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Welcome to our pain management, induction, assisted and caesarean birth padlet

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What is an assisted birth? A short NHS video. 

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What is an assisted birth? A short NHS video. 

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Find out about assisted birth or assisted delivery, which uses forceps or vacuum (ventouse) to get your baby out.

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What pain relief do women use in labour? 

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What pain relief do women use in labour? 

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Pain management: opioids (pethidine, diamorphine) 

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Pain management: opioids (pethidine, diamorphine) 

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Pain management: breathing and relaxation 

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Pain management: breathing and relaxation 

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Pain Management - a comparison from the  Obstetric Anaesthetists’ Association

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Pain Management - a comparison from the  Obstetric Anaesthetists’ Association

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Worcestershire Acute Hospitals NHS Trust

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The aim of this Cochrane Review is to find out if membrane sweeping is a safe and effective way of inducing labour at or near term and if it is more effective than the formal methods of induction.

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We included 44 studies (20 new to this update), reporting data for 6940 women and their infants. We used random-effects throughout.

Overall, the risk of bias was assessed as low or unclear risk in most domains across studies. Evidence certainty, assessed using GRADE, was found to be generally low, mainly due to study design, inconsistency and imprecision. Six studies (n = 1284) compared membrane sweeping with more than one intervention and were thus included in more than one comparison.

No trials reported on the outcomes uterine hyperstimulation with/without fetal heart rate (FHR) change, uterine rupture or neonatal encephalopathy.
Forty studies (6548 participants) compared membrane sweeping with no treatment/sham
Women randomised to membrane sweeping may be more likely to experience:

· spontaneous onset of labour (average risk ratio (aRR) 1.21, 95% confidence interval (CI) 1.08 to 1.34, 17 studies, 3170 participants, low-certainty evidence).

but less likely to experience:

· induction (aRR 0.73, 95% CI 0.56 to 0.94, 16 studies, 3224 participants, low-certainty evidence);

There may be little to no difference between groups for:

· caesareans (aRR 0.94, 95% CI 0.85 to 1.04, 32 studies, 5499 participants, moderate-certainty evidence);

· spontaneous vaginal birth (aRR 1.03, 95% CI 0.99 to 1.07, 26 studies, 4538 participants, moderate-certainty evidence);

· maternal death or serious morbidity (aRR 0.83, 95% CI 0.57 to 1.20, 17 studies, 2749 participants, low-certainty evidence);

· neonatal perinatal death or serious morbidity (aRR 0.83, 95% CI 0.59 to 1.17, 18 studies, 3696 participants, low-certainty evidence).
Four studies reported data for 480 women comparing membrane sweeping with vaginal/intracervical prostaglandins
There may be little to no difference between groups for the outcomes:

· spontaneous onset of labour (aRR, 1.24, 95% CI 0.98 to 1.57, 3 studies, 339 participants, low-certainty evidence);

· induction (aRR 0.90, 95% CI 0.56 to 1.45, 2 studies, 157 participants, low-certainty evidence);

· caesarean (aRR 0.69, 95% CI 0.44 to 1.09, 3 studies, 339 participants, low-certainty evidence);

· spontaneous vaginal birth (aRR 1.12, 95% CI 0.95 to 1.32, 2 studies, 252 participants, low-certainty evidence);

· maternal death or serious morbidity (aRR 0.93, 95% CI 0.27 to 3.21, 1 study, 87 participants, low-certainty evidence);

· neonatal perinatal death or serious morbidity (aRR 0.40, 95% CI 0.12 to 1.33, 2 studies, 269 participants, low-certainty evidence).
One study, reported data for 104 women, comparing membrane sweeping with intravenous oxytocin +/- amniotomy
There may be little to no difference between groups for:

· spontaneous onset of labour (aRR 1.32, 95% CI 88 to 1.96, 1 study, 69 participants, low-certainty evidence);

· induction (aRR 0.51, 95% CI 0.05 to 5.42, 1 study, 69 participants, low-certainty evidence);

· caesarean (aRR 0.69, 95% CI 0.12 to 3.85, 1 study, 69 participants, low-certainty evidence);

