| | Women's experiences of being induced for post-date pregnancyReceived 17 October 2007; received in revised form 22 June 2009; accepted 23 June 2009. Summary AimTo explore the women's experiences of being booked for induction of labour for a pregnancy greater than 41 weeks gestation. Participants23 primigravidae who were booked for induction: 18 were induced (induction group) and 5 went into spontaneous labour (comparison group). MethodData were collected by a series of interviews from booking to after birthing: interpretative techniques analysed verbatim transcriptions. FindingsTwo dimensions of being in the process of induction were identified: (1) a sense of “Time's Up,” when the natural, temporal aspects of pregnancy end with an imposed birth date and sequenced induction procedures and, (2) a required “Shift in Expectations” from the women's original plan for labour and birth. The women varied in their responses from welcoming the end of pregnancy to feeling that their body or their baby was not ready for birth. A lack of meaningful information regarding the process of induction was also identified. The comparison group focused their worry on the impact of induction on the baby whereas the induction group expressed concern about the effect on themselves and loss of a natural birth. Worries in both groups were dissipated by successfully birthing a healthy baby. Implications and outcomesThe findings sensitise midwives to women's possible responses to being booked for induction. Antenatal educators can use this knowledge to prepare women and their partners for required shifts in their birthing plan when induction is deemed necessary. Midwives can help women adapt their birth plans during the induction process. “It is true of induction of labour as it is of the antenatal procedures … that being at the receiving end of this obstetric innovation is a neglected research topic”.1 Post-date pregnancy (described as 40 or more weeks) is the most common reason for induction of labour.2 Defining pregnancies that go “overdue” is not precise. A post-date pregnancy is defined as continuing past the expected date of confinement (EDC) whereas a prolonged pregnancy is one exceeding 42 weeks gestation.3 The interchangeable use of these two definitions often confound the meaning of these terms and impact on the accuracy of determining best practice.4 Current best practice, within the Area Health Service where this study took place, is to set a date for induction of labour for women whose pregnancies exceed 41 weeks gestation (post-date pregnancies).5, 6 While the research literature7 debates expectant management versus elective induction, numerous systematic reviews all conclude that perinatal risks increase after 42 weeks, especially for the baby and that induction at 41–42 weeks reduces the incidence of stillbirth and caesarean delivery rates without increasing adverse outcomes.8, 9, 10, 11 Since the early 1990s the induction rate has been steadily increasing in most western countries. In New South Wales, Australia the rate of induction has risen from 17.9% in 1990 to 24.7% in 2006.12, 2 Post-date pregnancy is the most common reason for induction. This study was motivated by two factors. In the study hospital, women are admitted the day before a booked induction and begin the process of cervical ripening with prostaglandin gel to facilitate artificial rupture of the membranes the next morning. In some women, prostaglandin is all that is required to initiate and maintain labour. For most women, the prostaglandin gel is followed by a Syntocinon infusion to stimulate contractions. The midwives caring for these women observed difficult pre-labours, often occurring at night, leaving the women sleep deprived when active labour began. A review of the literature provided little evidence upon which to propose changes to this protocol.10, 11, 12, 13 Secondly, Oakley's 1986 1 statement remains as true today as it was 23 years ago; there are few studies which include women's experiences of induction. Induction research in both medicine and midwifery focuses on methods and management of induction of labour.10, 11, 14 One Canadian study of women who had booked to birth with midwives found the women did not perceive a longer pregnancy to be a medical problem but rather a worry to others and an inconvenience to themselves and took it upon themselves to try to induce labour in any way they could.15 Shetty et al.16 reported lower birth satisfaction with induction whereas a Finnish medical study17 observed women had mainly positive feelings about the induction experience. Davies18 found that women needed more information about induction and more involvement in decisions about the timing of induction. The aim of this study was to gain an understanding of primigravid women's experiences of having labour induced with Prostaglandin for pregnancies exceeding 41 weeks. Setting: The study hospital is a