Horizon (1964) Episode Scripts

N/A - A Time to Be Born

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'This woman is about to have a baby.
' HEARTBEA 'She's had her labour induced, 'artificially started by the use of a hormone, oxytocin.
'This hormone, fed into the bloodstream throughout labour, 'controls her contractions up to the moment of birth.
'In some hospitals, over half the expectant mothers are induced.
'The timing and progress of their labour is decided for them 'by their doctor.
For thousands of women, 'the experience of giving birth has been totally changed.
' I think, undoubtedly, our induction policy has changed.
I think we may be looking at the shape of obstetrics to come.
Um Something awfully nice about having a baby all by all by plan, shall we say - a nice night's sleep, comes up onto labour up onto the labour suite floor in the morning at nine o'clock, is simply induced, has it all over by tea-time, another night's sleep after it.
There's something cool, calm and collected about it.
'But not everyone agrees.
'Induction is the subject of a fierce debate 'among the medical profession.
'Many doctors are raising serious doubts about the safety 'of the technique, the necessity for so many inductions, 'and the desirability of high-technology birth.
' Women regard having a baby as a natural process, and why shouldn't they? It is a natural process, and generally speaking, it's a very safe one, and the role of the obstetrician is really to stand by and see that safety is maintained.
His role is not to produce safe conditions.
It does seem to me that we've got carried away with technology and that technology has now taken over.
It seems to me that we've reached the days of George Orwell's 1984 in 1974, and I am aghast at this.
Breathe through your mouth.
Give us a push.
'For every woman, the birth of her baby is a unique and special event.
' BABY CRIES Here you are.
Can you see him down here? 'But an increasing number of mothers are saying that induction of labour 'takes away their central role in the birth of their child.
'In the past, mothers had their babies when they were ready.
'Now the rapid spread of induction means babies can be planned 'to arrive on schedule when the hospital is ready.
'Many mothers now feel they've been taken over by timetables 'and high technology.
' Come on, young man.
Over we go.
'In the last three or four years, 'more and more babies have been induced.
'Why has this happened? 'Why have so many obstetricians 'adopted a policy of intensive induction? 'At the John Radcliffe Hospital in Oxford 'is one of the pioneers of the technique, Prof Alec Turnbull.
' I think it became increasingly popular on the basis of work done on the risks of prolonged pregnancy in the late '40s and early '50s.
And it was shown then that a policy of selective induction in certain high-risk patients to avoid prolonged pregnancy did then reduce the chances of babies dying in these circumstances, and these were eminently preventable deaths, occurring in normal babies where the pregnancy had gone a way past term.
It seemed only sensible, then, to avoid this.
But, of course, in those days, we just did this in the highest-risk cases, and the instance of induction was still quite low, perhaps 15 or 20% at most.
Um Then a bit later, more work was done on improving the techniques of induction, and they are now really, by and large, very efficient, and I think it was that change which began to encourage obstetricians increasingly to use induction of labour in cases with a less high risk.
'It's two in the afternoon at the John Radcliffe Hospital.
PHONE RINGS Hello, John Radcliffe reception.
'The mothers booked for induction the next morning are checking in.
' - Can I have your name? - Christine Hanswell.
- Would you like to take a seat? - Thank you.
'The increased rate of inductions has led to planned deliveries, 'with a busy hospital schedule designed to deal with a prearranged 'number of births every day.
' Mrs Winand? One second.
'The natural pattern of childbirth has been changed by this.
'Most babies are now born during a nine-till-five working day.
'Fewer babies are born at night, fewer at weekends 'and fewer during public holidays, at Christmas, 'but even at this hospital, where the induction rate is 50%, 'doctors are asking questions.
'Should so many mothers be induced? John Bonnar.
' Approximately 5 to 10% of pregnancies are complicated and need a great deal of skilled obstetric supervision and care during labour.
The induction rate appears to be climbing in the maternity services.
Now, this depends on the selection of patients going into the hospital.
If the hospital was dealing with purely complicated cases, an induction rate of 50% would, in fact, be quite low.
But in a hospital that was dealing with normal pregnancies on unselected group of pregnant mothers, an induction rate of 50% would be exceedingly high.
LOW CHATTER 'No-one disputes the use of induction 'for mothers like Mrs Valentine.