· maternal death or serious morbidity was reported on, but there were no events.
Two studies providing data for 160 women compared membrane sweeping with vaginal/oral misoprostol
There may be little to no difference between groups for:

· caesareans (RR 0.82, 95% CI 0.31 to 2.17, 1 study, 96 participants, low-certainty evidence).
One study providing data for 355 women which compared once weekly membrane sweep with twice-weekly membrane sweep and a sham procedure
There may be little to no difference between groups for:

· induction (RR 1.19, 95% CI 0.76 to 1.85, 1 study, 234 participants, low-certainty);

· caesareans (RR 0.93, 95% CI 0.60 to 1.46, 1 study, 234 participants, low-certainty evidence);

· spontaneous vaginal birth (RR 1.00, 95% CI 0.86 to 1.17, 1 study, 234 participants, moderate-certainty evidence);

· maternal death or serious maternal morbidity (RR 0.78, 95% CI 0.30 to 2.02, 1 study, 234 participants, low-certainty evidence);

· neonatal death or serious neonatal perinatal morbidity (RR 2.00, 95% CI 0.18 to 21.76, 1 study, 234 participants, low-certainty evidence);

We found no studies that compared membrane sweeping with amniotomy only or mechanical methods.

Three studies, providing data for 675 women, reported that women indicated favourably on their experience of membrane sweeping with one study reporting that 88% (n = 312) of women questioned in the postnatal period would choose membrane sweeping in the next pregnancy.

Two studies reporting data for 290 women reported that membrane sweeping is more cost-effective than using prostaglandins, although more research should be undertaken in this area.

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Membrane sweeping for induction of labour

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We included 44 studies (20 new to this update), reporting data for 6940 women and their infants. We used random-effects throughout. Overall, the risk of bias was assessed as low or unclear risk in most domains across studies. Evidence certainty, assessed using GRADE, was found to be generally low, mainly due to study design, inconsistency and imprecision.

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Induction of labour at or before 42 weeks of pregnancy: new evidence

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Induction of labour at or before 42 weeks of pregnancy: new evidence

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Their paper is freely available and describes a cohort study based on data from women in Denmark (Rydahl et al 2019). They looked at what happened before and after the recommended timing of induction of labour was changed from 42 weeks of pregnancy to 41+3 weeks of pregnancy. Rydahl et al (2019) looked at lots of outcomes and compared what happened during the two time periods in which the different induction of labour protocols (or recommendations) were in place.

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Another study has added to our knowledge about induction of labour at or before 42 weeks of pregnancy.

This topic has been in the news probably more than any other pregnancy and childbirth related issue in recent months. I have also spent a lot of time debunking and challenging some of the spin that has been put on this issue. The latest study has been published by Rydahl et al (2019), and their study shows that the evidence isn't nearly as clear-cut as some people and organisations would like us to believe.

Their paper is freely available and describes a cohort study based on data from women in Denmark ( Rydahl et al 2019). They looked at what happened before and after the recommended timing of induction of labour was changed from 42 weeks of pregnancy to 41+3 weeks of pregnancy. Rydahl et al (2019) looked at lots of outcomes and compared what happened during the two time periods in which the different induction of labour protocols (or recommendations) were in place.

What did they find?

The researchers found that there were no differences in stillbirths, perinatal deaths or low Apgar scores, which are considered to be the most important short-term, physical outcomes. However, in the time period in which women were offered earlier induction, there were more inductions (which one would expect) and women experienced more interventions. Not just those which are part of the induction process, but other kinds as well. This isn't new or particularly surprising; we know that intervention tends to lead to more intervention.

In Rydahl et al's (2019) study, earlier induction of labour was also associated with an increase in uterine ruptures. The rate went from 2.6 per thousand to 4.2 per thousand. Again, this is not entirely surprising. Iduction of labour often involves the use of powerful drugs which stimulate the uterus to contract, and these can sometimes stimulate the uterus too much. But this finding is worrying, and serves as a reminder that induction of labour is associated with possible risks and negative consequences as well as possible benefits.

So what do the findings tell us about induction of labour at or before 42 weeks?

