I think we have all seen this at some point in our working lives: you walk into the antenatal ward, or the ward used for induction of labour (IOL), at the start of your shift and are greeted with the scene of women lying woefully on their beds. Their partners are sat next to them, reading the paper, and they’re all looking at you expectantly (excuse the pun!), as if you can free them from this endless wait for labour to begin.
When you speak to them to introduce yourself, they will tell you that they are experiencing contractions, irregularly and painfully, or that nothing is happening at all. They are all at different stages, ranging from having had one or two doses of prostaglandin gel over the course of the day, or they are able to have an artificial rupture of membranes (ARM) and are awaiting admission to the labour ward. Some may be waiting for a syntocinon infusion, as they had ruptured their membranes over the previous day or so.
Often the labour ward is too busy to take them immediately, so this means more resting in bed and longing looks in the midwife’s direction, that eventually become pretty hostile in some cases. We monitor them and their babies and continue to wait. Very occasionally, a fetus will become distressed by a hypertonic uterus and the woman will be rushed over to the labour ward, while the other women look on with jealousy, little realising that this is a serious situation for the baby, and not a necessarily pleasant one for the mother either.
But there is something that can be done to help nature, or prostaglandins, along – although the suggestion will probably not be greeted very enthusiastically. That suggestion is to get up and get walking. I don’t mean the usual slow amble of the heavily pregnant woman, but a brisk, energetic walk with her partner, and not just for ten minutes either; it should last for at least half an hour, then back for a rest and a listen to the fetal heart, and if no change, then send them off for another walk.
As long as the woman is well and the fetal heart is normal there is no risk in this, and it stimulates labour in many women. We are also all familiar with the positive action of ambulation on fetal positioning and descent.
I looked after a woman while she awaited syntocinon, as her membranes had ruptured the night before. She was very unhappy, and was getting the odd, painful tightening, which she was feeling far more intensely than she should because she was becoming anxious. After doing observations on her and her baby, I encouraged her to go out for a walk. I was caring for other women, and she kept coming back to the unit for auscultation of the fetal heart and her observations. When I started the shift she was 2cm and when I left, she was labouring well, contracting four in 10, using Entonox alone for pain relief and had progressed to 8cm. The fetus was OA and +1 below the spines. She had a normal birth, with no IV syntocinon, no cannula, no continual fetal monitoring, and she was hardly ever on the bed. She was thrilled with her birth experience.
Another woman came to me on the labour ward for ARM at 2cm and syntocinon. After performing the ARM, I did 20 minutes of CTG to ensure fetal wellbeing and – you guessed it – sent her off walking. She came back after about three quarters of an hour experiencing good, regular contractions. I continued with intermittent auscultation throughout labour and left her in the capable hands of the night midwife. The woman was thrilled to be 9cm dilated.
The highlight of this shift was when my client was having 10 minutes on the CTG to assess fetal wellbeing and the medical team came round to review. My client was very disturbed by five people crowding into the tiny room – she’d written in her care plan that she only wanted one midwife in the room with her – and I tried to encourage a quick assessment as everything was progressing well.
The consultant spoke to her, telling her that she may need a ‘hormone drip’ to speed up contractions. I couldn’t help feeling amused and politely pointed out that she had been having contractions six in 10 for quite a while with absolutely no fetal distress – something I had never seen before without IV syntocinon or prostaglandin IOL, usually resulting in a stressed fetus – and asked if the medical team wanted eight in 10 instead! When the consultant realised this, he laughed and asked where she went for her walk, so he could send other women there who need IOL.
The titration of syntocinon
Another interesting reflection is the titration of syntocinon in IOL. We have probably all been in the frustrating situation of increasing the titration to obtain adequate contractions, but also find that this level induces fetal distress, often in the form of a bradycardia, which necessitates the syntocinon being stopped, then re-started gradually when the fetus is no longer distressed, thus prolonging the labour and often resulting in rebound fetal tachycardia.
I asked a senior consultant if we, as midwives, could bypass the prescribed titrations, and increase the dosage by half the particular titration that resulted in fetal distress – making it somewhere in the centre of the lower and upper doses? He replied that he saw no problem with this, as long as we got a consultant’s approval first. I wonder if this could be done on a wider scale, what the outcomes would be? We would be able to use our skilled judgment more effectively, as midwives are the professionals who are most aware of the wellbeing of the fetus we are caring for, and the progress of the labour.
It would be very interesting to perform a controlled trial on midwife-led titration of syntocinon, to keep the dosage as low as possible while ensuring effective contractions, and to assess its effectiveness on a wider scale than just reflection, and any positive effects on lessening fetal distress, and subsequent caesarean section rates.
I would love to hear what other midwives have to say about using fast walking to help induce labour, and the titration of syntocinon, and how much control they have with this in their particular unit.
Labour ward midwife
What are your experiences of using a brisk walk to help induce labour? Join the discussion at: http://communities.rcm.org.uk