'She is one of the 10% of higher-risk cases.
'She's lost two babies already and risks another stillbirth 'if the baby isn't born soon.
' This is the first time I've been down here, ever.
Is it really? Now, let me just see your tummy.
- Did you sleep well last night? - Yes, thank you.
Well, this morning, you know we're going to get you into labour.
Just bend your knees up, just a fraction.
'Because of Mrs Valentine's complications, 'John Bonnar has no doubts that this is a very strong case for induction.
'It would be most unwise to let the pregnancy continue beyond 38 weeks.
' Well, the baby's in excellent shape.
So, I'm going to examine you internally.
'So, what happens in induction?' 'First, the membranes surrounding the baby are ruptured, 'letting out the amniotic fluid.
'Once this protective barrier is broken, the baby is open to 'the risk of infection, 'so the doctor is now committed to delivery.
' That's it.
Connect up this.
'The other part of induction 'involves fitting a catheter into the arm 'and infusing the hormone oxytocin into the mother's blood.
' 'It's this hormone that causes the uterus to contract 'and the baby to be born.
' Fine.
Thank you.
And the drip's running quite slowly.
Fine.
- Is it quite comfortable? - Yes, thank you.
Good.
You did very well.
Doing quite well, aren't I? 'Four hours after induction, Mrs Valentine is having contractions.
' Marvellous.
'But whether you're induced or not seems to depend 'more on the general policy of the hospital you attend or your doctor 'than on you and your baby.
'Why does the number of women induced 'range from below 20% in some areas 'to above 60% in others?' Wherever we've got such a wide range in the way that we manage anything, I think the answer is that people don't know and are seeking an answer.
And I think to go ahead in seeking the answer with very active intervention at very high rates without knowing whether it's doing good is irresponsible.
PHONE RINGS - Hello.
- Would you like to take a seat? - Can I have your name? - Mrs Biles.
'To find out what the new childbirth is like, 'we followed two mothers through the course of their labour.
'This is Mrs Biles.
It's her second pregnancy.
'It's 2.
30 and she's booked in.
Her baby is planned for tomorrow.
' If you'd like to come along, Mrs Biles.
Mr Biles.
- Shall I carry him? - Yes, if you want.
These are all the things that you brought? - Yes.
- Fine.
'At eight o'clock the next morning, she's taken down to the labour floor 'and to the room where she's going to have her baby.
' 'Our second mother is Mrs Lindsay.
It's her first pregnancy.
'In the last three or four years, 'doctors have extended the medical grounds 'on which they're prepared to induce a birth.
'For any one mother, there may be several medical reasons.
'One of the commonest is high blood pressure - 'just one of the reasons for Mrs Lindsay's induction.
' - Hello.
- Hello.
Well, now, listen, dear.
We've been through all this before, and I'm going to explain it all to you again, so that you know precisely what is going to happen.
Your baby is all ready to come.
You are very nearly due.
You've just got a little touch of blood pressure.
Nothing that's going to worry you and nothing that's going to worry the baby, but we feel the time has come when the baby is just going to be a little bit happier in the cot than in here.
I think a rise in blood pressure is always significant, even if it's a response to a bit of excitement and emotional stimulus.
It doesn't do the baby any good at all.
And I don't think a woman who shows an unstable blood pressure should ever be allowed to run past her date.
In something like 2 or 3% of women, nobody would dispute that the rise in blood pressure was sufficient to justify the intervention.
One might even push that figure up to as high as 5, 7%.
But small rises in blood pressure, say, just above 90, or even single rises just to 90, it's very doubtful whether these constitute a dangerous condition for the woman and her baby.
In fact, there's some evidence to suggest that such a small rise in blood pressure may even be a protective a natural protective mechanism on the part of the woman's body against the pregnant process and endeavour, really, to make up for deficiencies in the placenta, and that small rises in blood pressure might be beneficial to her and her baby.
Certainly, to say that such minimal rises are harmful in every woman is not proven.
'If raised blood pressure is being questioned, 'so is another common reason - prolonged pregnancy.
'But what are the risks in letting a baby go beyond term, 40 weeks?' The danger to the baby doesn't really begin to increase until something like 42 weeks.