The findings of this study show that there was no advantage to bringing the nationally recommended induction date forward from 42 weeks to 41+3 weeks ( Rydahl et al 2019). This will be a moot point in many areas of the world, as induction of labour is already recommended before 42 weeks weeks. But this data is still quite important right now, not least because of a Swedish study which recently made media headlines when it was stopped because of concerns about stillbirth. The fact that the Danish data shows that stillbirth rates did not differ between 41+3 and 42 weeks is significant for women's decision making. It highlights the very uncertain nature of our knowledge in this area and the fact that there are more factors to take into account than population-level data which is not considered in the context of the individuals concerned.

Some people and organisations are calling for earlier and earlier induction, either as a population-level policy or in certain groups of women who are deemed to be at higher risk (often without good evidence that induction of labour will do anything to lessen the chance of a problem). But it is clear that there is more to this picture than they would have people believe.

Where do we go from here?

If you would like to know more about induction of labour, I have a whole page of resources on this website and a book which helps explain the issues and the evidence.

We need more than this, though.

It is also really clear to me that we need to do more to help women and families understand this topic and the evidence that relates to it, and in 2020 we are offering new and updated online courses which will help midwives and birth folk to focus in on this area and develop their skills and confidence in understanding this data and discussing induction-related research with their clients. If you'd like to know when these are launched, jump onto my newsletter list, which means you'll also receive my free, monthly Birth Information Update.

Rydahl E, Declerq E, Juhl M et al (2019). Routine induction in late-term pregnancies: follow-up of a Danish induction of labour paradigm. BMJ Open 9:12. https://bmjopen.bmj.com/content/9/12/e032815

Would you like me to email you a relevant, reliable, regular update?

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Induction of labour at or before 42 weeks of pregnancy: new evidence - Dr Sara Wickham

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Another study has added to our knowledge about induction of labour at or before 42 weeks of pregnancy. This topic has been in the news probably more than any other pregnancy and childbirth related issue in recent months. I have also spent a lot of time debunking and challenging some of the spin that has been put on this issue.

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Ten Things ...I wish every woman knew about induction of labour by Midwife Sara Wickham

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Ten Things ...I wish every woman knew about induction of labour by Midwife Sara Wickham

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Dr Sara Wickham - author, speaker, researcher. Evidence-based pregnancy and birth information for women, families, midwives and birth folk.

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🎈 A Balloon Catheter - used to aid the Induction of Labour (IOL) 🎈 

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🎈 A Balloon Catheter - used to aid the Induction of Labour (IOL) 🎈 

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The aim of using a double balloon catheter is to help induce labour by causing the cervix to soften and dilate. It is usually done with the birthing person lying on their back, often with their legs in stirrups. A sterile speculum is put into the vagina, so the cervix can be cleaned using an antiseptic.

The catheter is then inserted so that 1 balloon is in the uterus and 1 is in the vagina. The balloons are slowly and alternately inflated with saline. When the balloons are fully inflated and in place on both sides of the cervix, the speculum is removed. The end of the catheter is loosely taped to the inner thigh.

The device is left in place for about 12 - 24 hours. Both the birthing person and baby are monitored during the procedure. If labour begins, the device comes out, the waters break, or the baby seems to be in distress, the balloons are deflated and the device is removed. If labour does not begin, the waters are broken artificially and an oxytocin infusion is started (NICE, 2015)

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What skin to skin can look like for a cesarean birth.

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What happens during a planned Cesarean birth? A short NHS video. 

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What happens during a planned Cesarean birth? A short NHS video. 

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(please note breech does not automatically mean cesarean birth, skin to skin and even breastfeeding your baby is possible in theatre!)

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Planned caesarean section at North Bristol NHS Trust

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Planned Caesarean Birth advice from RCOG

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Planned Caesarean Birth (Consent Advice No. 14) | RCOG

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This guidance is for healthcare professionals to aid the provision of appropriate and balanced information about the potential benefits, risks and alternative modes of childbirth to those considering a planned (elective) caesarean birth.

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This film follows Pandora and Matthew as they experience a more gentle, woman centered approach to Cesarean birth. 

