Episode 186 Induction of Labour Update

In this update I talk about why induction of labour is such a charged topic and why the real-world experience can feel long, uncomfortable, and out of step with what the evidence promises. We explain how drug shortages and new research are pushing the NHS towards oral and mechanical methods that could make induction more streamlined and less intrusive. 

What if you could take a tablet to start your labour?

Would you be willing to help shape treatment for the future by participating in research ? 

Want to know more?

https://www.nice.org.uk/guidance/ng207/resources/inducing-labour-pdf-66143719773637

https://www.chelwest.nhs.uk/services/maternity/moli-study

If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the ObsPod to anyone you think might find it interesting. If you've enjoyed my episodes and by chance you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. If you want to get in touch to suggest topics for future episodes, you can find me at the Obspod on Twitter and Instagram, and you can email me theobspod at gmail.com.

Thank you all for listening,  My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Transcript

Welcome And Who This Is For

Florence 0:00

Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician, hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case, and for that matter anyone else that's interested, the Obspod is for you. Induction is a really hot topic at the moment. I recorded a video recently on Instagram discussing induction and it got so many hits. We know there are rising rates in the UK, and so I thought it was time to revisit this topic a little bit, particularly because there are some changes happening in the way we induce labour. Today's episode is going to build on my previous episodes, episode 35, induction of labour, and episode 150, experience of induction of labour. So you might want to just have a little look, check back, and listen to those if you haven't already done so. Today I'm going to focus on some new developments in induction of labour because it's a few years since I recorded my episode about the kind of general principles of induction and why it's quite common. If you listen back to the episode about experience of induction of labour, there is a lot wrong with the way we're doing induction at the moment. We end up in a situation where we recommend someone has their baby because of concerns about either their well-being or that of their baby, and then we subject them to a very long, quite dysfunctional process, which is limited by the agents we are able to use as well as staffing beds and how ready or not their body is for labour. So in my previous episodes, I explained that whilst the evidence is there that if you induce from 39 weeks, you don't increase intervention and you may have some benefit as far as the baby's concerned, in practice, that really isn't what we see. And one of the reasons that induction can be such an unpleasant experience for women is that they may end up in hospital for prolonged periods of time and they may also require repeated vaginal examinations. Now having a vaginal examination at the best of times, as any woman will tell you, is something that you don't particularly enjoy, even if it's not uncomfortable or painful, it's not pleasant. So for many years people have thought a bit about could you have a tablet, an oral agent, an oral medication that might trigger induction of labour? And that's mainly what I'm going to focus on today. In medicine, we often talk a bit about how long it takes from evidence, so the latest research telling us how good or less good something is, to become implemented and embedded into practice. Unless, of course, there's something pushing us to change. The COVID pandemic was a classic example of that. Suddenly, many things that we'd wanted to do previously, such as remote prescribing so that women could pick up medications from their local pharmacy, or telephone or video consultations, suddenly became the norm when we were pushed to do so. We had to accelerate the change. And in some ways, this is what we're actually seeing at the moment. Women may or may not be aware that there are shortages of the medication, the hormonal prostaglandins that we use for induction of labour. There's a national shortage. So behind the scenes, there are lots of doctors and midwives wondering how best to get women into labour without the drug that we commonly use. And when I say that implementation, research to implementation can be very delayed, I'm going to take you to the induction of labour guideline by the National Institute of Clinical Excellence. Now this guideline is not recent, it's dated 2021. So it's been there for four to five years. If you turn to the section about induction of labour and what methods of induction of labour there are, you can clearly see that the committee making the recommendation recommend vaginal dynoprostone, that's the vaginal prostaglandins that I've discussed in my previous episode and that are commonly used, or oral, that is tablet misoprostal. It even says the committee note that for low-dose oral preparations of misoprostal, the risk of hyperstimulation, that's overstimulating too many contractions, appears to be the same or lower than with vaginal dinoprostane. Therefore, the committee agreed that misoprostal could be an alternative to dinoprostone for induction of labour, particularly for women who would prefer