By Tessa of www.tessayoga.co.uk, Jan 11 2017 01:59PM
I teach Pregnancy Yoga and the number of my clients that are induced is much higher than I would like. When I open an email with a birth story from a new mum and she writes “then I was induced”, my heart sinks because it often ends in a caesarean.1 Don’t misunderstand me; there are times when I am so grateful that we live in a place where women have access to that life-saving surgery. However, when I read their birthing stories, which are often very detailed, I can see that there is a grey area where if they had been given a little more time before being induced, or being augmented where contractions were weak, given consistent care so they felt in familiar hands or had a doula that could provide an underlying confidence in natural birth, the outcome may have been different. I sometimes feel that the system is failing pregnant women in this respect and I want to talk about two things that women who are planning to conceive can do to increase their confidence in making a decision around induction.
As a pregnancy yoga teacher I am very careful about what I say regarding whether to be induced or not. Some women who have told me their stories felt pressurised to be induced and talk about being emotionally bullied by health professionals. There is talk about putting the baby at risk of dying. It is a very strong woman who with that having been said out loud by their care-giver can say that they still want to wait and not be induced. Usually they will have done a lot of reading beforehand and are well versed in statistics, physiology and other things that make them resolute as long as their baby appears happy and healthy in utero. If you are a woman that did not know that induction can lead to a cascade of intervention you might not have thought to read up about it. Or you may just be so desperate to meet your baby, you ask to be induced earlier than recommended, perhaps having a sweep on your 40 week appointment. Given that due dates are an approximation, we can easily do something that will give us confidence about when our baby is likely to be ready to trigger labour.
Prevalence of induction
First, a bit of context. The 2014 NICE guidelines state that information to women at the 38 week appointment should cover the possibility of induction between 41+0 and 42+0 weeks.2 The Maternity Statistics for England for the year ending 2014, reported an induction rate of 25.0%, which is part of an upward trend.3 Locally, an ‘uncomplicated singleton’, that is, a healthy single baby, would be induced at 40+12 (rather than 42 weeks) and that has led to the number of inductions increasing to 15.5% in 2014-15. This is lower than the national average, but this does not include the women who were augmented for weak contractions, which account for another 13.4%. Of those induced (rather than augmented), 21.8% were induced within 7 days of the estimated date of delivery (EDD), 33.4% after 41 to 42 weeks and 9.3% at 42 weeks, and 53.9% of those induced were nulliparous (first babies). There were only two that went ‘significantly over’ the 42 weeks, with one being a typo with 50 weeks being recorded! These figures show you how importantly a hospital will take your ESTIMATED date of delivery (but also how mistakes are made).
A meeting organized by the World Health Organization on Appropriate Technology for Birth, held in Brazil in 1985, recommended that “No geographic region should have rates of induced labour over 10%”.4 Obviously we are well over that figure in England, but practices around the world show that lower rates are possible. Ina May Gaskin has delivered thousands of babies at ‘The Farm’ in Southern Tennessee with a spontaneous birth rate of 94.5%.5 This is compared to 60.3% of spontaneous births at my local hospital (which included the augmented deliveries, which The Farm’s data does not).1 Some practices within the UK have other thoughts, like the now-closed Albany Midwifery Practice, whose co-founder states: ‘some mothers with pregnancies of 42 weeks or longer need reassurance that they are neither crazy nor irresponsible for resisting induction when all signs are good’.4 I had a mother in my class who personally gestates for 43.5 weeks, so did her mother and grandmother: that is normal for her family.
My story of going overdue
With my first daughter, Zara, I was booked in for an induction at 42 weeks at my 40 week appointment. The 42 weeks arrived and I went into the hospital with my husband for the appointment. Zara was fine and it was suggested that I be given a pessary to start induction. I said that I would rather wait since she appeared very happy there and fortunately I wasn’t given a talk about risking my baby’s life. The maternity department was very busy that day and the midwife had to keep leaving to assist with births. Five times she came back and offered me the pessary and five times I reminded her that I didn’t want it thank you very much. On the fifth time, she suggested a sweep and I agreed, something that in retrospect I would refuse if I was in that situation again. I agreed that I would return for monitoring each day. I was happy that I had done my reading and had a supportive partner with me at the hospital. Fortunately I went into labour that night and she was born at 11am the next day. Our decision was based on two things: one, the fact that the monitoring said my baby was fine (I instinctively knew that to be the case) and, two, that I knew precisely when she had been conceived and that my EDD was wrong. She wasn’t an IVF baby, but I had been charting my cycle ahead of conceiving and knew when I had become pregnant by a sustained rise in basal temperature. That information gave me so much confidence.