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This film follows Pandora and Matthew as they experience a more gentle, woman centered approach to Cesarean birth. 

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Lots to think about here, especially if you are having a planned cesarean or are writing a plan- c for your preferences.

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Jentle Childbirth Foundation Natural Caesarean

Shot in one day, this film follows Pandora and Matthew as they experience a more natural approach to caesarian childbirth. With a crew of two, so as not to disrupt proceedings, we documented the birth process and interviewed key people to gain insight into the technique. The film was produced on a very tight budget as part of an ongoing campaign to make caesarian sections a more natural experience for the baby and parents alike. It has achieved over 500,000 views on YouTube and has been used in a news reports across the US.

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Jentle Childbirth Natural Caesarean - Flutterby Films

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Shot in one day, this film follows Pandora and Matthew as they experience a more natural approach to caesarian childbirth. With a crew of two, so as not to disrupt proceedings, we documented the birth process and interviewed key people to gain insight into the technique.

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Doula UK - The non-profit association of doulas in the UK

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Doulas support the whole family to have a positive experience of pregnancy, birth and after the birth of a baby. Find a doula to support you.

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When babies are born vaginally they pass down the birth canal and pick up this ‘starter kit’ of vaginal/gut bacteria, which establish baby’s microbial communities and help train the immune system, during a caesarean birth this doesn’t happen so the baby potentially starts life with a different set of microbes and this matters!

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There are many reasons why a baby might need to be born by caesarean, from maternal choice to placenta previa (when the placenta blocks the cervix), it's fantastic that caesarean births are an option, there are countless infants whose lives have been saved by them. On a personal note we might not still have our eldest if we couldn't have gone to caesarean to get him out when he needed it. I'm delighted and grateful that he could be born by caesarean! But if I had know more about the microbiome 19 years ago when he was born, I would have done more to protect his, which might have meant a life without the medical conditions he now lives with.

When babies are born vaginally they pass down the birth canal and pick up this 'starter kit' of vaginal/gut bacteria, which establish baby's microbial communites and help train the immune system, during a caearean birth this doesn't happen so the baby potentially starts life with a different set of microbes and this matters.

VAGINALLY DELIVERED INFANTS HAD BACTERIAL COMMUNITIES RESEMBLING THEIR OWN MOTHER'S VAGINAL MICROBIOTA.C-SECTION INFANTS HARBOURED BACTERIAL COMMUNITIES SIMILAR TO THOSE FOUND ON THE SKIN SURFACE

"There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. "

Increasingly though from being a little used, absolute emergency procedure, caesarean birth has become incredibly widespread; in 2015 worldwide an estimated 29·7 million (21·1%) births occurred by caesarean. This matters because babies born by caesarean are at increased risk of both short term and long term health alternations:

It is thought that while there is an epigentic element to this (the experience of labour 'turns on' genes) but mostly alterations to the baby's initial microbes are thought to be significant, because even though after a few weeks the microbiomes of caesarean and vaginally born babies look more similar, some differences remain . More importantly it is the training of the immune responses that happened at the start of life that can can have consequences throughout a lifetime.

Training the immune system

To coexist with the trillions of bacteria we live around every day our immune systems have to juggle which are 'friendly' and which are 'foe'. The fact that some are allowed to live in us is quite amazing as our entire immune system is designed to fight off foreign invaders.

"Once you're born, you're assaulted by billions of bacteria, so if the babies' [immune systems] responded in the appropriate adult manner, they would just be auto-inflammatory bundles," says Grace Aldrovandi, a professor of pediatrics at the University of California, Los Angeles. "The [question] then is: How does the immune system learn when to relax and when to respond?"

It is thought that the first microbes we encounter are the ones that 'train' the immune system - so what gets in first matters. If the immune system is incorrectly trained it can result in autoimmune responses such as asthma or allergies and later in life by more serious conditions.

It's really important to remember that caesarean is a good, safe option for birth. Protecting the microbiome just helps redress any potential alterations and effects on the microbial start in early life. I am so grateful that my eldest be born by caesarean when he needed it.

This is just about doing better at every birth and giving every baby the best bacterial start.