an oral preparation. And it's interesting because I'm not aware of that many hospitals that are already doing tablet induction of labour. But because the national shortage of vaginal pessaries, people are now accelerating that change. And my trust are looking into this just as many other trusts are. So we put a speculum in to get a clear view of the neck of the womb, and then we put these little rods, usually three or four rods, just push them through the neck of the womb. Now this can be uncomfortable because the neck of the womb is before labour quite long and firm, and there's not much space to push these rods through. So sometimes you can get a bit of crampy pain when we're doing that, and sometimes we give women gas and air if they'd like that. These little rods are thinner than a pencil, they're quite small, and what happens is they absorb water from the cervix and mechanically dilate the cervix by swelling up over a period of usually 12 to 14 hours. So again, that will start to release the woman's own natural hormones, prostaglandines, and open up the neck of the womb so we can get to the point where we may be able to break the waters. So this is called an osmotic cervical dilator, in that it's drawing in water. And if you look back to that National Institute of Clinical Excellence guidance, they list it as a possible method of induction of labour. The advantage of this is that there's no over-stimulating the womb, there's no increased risk of hyperstimulation, too many contractions, but they do also comment that they don't seem to be that effective in triggering labour, promoting vaginal birth within 24 hours, and I would agree with, and I would agree with that. After you've had that dilapan, that mechanical method. One of the reasons we use this mechanical method, dilapan, is that it's very good for women that were concerned may not be able to have hormonal methods. So, for example, if you've got a scar on the womb because you've had a previous caesarean birth, or if your baby is very small and growth restricted and may not tolerate contractions very well, then a mechanical method to get the neck of the womb to open up enough to then be able to have oxytocin titrated to make sure that the contractions are just the right amount, not too much and not too little, then that can be a really good option for induction of labour. And you may want to have a listen to episode 165, oxytocin use, to understand a bit more about that. Then there is one more new kid on the block, as it were, in terms of induction, and this is another oral agent, so a tablet that you can take by mouth. And this agent is actually currently a trial called the MOLLE trial, M-O-L-I. So this may or may not be available at your local hospital depending on whether they're participating in this trial. The MOLLE trial is looking at mithipristine. It works by blocking progesterone, which can make labour start, and it's currently used in some other countries to induce labour. So it's something that is being used outside the UK but not in the NHS. Those studies outside the UK have shown that in an uncomplicated pregnancy, myfopristine can be effective and safe. The MOLLI trial is trying to establish this in the NHS with a larger number of women. There are suggestions from other countries that using mifepristine may increase the number of women with vaginal births, reducing the chance of cesarean and intervention. So it'd be fantastic if that is the case and if we can introduce it successfully. The MOLLI trial is what's called a double-blind randomised control trial, and what that means is if you participate, you may get mifepristone, the active agent, or you may get a placebo, and you won't know which, and the healthcare professionals looking after you won't know which. So the more of us can adopt some of these new methods and get involved in pushing this research forward, the better. As a woman facing induction of labour, obviously you've got the same considerations as before. What are the pros, what are the cons? Why do you want why you why is it being suggested? What's the rationale? What are the alternatives? And obviously, the default is waiting for spontaneous labour. Don't be frightened if you start to see some changes in what you're being offered. And if you're offered tablets, then that may be a real positive opportunity to experience a much more streamlined, effective process. If you're asked if you would be willing to participate in the MOLLE trial, of course you don't need to, but please do read the information and think about if you were willing to participate, then that could improve things not just for you, but also other women going through induction of labour processes in the future. We can only make improvements to care with your help and your consent and your participation in what we're trying to improve. I very much hope you found this episode of the Obspod interesting. If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the ObsPod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician, and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I. Have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you've found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the Obspod on Twitter and Instagram, and you can email me theobspod at gmail.com. Finally, it's very important to me to keep the Obspod free and accessible to as many people as possible. But it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.