And if we leave all women alone to go into labour, 90% will have had their babies by the end of the 42nd week, which means there would only be need to induce one in ten women after the end of the 42nd week, if we left them alone, just because pregnancy was prolonged.
Before the end of 42 weeks, the increased risk to the baby is so small that it's very doubtful indeed whether the risk of inducing labour is justified just for that reason.
'So, is prolonged pregnancy still a good reason for induction, 'or will policy change? Prof Turnbull.
' I think it's quite likely we'll find that the risks of prolonged pregnancy are now less than they were.
It'll be quite technically difficult to work out whether that's a spontaneous improvement or the result of increasingly avoiding prolonged pregnancy .
.
by a process of induction.
Certainly, figures I took out in another centre in which I work suggested that the risks of prolonged pregnancy had flattened out quite a lot, and I think that's what the new survey will show.
And that might certainly influence us in reviewing our policy about induction.
Should be cooked.
Good.
Thank you.
'It's ten o'clock.
'Mrs Biles is having the final examination of her baby 'before the oxytocin drip is put into her arm.
' If I can find where the back is 'For the 10 to 20% high-risk pregnancies, induction can be 'a very valuable procedure, but induction itself carries risks, 'small, but not negligible.
'So, as induction rates rise, there's growing concern 'that for some mothers, the risks from induction may be greater 'than the risks of letting labour occurring spontaneously.
' Now, Mrs Biles, I've got to put a drip in your arm now, dear.
It'll just be a little bit uncomfortable for a second.
Right, Mrs Lindsay, we're going to put a little drip in your arm, dear.
Open and close your fist a few times.
Tight fist.
That's grand.
'For Mrs Lindsay, too, it's time for her labour to be started.
' It'll be a bit uncomfortable just for a moment.
OK.
'Very little is known about what happens 'to a woman's body during labour.
'What is clear, though, is that oxytocin 'is only one part of the process.
'Dozens of complex changes take place 'and most of them are only partly understood.
' It'll tingle a bit in your arm.
Now, this is just the other drip with the oxytocin in it.
'One fear is that when labour is artificially started with oxytocin, 'what happens may be very different from normal spontaneous labour.
'The concern centres around the amount of the hormone being used.
'Prof Tim Chard.
' Now, when we induce labour, the sort of amount we use might be represented by the contents of that bottle.
But in normal, spontaneous labour, the amounts in the mother's bloodstream are probably more like the contents of this small ampoule.
And what this means is that when we induce labour, we're not using oxytocin to reproduce what normally happens in a spontaneous labour.
We're using oxytocin as a drug.
Well, our knowledge of the mechanisms which control the onset of normal labour are extremely scanty.
This is a very delicate, complex physiological mechanism and, indeed, when we induce labour, particularly with with drugs such as oxytocin and prostaglandin, it may not be labour.
What we are inducing is pharmacological uterine activity.
As far as we can assess, you know, by recording the contractions the patient gets, the labour which we bring on artificially is indistinguishable from normal.
We can achieve that.
But these are very powerful drugs, both oxytocin and prostaglandins, and if they're given in too great a dose, they can cause the contractions - that's the labour pains We don't like using that word, but I suppose people recognise it.
.
.
to come too often and to be too powerful, and they can run into each other, so the uterus goes into a spasm.
That could be dangerous for the mother and the baby.
We can tell that that's happening.
It's part of the ordinary clinical care in the course of induction.
HEARTBEA 'Doctors can monitor what's happening 'by using sophisticated machines.
'This one is designed to provide a feedback 'between the strength of the mother's contractions 'and the dose of hormone given.
' At the time the membranes were ruptured to induce labour in this patient, an electrode was placed on the baby's scalp, so that we are able to monitor the baby's heartbeat continually.
At the same time, a catheter was passed through the cervix to lie within the uterus and to measure pressure changes occurring.
This patient is now having good, regular contractions and we can see the changes in the pressure on this tracing.
The contractions are being stimulated by an intravenous infusion of the hormone oxytocin, which is in this bottle here.
The patient's requirements of oxytocin vary widely, so that some patients may require 20 to 30 times as much as others and, unfortunately, we've no way of knowing in advance what an individual patient will require.
This machine does just that for us and tailors the dose to the patient's requirements.
