal methods of induction involve synthetic hormones that will encourage the onset of labour.

Prostaglandin is a hormone like substance that helps stimulate uterine contractions by ripening the cervix.

Oxytocin can be administered through an intravenous drip allowing the hormone to go straight to the bloodstream. Once contractions have begun the rate of the drip can be adjusted so that the contractions occur often enough to make the cervix dilate without becoming too powerful.

Other methods of induction include a membrane sweep, which separates the membranes surrounding the baby from the cervix. Artificially rupturing the membranes or “breaking the waters” is no longer a recommended method of induction unless prostaglandins could not be used, as infection may occur. The procedure involves causing a small break in the membranes, which is successful in inducing labour when the cervix is soft enough for labour to begin.