INDUCTION OF LABOR: KICK OUT THE MYTHS

Every time I mention to my patient that she may require induction of labor, the suggestion is met with a lot of resistance. Such was the case with my patient Nasra*. Nasra was carrying her third baby. She had two little girls aged seven and four and the whole family was excited that they were going to add a boy this time round.

Nasra is a lovely lady, very friendly, inquisitive and eager to learn. She has a strong background in finance, and despite coming from a cultural background that does not encourage women in education, holds a masters level degree in finance and administration. She runs a successful company together with her husband and she comfortably fits into the category of a modern elite mom.

However, when she visited the clinic at 40 weeks gestation, after her check-up and assurance that all was well with the baby, I opened the discussion on possible induction of labor, at which point she balked! She completely refused to hear it. Having seen many women have a similar reaction, I took my time to dispel popular myths about induction of labor to help her calm down but she would have none of that.

She adamantly said that she would wait for labor to begin naturally. We agreed to see her again in a week’s time and she was fine with that. At the next appointment, all was well but we did need to fix a date for induction. After an hour of further explanations as to why it was necessary to induce labor, she agreed to come to the hospital three days later for admission and induction.

On the material day, by 7.00p.m., she had not reported and I made a mental note to talk to her the next morning. The phone call came at 2.00a.m., Nasra was in the wards, in labor but also with bad diarrhea. She was begging the midwives to do something to stop the diarrhea. We made her comfortable, started her on intravenous fluids and continued with monitoring of labor. The diarrhea was already subsiding on its own, and the little one was doing great. Five hours later, Nasra held her newborn son in her arms amidst tears of joy and relief.

Apparently, despite all the information given to Nasra, the old wives tales at home from her female relatives were more convincing. She opted to disregard her options and chose to try non-scientific methods whose effectiveness remains unproven such as  walking about a lot, having sex, rubbing her nipples and when all else failed, she resorted to good old castor oil. Castor oil in return led to intractable diarrhea and eventua labor. Now that the worst was over, Nasra was able to make great fun of herself and she swore to never again self-medicate at home. She chided herself for opting for the longer, uncomfortable route to achieving the same results and to date, is a strong advocate for clinical induction of labor.

Nasra’s biggest fear was pain. She had been told that induction of labor was much more painful than natural onset labor. She was avoiding this all along. Unfortunately, this misconception holds true for most women in Kenya. However, continued conversations reveal that most women do not know the difference between induction of labor and augmentation of labor.

Onset of labor is a process that is still quite mysterious despite several theories being fronted. The trigger for natural onset of labor is still poorly understood. However, the role of prostaglandins on ripening the cervix and triggering labor is clear. This has allowed us to have safe, effective and affordable methods of induction of labor. Before the advent of prostaglandins, the use of mechanical methods to open the cervix were commonly used, such as use of catheters placed in the cervix and inflated to stretch it open and trigger labor in the process.

Augmentation of labor on the other hand, requires labor to have already set in. This is irrespective of whether that labor set in naturally or was induced. The dreaded ‘drip’, as the oxytocin infusion is commonly referred to by mothers, is administered to mothers who are in labor but their contractions are not strong enough to ensure labor progresses at the desired pace. It is used to avoid prolonged labor that is both detrimental to the mother and the unborn baby. As the contractions gain strength and increase in frequency, it is expected that the pains will be more intense, hence the belief that the ‘drip’ is painful.

It is important to destigmatize the process of induction. Medically, once the mother is admitted for induction and all the necessary reviews have been done to assure us of the safety of the baby and the mother and their capacity to handle labor, the prostaglandin, in form of a vaginal pessary, is inserted high up in the vagina and the mother is allowed to rest and await the labor pains. Depending on the type of pessary used, repeat insertions may be done every twelve hours for the long-acting one, or every six hours for the short-acting ones. The general rule is that within 24 hours, labor should have commenced.

Once labor commences, it will proceed just like a natural onset labor. Therefore, the strength of contractions will determine whether augmentation is needed or not. It is also critical to note that just because labor was induced does not guarantee a vaginal birth. Complications may arise that may necessitate a caesarian section. The induction process itself may also fail, leaving us with the option of a caesarian section.

Reasons for induction of labor vary but the commonest is due to post-datism. This is when the baby goes beyond the expected date of delivery. Usually a grace period of a week to maximum two weeks will be allowed, depending on the doctor and the hospital protocols. Other reasons include compromised well-being of the baby or mother and breaking of waters (rupture of membranes) before onset of labor in a term pregnancy. The goal for all of us remains a healthy baby and a healthy mother!