It starts with a very low dose and steadily steps up the dose rate until effective contractions are occurring.
At that point, no further increase is necessary and the machine will hold the dose rate steady.
There is no doubt that this pump has made a big contribution to obstetrics but, like everything else which is new, it has its problems.
And the problem is this.
We know that every woman is going to need a different dose of oxytocin to start the uterus contracting.
So, let's say for Mrs X, the dose, or the optimal level in the blood, is indicated by this dotted line.
When we start the pump off, the level of oxytocin in the blood will rise steadily and at a certain point, at a certain level, the uterus will start contracting, and that is when we stop the dose rate from the pump increasing.
But because of the design of this pump, the blood level in fact overshoots at this point.
So it continues to rise and only reaches a plateau 10 or 15 minutes later.
So, you can see that at this point, we are giving a dose which is actually considerably more than the optimal dose which we need to make that uterus contract.
Then there's another problem.
As labour proceeds, as the uterus contracts, so its sensitivity to oxytocin increases, so that if this was the right level at the beginning of labour, towards the end of labour, the right level may be something more like this.
If we hadn't done anything to the dose rate being given by the pump, the difference between the right dose and the dose that we're actually giving is now even wider.
And if you've given overdose in this way, of oxytocin, then the uterus will show excessive contractions.
There's no doubt, with the instrumentation we have available, we are now much better able to control this, but there are still situations where uterine activity of a degree that is undesirable do occur in response to the use of these agents.
How do you feel? Not so bad now.
I'm feeling a bit more now.
'4pm.
Mrs Biles is finding contractions quite painful.
'Many women find that the increased frequency 'and strength of contractions make induced labour much more painful.
' SHE BREATHES DEEPLY In spontaneous labour, the woman goes at the pace of her own body.
Usually, the contractions begin quite weakly, they're quitethey're not felt very strongly by her, and they come relatively infrequently, and she gradually builds up both the strength of the contractions and their frequency, and she can adjust to this in her own time, in the time of her body.
Induced labourthe pace can be forced, and where people are very anxious to get babies born within a certain time, there's a big temptation for the obstetrician to force the pace even more and, undoubtedly, contractions that are made to come very quickly and very strongly before the woman's had a chance to adapt are more distressing.
'The higher levels of pain felt during induced labour 'force doctors to use more painkilling drugs.
'Where epidurals are available, 'an increasing number of these are having to be given.
' My fingers on your back again, Mrs Lindsay.
And then in a moment, a tiny little prick in your back.
Mm-hm.
Going there Try not to move.
Just a tiny little sting.
Just a little bit of local anaesthetic going in.
That's all right.
Now a little pressure on your back, but not painful pressure.
'Epidurals are local anaesthetics injected into the spine.
'Five hours after she was induced, 'Mrs Lindsay has decided she needs one.
'It's the fifth tube going into her body.
'Two are feeding drips into her arm, 'two go into her womb, measuring her contractions and her baby's heart, 'this one will feed her with anaesthetic.
' Sometimes you feel a little twinge in your back.
Or your bottom or the leg, as this is done, sometimes not.
The needle's out of your back and there's just this little soft tube in there.
'The epidural works as a nerve block, 'killing all sensation in the lower part of the body.
'For many mothers, it provides welcome relief from pain 'though it can result in severe headaches for some days afterwards.
'Epidurals kill not only pain but all sensations.
' Now, I'm going to take this little towel off your back.
OK.
Just some sticking plaster going on now.
OK.
Now, if you can straighten your legs out a little bit, move into the middle of the bed and roll over onto your back.
If you are induced, you get an accelerated labour and if you get an accelerated labour, it hurts, and if it hurts, you need to have an epidural, but I think epidurals are the biggest single advance out of all those things.
Doing obstetrics when all that you could do was give somebody pethidine, which made them dopey and removed them from the pain and left them quite unable to appreciate what was going on, was terrible.
I mean, the big thing about an epidural is it gives youalmost the situation that advocates of natural childbirth are trying to produce, that is to say, a totally conscious mother who can help the baby out and not be worried about the pain.
We'll just stick this up on the front of your shoulder here.
OK.
'But just how like natural childbirth is it? 'Is the mother really in control? 'What was it like for Mrs Lindsay?' It goes like pins and needles first of all and then you don't feel anything at all.