tertiary referral centre with antenatal care provided in midwives’ and doctors’ public clinics, team midwifery and a free-standing Birth Centre. The hospital database shows the majority of the 20% of women who are induced are primigravidae with a post-date pregnancy. Induction of labour is explained to women in their 40th week of pregnancy and they are booked for induction unless they ask for expectant management. An agreed date is set for admission usually within the 41st week of gestation. Ethical approval was obtained from both the Area Health Service and university ethics committees. Participants: Healthy primigravidae with a cephalic presentation of a single fetus were invited into the study when they were booked for induction for a post-date pregnancy. Women who consented and were admitted for induction with no signs of labour formed the Induction Group (n =18). Those who went into labour spontaneously after being booked for an induction formed a comparison group (n=5). The sample size was based on obtaining saturation of the data. Table 1 indicates the original model of care from which the women were recruited in public clinics. | | |  | Group | Midwives clinic | Team midwifery | Birth Centre | Doctors clinic | |
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| Induction | 2 | 2 | 7 | 7 | | | Comparison group | 1 | 1 | 0 | 3 | | | | |
Method: An exploratory study was used to gain an understanding of the women's experiences. Tape-recorded interviews were conducted using an interview guide (Fig. 1) with focused questions that invited women to describe their experiences. All women were interviewed when booked for induction and again 24–48h after giving birth. Those in the induction group were also interviewed within 30min to 2h following insertion of the first dose of prostaglandin. A chart audit recorded information such as the woman's age, gestation at induction, induction process, timing and reason/s for transfer to the Delivery Suite, factors related to labour and delivery, Apgar scores of the infant and any postpartum complications. Data analysis: The interviews were transcribed verbatim, and wide margins were left on each page. Every member of the research team read the transcriptions independently identifying reactions and concerns expressed by the women. In meetings, the research team listened to each tape-recorded interview and compared notes, and where discrepancies were found, the interview was reviewed and further discussion took place. Similarities and differences within and between the induction group and comparison group were identified and exemplars selected. As the analysis progressed, the exemplars were arranged into groups expressing similar aspects of the experience and eventually key dimensions of the women's experience emerged. Findings  Using the study hospital's database, a comparison with the annual hospital population of women who were induced for a post-date pregnancy showed the study sample was similar in maternal age and gestational age at delivery. Table 2 compares the induction and comparison group. Interestingly, the induction group has a higher incidence of mothers and sisters who had experienced induction. | | | | Group | Maternal age (years) | Mother induced | Sister induced | Mean gestation (days) age at birth | |
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| Induction | 32 (20–43) | 50% | 22% | 292 | | | Comparison | 35 (32–39) | 20% | 20% | 289 | | | | |
Two dimensions in women's experience of induction for post-date pregnancy were revealed during the interpretive analysis. The first is a sense of time's up, when an induction is booked and the woman becomes situated in a prescriptive sequence of timed procedures and expected outcomes. The second dimension is a “shift in expectations” from the original plan for the labour and birth experience. Women differed in their willingness or ability to make this shift. These dimensions are presented with exemplars. Women's names are pseudonyms with (I) or (C) indicating the induction or comparison group. Booked for induction “Time's Up!” All women described the induction as being imposed externally, with hospital policy defining when time was up. They understood they had a limited time left for the natural onset of labour. Jane (C) said, “I understand that I am overdue and that hospital policy is not to let a women go over 14 days without some kind of induction,” and Lara (I) declared, “I feel like I was on someone else's clock.” Poppy (C) and Valerie (C) felt congruent with the time's up policy. They agreed that their time of being pregnant was up and were pleased with the plan for induction as describe: I am just relieved that something is going to happen to be honest because I have been waiting and waiting and it is time basically. It's time for the baby to be born. I just want to meet the baby now. However, Jess (I) discovered that induction was not encouraged before time