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An interesting debate and a topic that I am particularly interested in, but I wonder if important points are being missed by focusing on whether labour induction for prolonged pregnancy should be categorised as low risk or not? What do women think? Do they realise that when they are "offered" labour induction for prolonged pregnancy that they will be admitted onto an antenatal ward and that the process of cervical ripening may take a few days? Do they consent to this? Are they making a fully informed choice? Allison previously raised some of these points. I asked women about their experiences of cervical ripening on an antenatal ward through undertaking a small qualitative study in the UK. There is a perception that an antenatal ward is a safe environment for cervical ripening however, women stated that they felt alone, separated from significant others and that they had not been adequately informed about the process of cervical ripening. I wonder where the ring fence of safety ends when women are admitted to hospital for cervical ripening? Women I spoke to were permitted to leave the ward for periods of time, which a few said they did in order to spend time with their partners. One woman and her partner sat in their car in the car park of the hospital. So, is sitting in the hospital café or in a car in the car park safer than going home? What care do we offer women when they are admitted to an antenatal ward? Intermittent assessment of the fetal heart rate or intermittent monitoring tells us very little. Women I spoke to stated that they felt that their complaints of pain were ignored. I wonder if they had been allowed to go home for a period of time and advised to return to hospital when they were feeling uncomfortable, if their complaint of pain would have been more readily addressed? I agree that the procedure of cervical ripening should not be considered a "low risk" intervention, but I am not convinced that inpatient cervical ripening reduces risk significantly. My interest in this area does stem from previously working as an obstetric nurse in BC, Canada, where women were (and still are) routinely discharged home during cervical ripening. I am not saying that all women should be discharged home, but I do think that women need to be adequately informed about the process, risks and offered a choice of environment. There is more to this than determining whether the process of cervical ripening should be considered low risk or not. There are risk to women sitting on an antenatal ward for hours, being separated from their families and feeling like they are not being listened to. Perhaps we need to involve the views of service users in this debate. Sheila On 12 June 2015 at 09:45, Allison Farnworth <[log in to unmask]> wrote: > We’ve been doing some work with practitioners and pregnant women around > this issue in Newcastle as part of an NIHR Knowledge Mobilisation > fellowship, with the aim of increasing the use of high quality evidence in > discussions about induction; we have chosen to focus on the issue of > postdates induction as an issue of concern raised by service users and > staff. Note that we are trying to increase the use of this evidence, not > suggest that it is the only form of knowledge used in individual decisions > about IOL – we just want to make sure it’s somewhere in the discussion. > > > > The qualitative work we did suggested that a major barrier to evidence use > is the way in which postdates IOL is offered; not as a choice but as > something that ‘happens’ (the phrase ‘what we allow’ and ‘what I’m allowed > to do’ came up again and again, as it sadly does in many aspects of > maternity, and indeed health care). The set-up of services created an > additional layer of influence in terms of what is viewed as a ‘good’ choice > (i.e. go along with local guidelines, midwife will arrange the induction) > and what is viewed as problematic (i.e. you want something different? You > need to see a consultant). Where a choice is not presented as a choice > (i.e. the alternatives are not described) then this decreases a woman’s > motivations to seek information about her options, and where women don’t > ask questions health care professionals assume that they’re happy and don’t > want any more information (added to that the difficulties of accessing, > interpreting and discussing the evidence base, particularly when it > involves discussion of risks around difficult topics like stillbirth). > Additionally, the issue of who holds the power to decide was relevant, with > midwives shying away from discussion of risks and benefits when they felt > that they ultimately couldn’t sanction decisions (e.g. not wishing to > provide information which could support