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There are many reasons why a baby might need to be born by caesarean, from maternal choice to placenta previa (when the placenta blocks the cervix), it's fantastic that caesarean births are an option, there are countless infants whose lives have been saved by them.

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This Aims article is very statistical so I think this excerpt from it is very helpful:
“So, we have ten years of data which consistently shows that the stillbirth and perinatal mortality rates have been lower for women birthing at 42+ weeks than for those who birthed at 37 - 42 weeks. The numbers of women concerned is huge; around 20,000 women every year take part in the natural experiment of allowing pregnancy to continue until 42 or more weeks"

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To read or download this Journal in a magazine format on ISSUU, please click AIMS Journal, 2019, Vol 31, No 1 By Debbie Chippington Derrick and Nadia Higson here
It is very common for women to be told they need to have their labour induced before 42 weeks because otherwise they are at increased risk of stillbirth. Here we look to see if the evidence actually supports this belief.

There are different types of evidence that might help us answer this question, but unfortunately this evidence is contradictory, and there has been much contention about whether induction of labour should be offered to women purely on the basis of longer pregnancy. Term birth is defined as a birth that occurs anywhere between 37 and 42 weeks of pregnancy, with births after 42 weeks being classed as 'post-term'. However, induction of labour at some point after 40 weeks of pregnancy has been routinely carried out by some in obstetrics since the 1970s.
What do the guidelines say?

Definitions used in this article

' Stillbirths ' refers to deaths which occur before birth. It can be sub-divided into antepartum stillbirths (those which occur before the start of labour) and intrapartum stillbirths (which are where a baby was alive at the start of labour but shows no signs of life at birth and cannot be resuscitated).

' Neonatal deaths ' are where babies who were born alive die in the first week of life.

' Perinatal deaths ' are the total of all stillbirths and neonatal deaths.

It is normal to give rates of stillbirths and perinatal deaths as deaths per 1000 births, whilst neonatal deaths are given as per 1000 live births.

The NICE Guidelines on Induction of labour and the update both recommend that induction is offered between 41 and 42 weeks of pregnancy, stating that there appears to be a reduction in perinatal deaths with induction of labour at this point, compared with waiting beyond 42 weeks. The NICE update mainly bases this on the Cochrane review. There has since been another Cochrane review which has the same conclusion and we can expect to see the NICE guidelines which will be published in July 2020 to repeat this information and the recommendation for induction purely on the basis of longer gestation. However, these reviews do acknowledge that the risk of stillbirth appears to be very low in longer pregnancies and the latest one suggests it would be necessary to induce 426 women around 41 to 42 weeks to avoid one stillbirth.

Types of Research

The Cochrane reviews are what is called a meta-analysis which combine the data from a number of research trials. One problem with this type of review is that the results can vary depending which trials the authors choose to include. Other reviews which have addressed the same question have reached different conclusions. For example, one which looked only at studies of induction at 41 weeks or beyond found no evidence that this was beneficial. Another, which included only trials published since 1990 found no significant difference in perinatal mortality whether labour was induced before 42 weeks or not.

Population Studies
UK Confidential Enquiries
Another type of information comes from population studies, which looked back at the records of outcomes for mothers who gave birth at different gestations. Although it's true that some of these have shown a rise after 40 weeks in stillbirth rates or perinatal death rates (which includes stillbirths and deaths in the first week of life), the risk remains low, and is no greater at 42+ weeks than it was at 37 weeks. The two graphs below show the data from these studies.

Most years since 2005 the UK confidential enquiries have reported on the data collected from the 20,000 or so women whose pregnancies have continued to week 42 or beyond and these mothers have provided us with a more recent UK based population study. This current article is based on an update of the detailed analysis of this data previously published by Margaret Jowitt.

What the confidential enquiries enable us to do is to look at how the outcomes of post term pregnancies compare with the outcomes of pregnancies where birth took place between 37and 42 weeks. The last 10 Confidential Enquiry reports, from between 2004 and 2016, have consistently shown that the risk of stillbirth and neonatal death is lower for mothers who birth beyond 42 weeks than it is for all those who birth at term.