was up as: I went to the midwife the week I was due. I have decided that I’d like to be induced the very next week and they said, “Oh, No! We don’t induce you before 10 days.” My blood pressure went up that day. I just want to have the baby, so induction was the way to the baby. Understanding the reason for time's up: The women varied in their understanding of the reason they were being booked for induction. Jane's (C) and Mary's (I) understanding was that time was up due to changes in placental function: I think the placenta has sort of a bit of a used by date so it becomes not so productive so after a certain period of time, hmm, induction takes place. I understand that if the baby goes too far overdue, the placenta doesn’t work as well and there's a greater chance of stillbirth and it increases as time goes on. Others like Lisa (I) thought their body was the reason: It means to me that my body is not ready to push the baby out so it's just the way of helping my baby out in a time frame that's known to be good. The women in the comparison group accepted the imposed time frame when induction was discussed with them at 40 weeks. They were ready to give birth. Jane (C) expressed excitement with, “I’m very excited to get it out so any help to push it on the way would help.” Poppy (C) focused on the outcome, “I just want to be with my baby, that's all.” By contrast, Erica (I) described induction as, “the baby is being kicked out.” Understanding of timed procedures: Women identified that there was a sequential set of steps, and each next step would be implemented if the desired outcome was not achieved within a set time frame. Nicole (I) and Maria (C) described their tentative understanding of the procedures to be experienced: It appears that there are a number of different steps and if one doesn’t work then it automatically rolls to the next. I understand there's something put on your cervix first, like a gel or whatever, then, that's put on once or twice – then the waters are broken – and then – that's as much as I listened (laughing). Shifting expectations The second dimension of the experience of being booked for induction was a required “shift in expectations” from the women's original plan for labour and birth. Descriptions of shifting expectations for 18 (78%) of the women were similar to those of Erica (I) and Jess (I): I visualised all through my pregnancy that I will have my pre-labour at home that I would go into labour spontaneously. I prepared myself emotionally for that, so it was quite confronting to realise that time had run out. I would be induced. It meant quite a shift in my expectations. It is a pride, going into labour. My expectations are all changed. A couple of months ago there it was all going to be a natural birth and I will be in the bath - all wonderful, now it's all getting a bit clinical and a bit medicalised. Lara (I) and Mary (I) described their shifting feelings with, “I am having an induction as opposed to having a baby,” and “It just seems wrong without being wrong.” Alex (I) described surrendering to the need to shift her expectations: We are sort of surrendered to the whole thing anyway and open to whatever has to be and not really given much choice any more, so we have to do whatever has to be done. Lack of information and preparation: The women identified a lack of meaningful information given to them when induction was planned. Nicole (I) explains how details needed for shifting expectations were absent from the information received from health care professionals during the booking: It wasn’t clear to me that at the time that they did the prostaglandin that I will be staying in the hospital from that time on and I don’t have any idea whether or not there is a fetal monitor on me or on the baby and how restricted I’ll be. Jess (I) knew there was a drug involved but did not know whether it was taken orally or put in the vagina. She was unsure how the gel worked, what would happen after the first dose; whether she would need more or how long it would take to “work”. Fear of increased interventions: Shifting expectations included believing that induction led to more interventions. Lyndall (I) expressed a common concern: The perception is there that the more medical intervention you have at the start the more likely it is to escalate into something. Fear of the prospect of “the drip”, or “breaking the waters” was the most frightening aspect for 12 (52%) of the women. However, having labour initiated with the prostaglandin gel was within their definition of natural birth. It was the “drip” that crossed the line to an unnatural intervention for 17 (73%) as stated by Mary (I) and Lyndall (I): I always looked at birth as like a natural thing. I don’t like the thought of anything interfering with giving birth. It just scares me being touched or probed having to bring it on. I would rather it just go by itself. It's a very scary thought that