The only way you know you're having contractions is by looking on the machine and watching the graph.
WOMAN: Can you feel that contraction? It's quite a big one.
I can't feel anything at all.
'One problem with epidurals is that because mothers 'cannot feel their contractions, they don't know when to push, 'so more and more induced babies have to be helped out.
'Mrs Lindsay's baby was delivered by forceps.
'In many hospitals, the forceps rate has doubled 'as a result of inducing more mothers.
'Mrs Biles also asked for an epidural.
'At 5.
15, she was suddenly taken through into the operating theatre.
' BABY CRIES 'Her baby, too, had to be delivered by forceps.
'Like Mrs Lindsay, she preferred us not to film it happening.
'The risk to a baby born by forceps is small, 'but the more forceps deliveries being done, 'the more often you run that risk, 'and as more babies are induced, 'there's a greater opportunity for other things to go wrong.
' I was in labour for six hours, then, and they were just adding the hormone to my drip every now and then and then, by four o'clock, I hadn't done very much and I was just 4cm dilated, which isn't very much, and, um .
.
they increased the drip rate to quite a lot.
The pupil midwife that was with me said, "Are you sure?" to the registrar, and we sort of went "What's going on?" And he said, "Yes, yes, do it.
" And so she did it, and then my contractions were really bad and of course my BP went up and as soon as my BP went up, they said, "We'll have to give you an epidural," and I'd stated all along that that was the last thing I wanted, and I didn't want a forceps.
I know that some babies aren't born by forceps when they have an epidural but a lot are, and I just didn't want an epidural, I wanted a natural childbirth.
So, anyway, I had an epidural and they said, "You'll have to lie on your back now for 20 minutes.
" Before then, I'd lain on my back for a few minutes and the foetal heart monitor, regulating the foetal heart, had gone down, and the pupil midwife told him that he didn't like it when I lay on my back, but they said, "You'll have to lie on your back.
"You've had an epidural.
"That's too bad.
" And as soon as I lay on my back, it all happened so quickly.
The anaesthetist was still there, they hadn't left the room, the foetal heart monitor just went down to 30, and it was dropping to nothing, so it was sort of pandemonium let loose, and they said, "You'll have to have an emergency C-section.
" I said, "I know that.
Get on with it!" They shoved an oxygen mask on my face and I signed the consent form en route and I was shoved into theatre and had an emergency C-section.
The next day, the anaesthetic sister came round and said, "Of course, what we should have done was to have turned you "from side to side and probably it would have been OK.
" But that's a bit late, the next day.
'An experience like this is not only distressing to the mother, 'it can also be putting the baby unnecessarily at risk, 'and this isn't an isolated case.
' We have cases which do go wrong and this is one of the reasons why one must be concerned.
Erm This lady, for example, was induced in her last pregnancy, ermfor a reason that perhaps wasn't as strong as it might be.
She was started immediately on oxytocin.
She had very frequent, powerful uterine contractions and foetal distress occurred within half an hour.
And a caesarean section had to be done very quickly to get that baby delivered.
The foetal heart, as you can see in this tracing, showed marked deviations from the norm and was gradually going down to a very low rate and without caesarean section, being carried out as an emergency procedure, that baby might well have been lost.
'Doctors at the John Radcliffe Hospital are finding 'they're having to intervene more and more.
'Their annual report shows that in 1970, 'the number of babies lost was 17 per 1,000, the top figure.
'The caesarean section rate was nearly 5%.
'Three years later, the number of babies lost was unchanged, 'but the caesarean section rate had doubled to nearly 10%.
' Well, this must raise serious questions as to whether the present policy of induction and accelerated labour is not affecting the operative rate, particularly caesarean section.
It strikes me as exceedingly high, that one in ten patients in a normal pregnant population should require caesarean section.
Caesarean section was a much more hazardous procedure in the past.
We had bad anaesthesia, it was dangerous for the mother, the baby got a very large load of anaesthetic, the mother had a very bad post-operative period, because the incisions used were much less satisfactory than they are now.
I don't think that it's quite fair to put caesarean section on entirely the same plane as it was in the past.
