Informed consent and induction of labour at term gestation: process and implications

Abstract

Induction of labour is the most common intervention in maternity care. Induction of labour rates accounted for 20.4% of births in England in 2007/08, 29.4% in 2016/17, 31.6% in 2017/18, and 34% in 2022/23. While induction is sometimes indicated for clinical reasons, there is also concern that the rising rates do not always reflect clinical need, and it is not clear what health professionals and service users views and experiences are. Whilst there are some studies in this area, they tend to examine the views of service users only, and many studies are focused on induction for simple post maturity. In contrast, this study examines the issue of induction of labour in one NHS Trust (where the rate of induction at the time of the study was almost 50%) from the point of view of women with and without medical complications and the views of both midwives and obstetricians.
It is important to note that the interest of this study focuses on how informed consent for induction of labour is used in the United Kingdom. Different legal structures mean that this might not be the same in other countries. In the United Kingdom for example, the fetus does not have a legal status until it is born but this is not the case in other countries.
Following a systematic review of the current literature in this field, this study used questionnaires, interviews, and a discussion group to explore the experiences, views, and beliefs of maternity service users about how they gain information regarding induction of labour and how it affects their overall birth experience, as well as examining the views, beliefs and experiences of midwives and obstetricians.

Questionnaires were distributed to women being admitted to the antenatal ward for induction of labour in one NHS Trust over a six-week period with 98 women undertaking the questionnaire. Four semi-structured interviews were undertaken with postnatal women who had had their labour induced to discuss their birth experiences, with one written account also being received. Five semi-structured interviews were undertaken with midwives and obstetricians for their views and beliefs around informed consent and what factors impact upon this process when discussing induction of labour with women. A discussion group with midwifery birth suite co-ordinators and two ward managers (five staff members) was then undertaken to explore their views and experiences of looking after women having their labour induced and the impact upon women, the staff looking after them as well as the maternity unit environment in terms of being equipped from a resource perspective.

The study revealed that women were being induced for a variety of different reasons. These were reflective of the rise in diabetes and other medical complexities as well as the option for maternal request in the absence of any other rationale. In contrast to many other studies in this area, most of those responding to the questionnaire and taking part in the qualitative data collection, reported being happy to be offered induction. This may be because 85.2% of respondents (n=86) and all the service user interviewees were being induced for medical complications, rather than for uncomplicated pregnancies that proceeded beyond 41 week’s gestation. The questionnaire and interview findings highlighted that women use a variety of sources to obtain additional information including the induction of labour information leaflet, the internet, social media, partners, friends, and family. From a birth experience viewpoint, the interview findings highlighted that women’s retrospective views ranged between extremely positive to extremely negative. Although physical events involved with the induction process had a significant impact on women’s perceptions of induction of labour, relationships with health professionals were also an important factor.

The study revealed the individual nature of each woman’s account of her experiences, and that overall perceptions of induction were affected by multiple factors, including women’s individual personalities as well as their expectations for induction. Despite women feeling overall well informed, the questionnaires and interview findings showed there were some gaps in women’s knowledge about various aspects of the induction of labour processes. The disparity between expectations of induction and reality highlighted that some of the women were not fully prepared for the duration, intensity, how they would experience induction and the potential implications of an induced labour.

From the interviews with health professionals, findings highlighted how protective steering may impact on obtaining informed consent, the nature of informed consent in current practice and how the health professional as ‘second victim’ may impact upon the informed consent process. Suggestions by health professionals for improvements to assist with informed consent highlighted the need for more information on various aspects of the induction of labour processes during the antenatal period when discussing induction. These included statistics associated with risk and also accessibility of information and guidance to share with women, particularly in the community setting. Continuity of carer, improved hospital resources to meet demand, accessible information for more marginalised women and for staff in all settings, antenatal education about induction, birth choices/pre induction of labour clinics, staff education, and induction consent forms detailing risks and benefits were all noted by health professionals as having the potential to improve informed consent. Suggestions such as innovations around outpatient induction and balloon induction of labour were proposed. These have been discussed to mitigate some of the disconnect between expectation and experience. However, there are gaps in the scientific evidence about the acceptability, equity, feasibility, and efficacy of these approaches.

Overall, the study highlighted the scope available for improvements to the informed consent provision for induction of labour for women being offered induction for medical complications, to take account of how it might be experienced and how long it may take, and to acknowledge the environment in which it takes place, including how staff experience the rising rates of labour induction on their workload and capacity to provide optimal care.