the idea of going for care which is > ‘off guidelines’ when that would mean involving a consultant). So in terms > of implementation it is far more complex that just providing the > information, to either staff or women, there are cultural and institutional > forces at play – the fact that induction is viewed as routine is a major > barrier to increasing choices. > > > > The issue was just as difficult for women who requested IOL without > indication (similar issues to the elective CS debate which has been > occurring on the mailing list recently) – it seemed as if evidence was > given to them selectively, to support the position set out in the > guidelines (or the position of the individual clinician). Incidentally, > many women I spoke to were more than happy to complete their pregnancy as > soon as was possible and it’s important to note that many were engaging in > all kinds of activities to try and induce labour ‘naturally’ – some of > these activities were potentially dangerous (i.e. performing multiple > cervical sweeps on themselves or getting their partner to do it, castor oil > etc.). I think in our wish to give good information about the benefits of > physiological labour, we need to be very careful not to alienate women who > don’t place a lot of value on that (for some women, labour is just a means > to an end, and one they would happily accelerate or omit if they were able > to). > > > > We’re currently working on a service development initiative, working with > service users and frontline practitioners to see whether making choice > explicit, providing good quality information, and then supporting choice > makes a difference (in terms of knowledge, confidence and perceived > involvement in decision making). We’re also doing some work with a health > economist to look at the way in which women prioritise different factors > when making choices about induction at term. > > > > Sorry, I have rambled on a little there! To address the low risk/high > risk issue of the original post – risk is on a continuum and informed by > individual risks and population level risks. Low risk postdates induction > involves women with no pathology who just happen to fall into a category > where we know that risks of stillbirth are raised at the population level > (although this is rarely communicated well to women). It’s a very blunt > screening tool but, as we are not good at identifying which are the women > most likely to experience an adverse outcome, we offer IOL to all. > Induction itself is clearly an intervention, so not low risk, but if > evidence supports it being an intervention which can be safely managed in > an environment designed for low risk situations for women who are having > the procedure in the absence of an additional individual pathology, then I > think we should consider that – if that matches a woman’s preferences. > It’s worth remembering that we perform cervical sweeps at home/in clinics > and consider it a spontaneous onset if the woman subsequently labours – > but it *is* an intervention and one which appears to be administered to > ‘low risk’ women quite liberally and haphazardly in my experience, food for > thought! > > > > Thanks, Allison > > > > *From:* A forum for discussion on midwifery and reproductive health > research. [mailto:[log in to unmask]] *On Behalf Of *Yvonne > McGrath > *Sent:* 12 June 2015 12:47 AM > *To:* [log in to unmask] > *Subject:* Re: Isnt the concept of low risk induction a category error? > > > > Hi > > > > I also totally agree. The concept of a low-risk induction is slightly > bonkers and comes back to the interpretation of risk...going beyond 42 > weeks versus the risk of induction. In many cases women who may opt ( as > most actually labour spontaneously prior to 42 weeks) to decline induction > are treated as though they are playing a game of Russian roulette rather > than making an informed decision to wait for spontaneous labour. > > > > As we go 'forward' and things like the RCOG position paper on maternal age > and induction inform practice the more I feel like the importance of > properly informed consent (as enshrined in recent case law- health care > practitioners take note?) increases. To quote the adage- It's not an > informed decision unless you have all the information and just as we train > women to be 'compliant' midwives are often 'compliant' or even indeed to > 'believe' all of the 'information' that they give to women. "We offer IOL > as the risk of stillbirth increases" but without giving the actual > figures... > > > > Yvonne > > > > > > On Thu, Jun 11, 2015 at 11:41 PM, Lucia Rocca <[log in to unmask]> > wrote: > > Hi, > > I completely agree! > > We are getting to the paradox. In many Trusts if women agree to be induced > and start labour with 1 