I think that with people having smaller families, it might be very much more reasonable for somebody to have three or four caesarean sections than it was in the past.
'But many women are unhappy with the prospect of increasing intervention.
'Are there any benefits? 'Is induction saving more babies who would have been born dead or died 'within the first week? 'Has our national perinatal mortality rate 'continued to decline as expected?' From our own experience, in this country, perinatal mortality rates appear to have flattened out.
At the end of the 1950s, we were high in the European league table for perinatal mortality, together with the Scandinavian countries.
But we do seem to have lost our position and we now stand well down that table, somewhere about 10th or 12th in the league, way below France, which was, in the 1950s, way behind us.
Our attitudes have altered fairly radically, whereas practice in France has not altered all that much.
And I think therefore, we must ask ourselves whether the loss of position on the league table doesn't have something to do with what we're doing, rather than what France hasn't done.
I don't think that's a good yardstick, really.
I'm not at all surprised, even if I was surprised, I wouldn't say I was disappointed, because the overall results are so much better, in terms of baby health, maternal well-being, comfort, generally.
No, I wouldn't put the clock back, honestly.
'So how does Prof Donald judge the success of his induction policy?' Well, keeping one's ear to the ground and studying one's patients, as we do.
I don't know what yardstick you can use as a There's no single one.
If a patient is not contented, we know about it pretty quickly.
We don't have any evidence to substantiate the fact that our perinatal mortality is any lower, indeed, it could be the opposite.
It could be that by interfering with a large number of healthy pregnancies, that indeed, our perinatal mortality would be increased, insofar as these pregnancies, if left to go onto spontaneous onset, and spontaneous labour, may well have better results.
A labour that starts off spontaneously is much more likely to end up in a normal, uncomplicated delivery then any labour which is induced.
Mrs Rogers? 'Nearly half the mothers here at the John Radcliffe antenatal 'clinic are going to be induced.
'And when a labour is started artificially, there is 'a danger that the baby may not be ready to be born.
'It could be premature.
' Mrs Janice Wheeler? 'A third of mothers don't know 'exactly when their pregnancy started, 'so the baby's precise age could be doubtful.
' Now, can you tell me the date of the first day of your last normal period? - August 30th.
- August 30th.
Yes, that's of this year.
And that was a perfectly normal period, the loss was the same and you lost for the same number of days as usual? Yes.
It was longer, actually.
- Longer, not shorter? - No.
So that makes your baby due, 30, that's September 6th, which brings you to June 6th.
Next year.
Now, then, are your periods always regular? Usually, yes.
- Do they vary from 28 days at all? - They may be a little bit longer.
How much longer? How many days longer? About three days.
So, you could have a period any time between 28 days and 31 days.
Yes.
Which leaves a slight leeway.
The last cycle was 33, 33 days, I think.
33 days? Right.
So there is a slight doubt about the expected date.
'There are more sophisticated techniques for determining a baby's 'age in the womb.
Although these can only be provided for a few women.
'Ultrasonic waves from this machine pick out the baby's head.
'Its age can be estimated from the size.
' You can see that's the head there.
Can you see it? 'But even with the age known, other tests are needed to show 'whether the baby's mature enough to survive outside the womb.
' And this bit of tissue across the top, that's the placenta or the afterbirth.
That wedge shaped piece.
Now, what I will do is, I will move the baby's head upwards and then go in beneath it, so that I can't do any damage at all to the baby.
All right.
I'm going to push the baby's head upwards and you're going to feel pressure, all right? But apart from that, it shouldn't worry you.
'To test the baby 's maturity, a new and more complicated technique 'involves taking a sample of the amniotic fluid from inside the womb.
'This is then tested for certain chemicals which are only present 'when the baby's lungs have matured enough to breathe outside.
' How is that? All right? 'So, how accurately can the baby's age and maturity be measured?' There isn't a single technique that will enable us to estimate a baby's age sufficiently accurately to intervene on it.
One needs a battery of tests.
But even if you take a battery of tests, the accuracy's, at the best, in the order of plus or minus 2% to 3%.
And we're actually talking in this sense about saving about 1% of babies.
Even less, probably.
And so, we're using a very coarse tool to intervene on behalf of an exceedingly small number of babies.