The UK has made concerted efforts to bring down the perinatal mortality rate since 1991 when the Confidential Enquiries into Death and Stillbirth in Infancy (CESDI) was set up, and rates have steadily declined. These Confidential Enquiries look at some cases in greater detail to try and also try to tease out common factors in stillbirths and neonatal deaths. They look at factors like maternal age, ethnicity, birth weight and length of gestation. CESDI reporting was combined with Confidential Enquires into Maternal Death to become CEMACH in 2003 and from 2008 was renamed CMACE and run by the RCOG. In 2012 the contract for the work went to the National Perinatal Epidemiology Unit in Oxford and was renamed Mothers and Babies, Reducing Risk through Confidential Enquiries (MBRRACE-UK), leading to a gap in reporting, and therefore no reports for 2010 and 2012.

The Confidential Enquiries provide data for the whole of the UK giving numbers of stillbirths, (which since the reports in 2014 have been broken down into antepartum stillbirths and intrapartum stillbirths) and of neonatal deaths.

Induction of labour at some point before 42 weeks of pregnancy is being offered in an attempt to prevent antepartum stillbirth. In situations where this happens, no one, parents or health care providers can avoid the feeling that if only labour had been induced earlier, these babies might have lived. Antepartum stillbirths outnumber intrapartum stillbirths by a factor of 10:1 and so it is thought that the greatest scope for reducing the stillbirth rate is by inducing labour earlier. Whilst this may appear logical, we need to consider whether this recommendation is supported by the evidence. Women are often put under pressure to accept induction particularly at 41 weeks and certainly as they approach 42 weeks. Induction, however, is not without risk for both mother and baby,.

Even when trials are pooled in a meta-analysis such as the Cochrane review mentioned above, the numbers of births included in these studies are still very small compared to whole population statistics. In contrast, the huge numbers of births included in the data collected by MBRRACE-UK and its predecessors can help to give a clearer picture of the issue. While these statistics cannot provide an answer to the question as to whether induction protects against stillbirth, they do provide clear information about how many stillbirths and neonatal deaths occur in pregnancies in the UK which continue beyond 42 weeks, and give a comparison with the rates for preterm births (before 37 weeks) and at term (between 37 weeks to 41 weeks + 6 days).

Data from MBRRACE-UK and its predecessors

The following table provides the data from the reports between 2004 and 2016. The data collected and how it is presented has changed over the years. For example, in some years, details for each week of gestation were given, whilst other reports gathered together the data for several weeks. Nevertheless, the data still tells the same story
* Note: this figure was not given in the report
It can be clearly seen that none of the Confidential Enquiries reports support the statement that the risk of stillbirth increases with advanced gestation, on the contrary, the tables all show that the risk of both stillbirth and neonatal mortality is lowest at 42+ weeks.
Comparison of rates of term and 'post term' stillbirths
The data for 2005 and 2006 which was given by each week of gestation and these charts show clearly the declining rates for both stillbirth and neonatal death with gestation.

So, we have ten years of data which consistently shows that the stillbirth and perinatal mortality rates have been lower for women birthing at 42+ weeks than for those who birthed at 37 - 42 weeks. The numbers of women concerned is huge; around 20,000 women every year take part in the natural experiment of allowing pregnancy to continue until 42 or more weeks.

This data does not include numbers of congenital abnormality, and as some of the stillbirths recorded at all gestations will have been unavoidable because of congenital abnormalities, this information would provide a clearer picture. What is also lacking is classification of stillbirth rates by mode of onset of labour (spontaneous, induction or pre-labour caesarean).

Office of National Statistics Data

Another set of data, covering England and Wales, comes from the Office for National Statistics 'Birth Characteristics' reports. Although it records the same births and deaths, this data comes from birth registrations and "where relevant, birth registrations are linked to their corresponding NHS birth notification to enable analysis of further factors such as gestation of live births". Therefore the figures are slightly different, but show similar patterns to the findings which were reported by CEMACH, CMACE and MBRRACE. The live birth and stillbirth number by gestational age are available from 2014 to 2017 and the table below shows the rates for gestations of 37 weeks onwards. Again, it can be seen that there is no rapid rise is stillbirth rates beyond 40 weeks.