I have to be put on a drip and the drugs they give even though they are not harmful. It's difficult to suddenly switch your mindset from thinking ‘I’ll just breathe’ to suddenly “just get this in your arm.” If you’re a healthy person and you’re not used to needles and hospitals and you’re going to the Birth Centre where it's all nice and calm, suddenly you’ve got these wires. It's daunting! All 5 women in the comparison group maintained hope that they might go into labour spontaneously, as they eventually did. For these women there was no surrendering to an inevitable induction but they remained cautious. For instance Poppy (C) described her hope for a “natural labour” with acknowledgement that expectations would shift if necessary: I am a bit disappointed that I have to be induced. I would rather go into natural labour. I am just hoping something will happen otherwise. I will stay positive. Nevertheless, at the end of the day, I am going to have a baby and that is the main point and that's how I am looking at it right now. Focus of concerns: Only 2 of the 18 women who went on to be induced articulated a concern for the baby's welfare as being part of their shifting expectations when booked for induction. Erica (I) emphatically stated, “I hate that I have to be induced. I really feel helpless; it seems the baby is really helpless.” For the 16 others, their focus was more on themselves with lost expectations for natural labour, their failed body and worry about increased interventions as Mary (I) typically stated: “You kind of think that there is something wrong with your body and you’re holding something back.” In contrast, all five women in the comparison group expressed deep concern for the baby as a partner in the experience. Jane (C) whispered, “I hope it (the baby) is okay because when something's forced out there is just a little bit of concern” and Fiona (C) said, “I feel very emotional and teary and can’t wait to meet the little fellow. As long as the baby is healthy and gets through it I will be fine.” Between booking and birth/induction During the week after being booked for induction the women searched for information to assist them in shifting expectations and used self-induction methods to avoid induction. Search for information: The lack of information motivated the women to search and ask others during the week following the booking for induction. Table 3 shows the sources of information these women accessed. The major source of information was caregivers (health professionals), followed by family members who themselves had experienced induction. Self-Induction methods: Table 4 indicates the various methods women in both groups used to try to start labour in the week before the induction date. Both the comparison and the induction group made some attempt to initiate labour. Of note, only some in the induction group used castor oil and acupuncture. Valerie (C) and Karen (I) described their efforts at self-induction: I am very into natural delivery but I have said all through my pregnancy, whatever it takes to have the baby is what I will do but it has been turmoil. I went to everything I could think of to try and avoid an induction. I still hope things will kick in and deliver naturally. Even in the last acupuncture session- I just had a very gruelling session with the homeopath and was feeling very vulnerable like what I am doing here - and then I went on to my acupuncture and I had this amazing really empowering acupuncture where I just felt so strong and I was ready. Anita (I), whose first language was Spanish, continued to describe her very intense response to being induced and how she had tried to get herself into labour: I was very sad, very depressed, and very angry – angry with the baby as well and I feel guilty for that because I feel frustrated, everything is fine, he is engaged. I was drinking raspberry leaf tea, I was doing exercise and I keep moving. Everything is fine to have him. He is taking more time! Why? During the induction Once the women started the process of induction, a sequential set of steps in the procedure continued to be experienced similarly as “time's up”. As well, the women's expectations continued to shift. “Time's Up” When induction started the women continued to express their experiences as a feeling of time being up. For instance Lara expressed both anxiety and surrender: I am sort of resigned. Last night I felt like I was standing at the edge of a cliff and I was about to jump off when I knew that the end result would be good but it's kind of you know, you do have that feeling you are being on a precipice. In addition the women tended to predict a time frame for themselves that was not necessarily congruent with the time frame of the induction protocol used at the hospital. Jean said: I am hoping that just this little amount they have given me is going to be enough to push me on a bit long. I don’t think I will go as