Social induction

By Dr. Chow Kah Kiong
MBBS (S'pore), MMed (O&G), MRCOG (UK), FAMS

What is social induction?

Social induction: an induction for the convenience of either the pregnant mother and her family or the caretaker and the medical team. It is when labour is induced "electively" and there is no clear medical reason for the induction.

The World Health Organisation (WHO) recommends that induction rates should not exceed 10% (15% at most). However, despite the possible risks of induction, many people will still desire to select the birth date of a baby.

Reasons for social induction

Individual opinions of pregnant women often vary, depending on how they perceive induction. Many welcome the intervention happily. Possible reasons are:

• Choosing a date to fit in with the woman’s work or study schedule or with the partner’s work or leave arrangements or with sibling’s childcare; also for visiting relatives.
  
• Feeling tired of being pregnant and wanting the pregnancy to end. Having pregnancy complaints, (such as heartburn or varicose veins) can cause the pregnancy to be uncomfortable.
  
• Being due around a holiday season. Some women choose to be induced before Christmas, Easter or school holidays.
  
• Living a long distance from the hospital, especially in isolated rural areas may consider induction to avoid living away from home for weeks, awaiting labour or travelling long distances to birth.
  
• Anxiety about the baby due to a previous complication e.g. previous stillborn baby.
  
• The labour needs to be under controlled conditions. For example, the caregiver may suggest that a woman, who experiences a psychiatric disorder, would be better managed if the labour was planned for, and the woman was cared for, during periods of peak staffing at the hospital.
  
• Mother and father are ready; planned & completed their work and social schedules. This is preferred in a society where most activities are planned & scheduled. How nice when an impending child birth does not come unexpectedly and interfere abruptly your work & social schedules.
  
• To ensure the child is borne at a ‘decent’ time of the day when the labour and neonatal wards are well staffed and urgent laboratory, imaging and other support services are easily available.
  
• Allow the child to be borne on an auspicious day; making the whole family happy and adding a sense of confidence to the baby the rest of his/her life.

Possible risks of social induction

However, several possible risks have been identified and documented. For these reasons, many birth centres, hospitals, teaching institutions highly discourage social induction of labor.

• Premature baby, even if you believe your baby is term
• Failed induction and resorted to C-section
• Prolonged difficult labour
• Fetal distress (e.g. cord prolapse; hyperstimulation; long labour)
• Uterine Rupture (in the presence of previous C-section)
• Placental Abruption (sudden artificial rupture of membrane)
• Amniotic fluid embolism & Post Partum Hemorrhage

How to avoid these risks

However, several possible risks have been identified and documented. For these reasons, many birth centres, hospitals, and teaching institutions highly discourage social induction of labour.

Prematurity

Ensure correct dating of the pregnancy by:

• Taking a good menstrual history.
• Early dating with an ultrasound dating scan in the first half of pregnancy, especially in the first trimester.
• Perform an ultrasound assessment of the maturity of the placenta, prior to induction. Whenever there is a doubt on the dates of a pregnancy, avoid social induction.

C-section

Ensure a favourable cervix and absence of disproportion:

• Prior to induction, assess the cervix for favourability to induced dilatation. Cervical priming by prostaglins could help in cervices that are less favourable. However, time should be allowed for safe, gradual, monitored priming and patient’s prior agreement to call off the process when necessary.
• Baby should be assessed to be not disproportion to mother’s pelvis. Avoid inducing presentations other than cephalic and the head is fully engaged.

Prolonged difficult labour

To avoid this risk, ensure the following:

• A cervix should be assessed to be favourable or easily primed.
• Use of oxytocin drip early to ensure good regular uterine contractions.
• Continuous monitoring of labour with CTG.
• Artificial rupture of membranes only when uterine contractions are established, so that labour induction could be called off.

Fetal distress

Avoid this by ensuring:

• CTG assessment of baby prior to induction, including and not limited to an admission CTG test.
• Artificial rupture of membrane only when the head is well applied to avoid cord prolapse.
• Continuous CTG monitoring of labour.
• Prior agreement to call off induction and/or accept intervention by C section.

Uterine rupture

Ensure the following:

• Avoid social induction for previous C-section and other significant uterine surgery especially myomectomy and major corrective surgery for uterine malformation.
• Continuous CTG monitoring of labour.
• Avoid hyper stimulation with oxytocics.

Placental abruption

This is a rare complication of induction. However, the presence of excessive amniotic fluid and a history of hypertension in pregnancy may increase this risk. Avoid rupturing the membranes on purpose as much as possible until very close to the second stage, especially if there is a lot of amniotic fluid and the mother has high blood pressure. Use of continuous CTG monitoring reveals the unregulated uterine contraction the moment the membrane is artificially ruptured. The patient and family are prepared for an emergency C-section.

Amniotic fluid embolisation & PPH

Many obstetricians believe that these complications are increased in induced deliveries in some ways related to the use of prostaglandins to prime the cervix, plus oxytocics to enhance the uterine contraction, plus artificial rupture of membranes, and the rapid speed of labour due to these agents. There is very little to prevent these complications, but just be prepared to treat them. We could start a syntocynon infusion immediately after the baby is delivered. Close monitoring of the patient, even up to 12 hours after delivery. Start breast feeding immediately. Keep an intravenous line for 6 hours after delivery - may need to have blood grouped and X-matched ready.