Induced childbirth: too often imposed …


The testimonies – all anonymous – are damning. « During my birth plan, I had indicated that I wanted to wait 2 or 3 days after the due date before induce childbirth. It was not taken into account. I was summoned on the day of the term to the hospital and I was triggered, without offering me any alternative. This act and the piercing of the pocket of water were imposed on me. I experienced it as a great violence », Indicates one of the participants in the large survey of the Collective interassociative around the birth (Ciane *) dealing with “Childbirth initiated in a hospital environment”. Of the 18 responses from patients who gave birth between 648 and 2008, 2014% of the women questioned said they had experienced a “trigger”. A figure that remains stable in our country, since it was 23% in 23 (National Perinatal Survey) and 2010% during the last survey in 22,6. 

When is the trigger indicated?

Dr Charles Garabedian, obstetrician-gynecologist and head of clinic at the Jeanne de Flandres maternity hospital in Lille, one of the largest in France with 5 deliveries per year, explains: “Induction is an artificial way of inducing childbirth when the medical and obstetrical context requires it.. »We decide to trigger for certain indications: when the due date has passed, depending on the maternities between D + 1 day and D + 6 days (and up to the limit of 42 weeks of amenorrhea (SA) + 6 days maximum **). But also if the future mother had a rupture of the water bag without putting into labor within 48 hours (because of the risk of infection for the fetus), or if the fetus has stunted growth, an abnormal heart rhythm, or twin pregnancy (in this case, we trigger at 39 WA, depending on whether the twins share the same placenta or not). On the part of the expectant mother, it can be when preeclampsia occurs, or in case of pre-pregnancy diabetes or gestational diabetes unbalanced (treated with insulin). For all these medical indications, doctors prefer induce childbirth. Because, in these situations, the benefit / risk balance tilts more in favor of the initiation of childbirth, for the mother as for the baby.

Triggering, a not insignificant medical act

« In France, childbirth is being started more and more frequently, reveals Bénédicte Coulm, midwife and researcher at Inserm. In 1981, we were at 10%, and that rate has doubled to 23% today. It is increasing in all Western countries, and France has rates comparable to its European neighbors. But we are not the country most affected. In Spain, almost one in three births is initiated. » Or, the World Health Organization (WHO) advocates “that no geographic region should register a rate of induction of labor greater than 10%”. Because the trigger is not a trivial act, neither for the patient, nor for the baby.

The trigger: pain and risk of bleeding

The prescribed drugs will stimulate uterine contractions. These can be more painful (few women know this). Particularly if labor is induced with the help of an infusion of synthetic oxytocin, there is a higher risk of uterine hyperactivity. In this case, the contractions are very strong, too close together or not relaxed enough (feeling of a single, long contraction). In the baby, this can lead to fetal distress. In the mother, uterine rupture (rare), but above all, the risk of postpartum hemorrhage multiplied by two. On this point, the National College of Midwives, in conjunction with anesthesiologists, obstetrician-gynecologists and pediatricians, have proposed recommendations concerning the use of oxytocin (or synthetic oxytocin) during labor. In France, two thirds of women receive it during their childbirth, whether it is initiated or not. “ We are the European country that uses the most oxytocin and our neighbors are surprised by our practices. However, even if there is no consensus on the risks associated with induction, studies highlight the link between the use of synthetic oxytocin and the greater risk of bleeding for the mother. “

Triggering imposed: a lack of transparency

Another consequence: longer work, especially if it is performed on a so-called “unfavorable” neck (a still closed or long cervix at the end of pregnancy). “ Some women are surprised they have to stay in hospital for XNUMX hours before real labor begins », Explains Bénédicte Coulm. In the Ciane investigation, a patient said: “ I would have liked to have been more aware of the fact that work might not start for a long time… 24 hours for me! Another mother expresses herself: “ I had a very bad experience with this trigger, which took a very long time. The tamponade followed by the infusion lasted a total of 48 hours. At the time of the expulsion, I was exhausted. ”A third concludes:” The contractions that followed the trigger were very painful. I found it very violent, physically and psychologically. However, before any outbreak, women must be informed about this act and its possible consequences. We must present them with the risk / benefit balance of such a decision, and above all obtain their consent. Indeed, the Public Health Code indicates that “no medical act or treatment can be performed without the free and informed consent of the person, and this consent can be withdrawn at any time”.