long as 12 hrs. I know my body quite well but I know you can’t say that. I am expecting to go into labour about tonight; I don’t think it will be as late as tomorrow. Anita continued to have an intense hope that her baby would come when he was ready, not via induced labour, saying emotionally: I prolonged this induction for today. The doctor suggested for Wed. I feel, NO! I can wait more. Maybe the baby is not ready. I can give him more time. The time was to have the hope that he will do something and he didn’t do anything! The women experienced the induction protocol as dominating the activity and time sequence when birthing their baby. One woman had asked to speak with her obstetrician after the vaginal exam to discuss a way of avoiding the induction. The midwife who did the Bishop's score for this woman said the cervix needed to ripen some more to which Jess responded with, “I guess that means I need to have the Prostaglandin” and reported: The midwife said, ‘Oh, it's already in’. I guess it implies consent that I have checked into the hospital. For her, that Prostaglandin has been so long out of the fridge but you know, my child and my feelings about labour are more important and she could just take another one out! Women found the arrangement of the hospital units forced them to move location as their labour progressed. When their time was up in one setting they were taken to another. Lyndall, Mary and Jess provided vivid descriptions of their experience of imposed changes to their care environment during induced labour: They (antenatal ward staff) came in and said your waters are broken; you’re going down to Delivery Suite. And then the midwife literally picked my bags up. We didn’t even get to finish our toast! It was obvious we were working to somebody else's timetable! So I went up stairs and down stairs and I don’t know which way I went. I went to Delivery Suite and they [contractions] got much worse from there rather quickly. So they took me down to the next level … they offered me a wheelchair … it was a lot less painful to walk … they put me into - I think it must be Delivery Suite. I can’t remember where it was. Timed sequencing was the dominating experience of these women during the induction. Shifting expectations Shortly after the initiation of the induction, there was evidence that the women were still re-formulating their thoughts and ideas about induction and how it limited options for their birth: Mary said: I am looking forward to it but I am scared at the same time. There is nothing much I can do about it but to go with the flow. Difficulty in shifting expectations was related to a continuing lack of meaningful information. Within the first 2h of the induction, Olivia explains: I have been going to the Birth Centre and have a clear idea of what happens there. I don’t really have an idea of what happens if we go to Delivery Suite. Does our support person come? I don’t know how it works. I think what was explained to me was if you need Syntocinon you will be transferred to the Delivery Suite. Beyond that, no discussion of how labour progresses there, what you can have and you can’t have. The women knew that if there were complications with the labour they would have to move from the birthing centre but there was no understanding of the details, and who would be allowed to go with them. After birthing Table 5 shows that both the induced and comparison groups had a range of labour and birth experiences, including one caesarean birth in the comparison group. More female infants were born to the induction group. | | | | Group N= 23 | NVD | Assisted V/D | Caesarean | Infant gender | NICU admission | |
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| | | | | F | M | | |
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| Induction | 8 (45%) | 4 (22%) | 6 (33%) | 67% | 33% | 4 (23%) | | | Comparison | 1 (20%) | 2 (40%) | 2 (40%) | 40% | 60% | 1 (20%) | | | | |
Shifted expectations Postpartum, the induced women revealed whether or not they had resolved the shift in expectations required of them when booked for, and during, the induced labour. The induced women were generally positive about the outcome of a healthy baby but not necessarily about their experience of induced labour. What the women expected in labour was different for each of them. However Anita (I), who had been so worried and anxious when booked for induction, had a very quick, intense labour after the second gel insertion. She laughed about how her expectations shifted during labour: I only used the Prostaglandin twice and my body work and I am happy. It was natural but in the time that I got the pain, I asked for everything!!! I wanted the Caesarean, she offered me an epidural and I said yes, and she went to find an anaesthetist and, I said to my husband that I thought I broke the waters but it was the head – and when I feel the baby out, it is amazing that the pain was gone and