Propess they are considered low risk and have > access to AMUs.... > > Why where those women induced in first place? > > xx > > Lucia > > > > > Lucia Rocca-Ihenacho > > Consultant Midwife for Public Health > > St George's NHS Trust > 4th Floor Lanesborough Wing > St Georges Hospital > Blackshaw Rd > SW17 0QT > London > UK > > PhD Student > > Centre for Maternal and Child Health Research > > School of Health Sciences > > City University London > > 1 Myddelton Street > > London EC1R 1UW > > > > 07989 230313 > > Skype contact: luciainsky > > > > > > > > On 11 June 2015 at 23:33, Soo Downe <[log in to unmask]> wrote: > > This looks like an important initiative that is likely to improve care > in many areas, but I have to say, I just don’t get the concept of a low > risk induction. If a woman/baby is low risk, why are they being induced? I > was always taught that you never undertake induction of labour unless you > are prepared to do an emergency caesarean for the reason that the induction > is taking place. So all women who have their labours induced are high risk > aren’t they, by definition? > > > > Or am I missing something fundamental here? > > > > All the best > > > > Soo > > > > *From:* A forum for discussion on midwifery and reproductive health > research. [mailto:[log in to unmask]] *On Behalf Of *Sandall, > Jane > *Sent:* 11 June 2015 17:05 > *To:* [log in to unmask] > *Subject:* NHS England London Strategic clinical network for maternity > toolkits to improve experience and outcomes across London > > > > Dear all > > > > The NHS England London Strategic clinical network for maternity had a > launch event yesterday. > > http://www.londonscn.nhs.uk/networks/maternity-childrens/maternity/ > > The Overarching aim is to reduce variation in outcomes and experience of > care for women and their babies in London. > FOCUS AREAS are > > § Maternal mortality > > § Reducing stillbirth > > § Women’s experience > > A range of briefings and implementation toolkits are available on the > website along with a fantastic film about IMPROVING MATERNITY EXPERIENCE > ACROSS NHS SERVICE. The Maternity toolkits cover two work streams on > models of care and improving outcomes, and are evidence based and address > implementation by providing examples from London. > > § You can see the *Full suite of toolkits* > <http://www.londonscn.nhs.uk/wp-content/uploads/2015/06/mat-suite-of-toolkits-062015.pdf>* > on the web page above.* > > § Continuity of midwife care > <http://www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-coc-toolkit-042015.pdf> > > § Outpatient induction of labour in low risk women > <http://www.londonscn.nhs.uk/wp-content/uploads/2015/05/mat-outpatient-iol-toolkit-042015.pdf> > > § Midwifery led units > <http://www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-mlu-toolkit-042015.pdf> > > § Maternity experience workshop > <http://www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-user-experience-toolkit-022015.pdf> > > § Post partum haemmorhage > <http://www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-post-partum-haemorrhage-112014.pdf> > > § Reducing stillbirth through improved detection of fetal growth > restriction > <http://www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-stillbirth-fgr-122014.pdf> > > § Fetal fibronectin testing > <http://www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-fibronectin-112014.pdf> > > > > Regards > > Jane > > > > > > > *______________________________________________________________________________* > > Jane Sandall > Professor of Social Science and Women's Health > > NIHR senior Investigator > Division of Women’s Health | Faculty of Life Sciences & Medicine | King’s > College London |Women’s Health Academic Centre | St. Thomas' Hospital > > London| SE1 7EH > > Florence Nightingale Faculty of Nursing and Midwifery > > http://www.kcl.ac.uk/lsm/research/divisions/wh/index.aspx > > > > [log in to unmask] | 020 7188 8149 | Skype | jsandall > PA Fiona George | [log in to unmask] | 020 7188 3639 > https://kclpure.kcl.ac.uk/portal/jane.sandall > > > Maternity and Women’s Health and Capacity Building theme lead > NIHR CLAHRC South London | www.clahrc-southlondon.nihr.ac.uk > King's Improvement Science | www.kingsimprovementscience.org > > > > *“Birth in Europe in the 21st Century" is now published in English and is > available * > *http://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/publications/entre-nous/entre-nous/birth-in-europe-in-the-21st-century.-entre-nous-no.-81,-2015* > <http://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/publications/entre-nous/entre-nous/birth-in-europe-in-the-21st-century.-entre-nous-no.-81,-2015> > > > > > > [image: logo] > > > > [image: athena swan silver] > > > > > > > -- *Sheila JS Brown* *07840 296 731*