Conclusion

Currently, women are being led to believe that there is a high chance that their baby will die if they continue with their pregnancy beyond 42 weeks. However, even those studies which appear to show a protective effect of induction before 42 weeks make it clear that the risks of continuing pregnancy beyond this point are extremely low; and the evidence presented in this article does not shows that women who are making the decision to continue their pregnancy beyond 42 weeks are encountering increased risk of stillbirth. It also shows that the rate of perinatal mortality is lowest at 42+ weeks.

Health care providers need to understand what this data shows and share it with women to allow them to make informed decisions about whether, or not, to accept induction.

We appeal to MBRRACE to reinstate the reporting by week of gestation instead of grouping the data as they have done in recent reports. We also call on the NICE Induction Guideline Development Group to consider and report on this data, and hope to see this included when the document comes out for consultation before its publication in July 2020.

REFERENCES

1. NICE Evidence Update (44). 2013 Induction of Labour, www.nice.org.uk/guidance/cg70/documents/cg70-induction-of-labour-evidence-update2

2. Wennerholm UB et al. December 2010. Induction of labor versus expectant management for post-date pregnancy: is there sufficient evidence for a change in clinical practice? Acta Obstet Gynecol. 88:6-17. obgyn.onlinelibrary.wiley.com/doi/full/10.1080/00016340802555948

3. Confidential Enquiry into Maternal and Child Health. Perinatal Mortality Surveillance, 2004: England, Wales and Northern Ireland. London: CEMACH; 2006.
www.hqip.org.uk/resource/cmace-and-cemach-reports/#.XNyG2o70nZQ

4. Confidential Enquiry into Maternal and Child Health. Perinatal Mortality
Surveillance, 2005: England, Wales and Northern Ireland. London: CEMACH; 2007.
www.hqip.org.uk/resource/cmace-and-cemach-reports/#.XNyG2o70nZQ

5. Confidential Enquiry into Maternal and Child Health. Perinatal Mortality
Surveillance, 2006: England, Wales and Northern Ireland. London: CEMACH; 2008.
www.hqip.org.uk/resource/cmace-and-cemach-reports/#.XNyG2o70nZQ

6. Confidential Enquiry into Maternal and Child Health. Perinatal Mortality
Surveillance, 2007: England, Wales and Northern Ireland. London: CEMACH; 2009.
www.publichealth.hscni.net/sites/default/files/Perinatal%20Mortality%202007.pdf

7. Centre for Maternal and Child Enquiries (CMACE) Perinatal Mortality 2009:
www.publichealth.hscni.net/sites/default/files/Perinatal%20Mortality%202009.pdf
United Kingdom. CMACE: London, 2011.

8. Manktelow BM, Smith LK, Evans TA, Hyman-Taylor P, Kurinczuk JJ, Field DJ, Smith PW, Draper ES, on behalf of the MBRRACE-UK collaboration. Perinatal Mortality Surveillance Report UK Perinatal Deaths for births from January to December 2013. Leicester: The Infant Mortality and Morbidity Group, Department of Health Sciences, University of Leicester. 2015
www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20-%20Perinatal%20Surveillance%20Report%202013%20-%20Supplementary.pdf

9. Manktelow BN, Smith LK, Seaton SE, Hyman-Taylor P, Kurinczuk JJ, Field DJ, Smith PW, Draper ES, on behalf of the MBRRACE-UK Collaboration. MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births from January to December 2014. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester. 2016.
www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK-PMS-Report-2014.pdf

AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services..

AIMS Journal articles on the website go back to 1960, offering an important historical record of maternity issues over the past 60 years. Please check the date of the article because the situation that it discusses may have changed since it was published. We are also very aware that the language used in many articles may not be the language that AIMS would use today.

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Published on 23rd May 2019

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Do stillbirth rates DROP after 42 weeks? | AIMS

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Debbie Chippington Derrick and Nadia Higson look at what the evidence from the confidential enquiries says about the chance of stillbirth when pregnancies go beyond 42 week

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Some ideas for writing a set of caesarean birth preferences 

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Some ideas for writing a set of caesarean birth preferences 