I start to cry. I was excited, happy all day yesterday. The birth of the baby was described as transforming and very powerful for 22 of the 23 women in this study. Mary (I) and Jess (I) described how the baby had shifted their focus: Definitely, the actual giving birth part was the hardest. When I am holding her and related to the thought of having to be induced, I was really scared about that … that's nothing. The outcomes can override everything. It all went horribly wrong in my plan – in my eyes it was compensated for in the care I got while I was going through (intense and induced) labour. Seeing the baby come out for the first time and holding him – that was definitely the best part. Discussion These findings indicate that women's attitudes vary from welcoming to resisting induction for post-date pregnancy. The voices of these women as well as those in other studies15, 16, 17, 18 are a reminder to midwives and others that women need information that is meaningful to their being in the induction process. These women knew there was a stepwise, time bound administration of procedures and were aware of the well documented cascade of interventions possible.19 They lacked an understanding of what the procedures meant for them as they coped with the new birthing situation. While preparation for a natural onset of labour is the appropriate emphasis in antenatal consultations and classes, the possibility of induction and the development of a back up birthing plan could help women apply their preparation when expectations for birthing have to shift. None of the women in the induction or comparison group in this study considered adapting their labour and birth plans nor did caregivers ask about their plan and help the women integrate what was possible during the induced labour. Women and their partners who are experiencing induction need a sense of involvement and inclusion. The difference in the focus of concerns between the induction and comparison group when booked for induction is intriguing. Research to further explore the strength of mind and body and the possible influence of women's self or baby focus on the onset of labour is indicated. Could helping women focus on the baby and empowering them to trust their body's ability to function reduce the need for induction? In conclusion, it is clear that both antenatal educators and midwives can use these findings to assist women and their partners shift their expectations of giving birth when induction is indicated. Understanding the variation in responses will assist in matching communication and guiding women throughout induced labour and birthing of a healthy baby. Olivia (I) summarises the goal for induced labour: “Giving birth is an amazing experience and it can still be an amazing experience with an induction”. Acknowledgements The study was conducted with resources in the Centre for Women's Health Nursing, Royal Hospital for Women, Sydney, Australia. It was supported by a development grant from the Faculty of Nursing and Midwifery, University of Sydney and a private donation to the Royal Hospital for Women Foundation. We are grateful to the women who were willing to describe their experience as it was occurring, often under difficult circumstances. The contributions of Jennifer Mathew RN, RM, Antenatal Educator, Avon Strahle RN, RM, Shamim Islam and Heidi Tsang in the development and execution of the study were important. Thank you also to Jane Svensson, RN, RM, PhD, Coordinator, Antenatal Education, Yvonne Paul, Librarian, Janice Gullick PhD, Michelle Wood and Alex Snellgrove for their editorial assistance. References 1. 1Oakley A. The captured womb: a history of the medical care of pregnant women. London: Isis; 1986;. 2. 2NSW Public Health Bulletin: Mothers and Babies. NSW Department of Health. NSW Midwives Data Collection; 2006. Available at: http://www.aihw.gov.au/publications/index.cfm/title/10634 [accessed December 9th 2008]. 3. 3Thorogood C, Donaldson C. Disturbances in the rhythm of labour. In: Pairman S, Pincombe J, Thorogood C, Tracy S editor. Midwifery: preparation for practice. Sydney: Elsevier; 2006;. 4. 4Enkin M, Keirse M, Nelson J, Crowther C, Duley L, Hodnett E, et al. A guide to effective care in pregnancy and childbirth. 3rd ed.. Oxford: University Press; 2000;. 5. 5MIDIRS. Informed choice, prolonged pregnancy—leaflet for professionals. 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a Faculty of Nursing and Midwifery, University of Sydney, NSW 2006, Australia b Outpatients Department, Royal Hospital for Women, Randwick, NSW 2031, Australia c Antenatal Unit, Royal Hospital for Women, Randwick, NSW 2031, Australia d Centre for Women's Health Nursing, Royal Hospital for Women, Australia  Corresponding author.
PII: S1871-5192(09)00049-3 doi:10.1016/j.wombi.2009.06.002 Crown Copyright © 2009. Published by Elsevier Inc. All rights reserved. | |
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