Induced childbirth: an imposed decision

In the Ciane survey, although requests for consent increased between the period 2008-2011 and the period 2012-2014 (the two phases of the survey), a still high proportion of women, 35,7% of first-time mothers (of whom it is the first child) and 21,3% of multiparas (of which it is at least the second child) did not have their opinion to give. Fewer than 6 in 10 women say they have been informed and have been asked for their consent. This is the case for this mother who testifies: “When I exceeded my term, the day before the programmed triggering, a midwife performed a detachment of the membranes, a very painful manipulation, without preparing or warning me! Another said: “ I had three triggers over three days for a suspected cracked pocket, when we had no certainty. I was not asked for my opinion, as if there was no option. I was told about a cesarean if the triggers were not successful. At the end of the three days, I was exhausted and confused. I had very strong suspicions of membrane detachment, because the vaginal examinations that I underwent were really very painful and traumatic. I have never been asked for my consent. »

Some of the women interviewed in the survey did not receive any information, but they were nonetheless asked for their opinion … Without information, that limits the “enlightened” nature of this decision. Finally, some of the patients interviewed felt that they were being asked for their consent, emphasizing the risks for the baby and clearly dramatizing the situation. Suddenly, these women have the impression that their hand has been forced, or even that they have been outright lied to. Problem: according to the Ciane survey, the lack of information and the fact that future mothers are not asked for their opinion seem to be aggravating factors of a difficult memory of childbirth.

Imposed induction: a less well-lived childbirth

For women who did not have information, 44% have a “fairly bad or very bad” experience of their childbirth, against 21% for those who have been informed.

At Ciane, these practices are widely criticized. Madeleine Akrich, secretary of the Ciane: “ Caregivers must empower women and give them as transparent information as possible, without trying to make them feel guilty. »

At the National College of Midwives, Bénédicte Coulm is firm: “The College’s position is very clear, we believe that women must be informed. In cases where there is no emergency, take the time to explain to expectant mothers what is happening, the reasons for the decision, and the potential risks, without trying to panic them. . So that they understand the medical interest. It is rare that the urgency is such that one cannot take the time, even two minutes, to settle down and inform the patient. ”Same story from Dr Garabedian’s side:” It is our responsibility as caregivers to explain what the risks are, but also the benefits for both mother and child. I also prefer that the father is present and that he is kept informed. You cannot care for a person without their consent. It is best to come and talk to the patient with a specialist colleague depending on the pathology, in an emergency and if the patient does not wish to be triggered. The information becomes multidisciplinary and its choice is more informed. On our side, we explain to him what we can do. It is rare not to come to a consensus. Madeleine Akrich calls for the responsibility of future mothers: “I want to say to parents, ‘Be actors! Inquire! You have to ask questions, ask, not say yes, just because you are afraid. It’s about your body and your childbirth! “

* Survey concerning 18 responses to the questionnaire of women who gave birth in a hospital environment between 648 and 2008.

** Recommendations of the National Council of Obstetrician Gynecologists (CNGOF) of 2011

In practice: how does the trigger go?

There are many ways to induce the artificial placement of labor. The first is manual: “It consists of a detachment of the membranes, often during a vaginal examination.

By this gesture, we can cause contractions that will act on the cervix, ”explains Dr Garabedian. Another technique known as mechanical: “the double balloon” or the Foley catheter, a small balloon that is inflated at the level of the cervix which will put pressure on it and induce labor. 

The other methods are hormonal. A prostaglandin-based tampon or gel is inserted into the vagina. Finally, two other techniques can be used, only if the cervix is ​​said to be “favorable” (if it has started to shorten, open or soften, often after 39 weeks). It is artificial rupture of the water bag and synthetic oxytocin infusion. Some maternities also offer gentle techniques, such as placing acupuncture needles.

The Ciane survey revealed that the patients questioned were only 1,7% to have been offered the balloon and 4,2% acupuncture. In contrast, oxytocin infusion was offered to 57,3% of expectant mothers, followed closely by the insertion of a prostaglandin tampon in the vagina (41,2%) or a gel (19,3, XNUMX%). Two studies are in preparation to assess the outbreak in France. One of them, the MEDIP study, will start at the end of 2015 in 94 maternities and will concern 3 women. If you are asked, do not hesitate to respond!

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