I had read Taking Charge of Your Fertility by Toni Weschler (www.tcoyf.com) and was charting my basal temperature, cervical mucus (or juices as I prefer a non-clinical sounding term), and recording when we made love. I found this process of charting exciting and it made me appreciate the intricacies of my body. The charting helps you understand when you are ovulating and make the most of your fertile phase (or conversely to avoid it if you are not wanting to become pregnant). You can tell when you are pregnant because instead of the temperature going down again, it remains elevated and signals buying the pregnancy test. Just imagine how having this piece of information of the day of conception can give you ammunition in the face of induction! When I was pregnant with my second daughter, I not only knew again the precise date of her conception, but also the length of gestation with my first baby. Before my first baby, my cycle was usually 32 days long and so the EDD would have always have been a bit out, notwithstanding sperm sometimes taking a couple of days to reach their target! Imagine how if my daughters have children, they could know not only the date of conception for their baby, but how long they were in utero before a spontaneous delivery. Generation on generation, we will know what has happened in our family: that is, what is normal for us.
Developing menstrual awareness
Since having Zara, I came across Alexandra Pope and her incredible work on menstruality. In her workbook, Women’s Quest, she focuses more on the emotional journey of the menstrual cycle than the physical signs. With Sjanie Hugo Wurlitzer, she has set up the Red School Online that enables a woman to reflect deeply on her menstrual cycle and the wisdom inherent in it. I intimately know my menstrual cycle and chart my emotions, physical signs and dreams day by day. It has given me a deep trust in my body and I am aware when I have not taken enough rest or paced myself kindly. I know that every four or five months I will have a longer cycle of 36 days and so I don’t worry about it; I’m happy to wait. I dream that more and more women will come to see their cycle not as a nuisance, but as a highly-tuned well-being sensor. And that their bodies are amazing.
If women trust that their bodies are amazing that would make my work as a Pregnancy Yoga teacher much easier! Sometimes I feel as if I am asking women to make a giant leap from distrusting their bodies that for so long they were worried about becoming pregnant through their teens, twenties, (thirties), that leaked menstrual blood at inconvenient times, or that they took pills to regulate the bleeding or to get rid of it totally, to feeling that their (pregnant) body was incredible and natural birth was possible. I do see that giant leap happening in class because pregnancy is a time of openness and the upcoming birth is a big motivator, but how much easier it would be if women were supported to already appreciate the awesomeness of their bodies. The transformation of pregnancy would be just the proof. This knowledge may result, not an induction where control of birth is given over to the hospital, but in allowing time to birth at the woman and her baby’s own pace. How empowering would that be?
For those women who experienced a challenging birth, you might find support from meeting with your Consultant Midwife to understand what happened, meeting with a Talking Therapies counsellor (postnatal women are prioritised), giving feedback through the local Maternity Forum anonymously or otherwise, seeking support through online groups or keep on talking it through with friends (but please not pregnant ones!) I hope though that you might approach your cycle, when it returns after the birth, with a new perspective. I feel that cycle awareness can provide a lot of healing and help us prepare for future children, and down the line, a smoother menopause.
Gifts of menstrual awareness for pregnancy and birth
By practising menstrual awareness we become experts on our own well-being, and thus can make more informed decisions when it comes to the well-being of our unborn babies too and trusting our instincts about our embodied experience. We realise through connecting with other women who are cycle aware that there is a diversity in the length of our cycles and we experience them differently (and similarly pregnancies last different lengths). Through charting our cycles before becoming pregnant, we have more accurate information on the date of conception rather than an estimate based on every woman’s cycle being the same length. This knowledge is personal power in the face of institutional policies and constraints.
Want to get started? Find a Red Tent near you ( I host the Caversham, Berkshire one) or visit the Red School Online. I am planning to run menstrual awareness workshops for couples so please get in touch if you are interested at www.tessayoga.co.uk (or for workshops for pregnancy yoga teachers/ doulas or mother blessings or FREE resources for pregnancy/postnatal women).
1 At my local hospital, the Royal Berkshire Hospital, if a nulliparous woman is induced she has a 33% chance of that leading to a caesarean. Source: Siddall, J. Maternity Services Report 2014-5; Royal Berkshire Hospital, Reading.
2See here for a summary of the guidelines: https://www.nice.org.uk/guidance/cg70/chapter/1-Guidance
3The NHS Maternity Statistics, England: 2013-14 can be found on the Health and Social Care Information Centre website at http://www.hscic.gov.uk/catalogue/PUB16725
4Wagner, M. Pursuing the Birth Machine: The search for appropriate birth technology. Camperdown, NSW, Australia: ACE Graphics, 1994.
5Gaskin, IM (2003) Ina May Gaskin’s guide to childbirth. Bantom Books: New York.
6Reed, B. (2016) Birth in Focus: Stories and photos to inform, educate and inspire. Pinter & Martin; London.