The 'active management of labour' was originally intended to ensure that birth happened within a specific time span. As such, it served organizational and management priorities rather than the interests of women.
There is in fact no clinical evidence to support any general benefits from a shorter labour (as demonstrated by the research of Enkin et al, 1995). Whilst some women would like their baby to be born within a specified time, the benefits of accelerating labour are outweighted by the pain of artificially induced stronger contractions and the likelihood of further intervention.
A cascade of intervention
So before you start on the path of induction you need to ask yourself if it is really critical to this pregnancy. There are some circumstances where induction is indicated, and these will be defined by a careful clinical assessment. The adverse effect of the injudicious use of induction is the possible triggering of the so called "domino" or "snowballing" phenomenon of increased intervention, which could end in emergency caesarean section if induction fails.
The decision to induce commits you to a delivery within a given timeframe. Therefore the benefits must clearly outweigh the risks. You must be prepared to take responsibility for any potential outcome of your clinical assessment - that's how strong the decision needs to be!
But you also need to communicate with the woman and her family, involving them fully in the decision-making process, and making them aware of the possible consequences of any recommended clinical actions.
One bad experience
It may be that the adverse outcome of one particular pregnancy has affected everyone's practice. Fear can be a powerful factor in determining attitudes, and a single atypical incident can create fears that are disproportionate to the real clinical risks.
Instead of just accepting this kind of defensive approach as 'best practice', consider the iatrogenic consequences that it may create. A failed induction, resulting in a caesarean section, is often overlooked and it does not trigger the same response.
Tips and tricks
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Next time you book an induction, ask who wants it - is it you, the woman, the doctor, the baby or the organisational time table? Does your service have guidelines for induction of labour and has the woman had an opportunity to discuss these in pregnancy? Are they based on the NICE guideline for induction of labour or are they different? The user version of the NICE induction of labour guideline can be useful to the woman and her family and aid your discussions around these issues.
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Check the clinical indicators - do they really justify induction at this point, or are there other alternatives that may result in a better outcome for the woman and baby?
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Find out her personal and family history of pregnancies - how long were they? If they have been later and/or longer, it is likely that this one will be too. It is not unusal to find a longer gestational period pattern in some families. And how accurate can you be that this pregnancy is 41-42 weeks? The magic figure of 42 weeks often raises anxieties in maternity departments and encourages defensive practice.
Further reading
Crowley P (2003) Interventions for preventing or improving the outcome of delivery at or beyond term
Cochrane Review, The Cochrame Library, Issue 3, Update Software, Oxford
Downe S, McCormick C, Beech BL (2001) Labour interventions associated with normal birth
British Journal of Midwifery 9 (10): 602-606
Sarkar PK (1997) Anxiety in women who go postdates
Contemporary Review in Obstetrics & Gynaecology 9 (2): 107-111
Royal College of Obstetrics and Gynaecology (2001)
The National Institute for Clinical Excellence, the Inherited Clinical Guideline D; Induction of Labour. RCOG, London