If you induce 100 cases, which you think are at 40 weeks or at term, the chances are, that in one or two of those, because of some mistake with the dates, that child will not be at 40 weeks, but will be at 36 weeks, or perhaps 32 weeks.
So, you deliver, unknowingly, a premature child.
And the premature child, because of the immaturity of systems such as the lung and the liver, stands a very high risk of either death or some sort of permanent damage.
There have been, within our own district, babies induced on very minimal grounds, who owing to an error in the dates, have subsequently developed severe complications or even died, as a result of induction.
'Of course, most babies come through 'an induced labour just as safely as through a spontaneous one.
'But there are paediatricians 'who are concerned about the quality of a few 'of the babies being induced.
'A small number may have difficulties in starting to breathe, 'like this baby.
'And if the baby doesn't breathe soon, 'it could suffer permanent brain damage.
' THEY SUCTION HIS AIRWAYS 'Almost a minute and a half has passed.
'The baby is still not breathing properly.
' 'This baby eventually made a successful recovery, 'but induction seems to be linked to a number of worrying effects.
'Prof Davis.
' We have perhaps to resuscitate more babies or at any rate, be prepared to resuscitate more.
More of the babies have enlargement of the spleen.
More have spikes of fever.
It's more difficult for them to maintain their body temperature.
They're floppier.
They seem, if I can put it that way, less enthusiastic about life, and particularly about feeding.
We could say, really, that where people have looked for effects, they've generally found them.
'One effect of induction that has only recently been uncovered is an 'increase in the number of babies born 'suffering from neo-natal jaundice.
'More of these babies may have to spend longer under special care.
' 'The latest studies show this jaundice 'is directly related to the artificial starting of labour.
' Now, this isn't like the jaundice, the severe jaundice coming on early, that we see with rhesus disease.
It's a higher instance of kind of physiological, normal jaundice, coming a little bit later, sometime between the second and fifth day.
And what it tends to do is to mean that the paediatricians ask the mother to stay in an extra day so that the jaundice will settle down.
Nevertheless, it's evidence of an effect of induction on the baby.
And it's something we want to know more about.
The degree of jaundice that results from managed labour, and I think all of the evidence is that the incidence of jaundice is increased in babies born this way, isn't of a kind that worries me from that point of view.
Why it worries me is that I don't understand why it happens and until I do, I don't know what's going on or what the consequences might be.
'Better understood are the effects of drugs on the baby.
'Over 100 different combinations of drugs are currently being 'used during labour.
' It's, I think, almost a principle that if something enters the mother, it's going to cross the placenta and into the baby.
There are exceptions, but they are few in number.
Of course, while the baby is part of the mother, metabolically, that could be said not to matter very much.
The mother deals with the whole situation.
But of course, the baby is then born.
He loses his contact with the mother across the placenta, he has to fall back on his own organs and these are in no way prepared by long experience for dealing with drugs, metabolically, or with the side effects of drugs.
I don't like to feel that, you know, a newborn baby who doesn't need any of the drugs, has got four or five of them acting on him at a most critical point in his life.
'One of the commonest painkillers used during labour is pethidine.
'A narcotic.
Dr Martin Richards.
' What we've found with pethidine was that for the first ten days, which is a period we followed up the babies in a great deal of detail, that over that period, the ones whose mothers had pethidine were much sleepier than the babies of mothers who had not had the drug.
Also, they didn't feed as well.
The feeds tended to be interrupted very often, because the babies didn't suck easily, the mothers had to work quite hard to get the babies sucking.
Beyond that, we found effects in the social relationship between the mother and the baby.
It's rather hard to interpret all of the effects we found.
I think the point to emphasise was that we do have some evidence that even a year after delivery, the babies are still rather different after the mother has had this drug.
'Similar effects on the baby's behaviour, his responsiveness 'and feeding patterns, have recently been found among those mothers 'who had an epidural during labour.
And this was quite unexpected.
' Indeed, it was widely believed early on, that when you gave an epidural, the anaesthetic compound used, which is injected into the mother, didn't get through the placenta to the baby and in some places, that is still believed to be the case.
But in fact, there are several studies that show that it does get through to the baby very quickly.
It has some physiological effects on the baby and now, very recently, we have research that shows it has the same general kind of psychological effects that have been established for pethidine.
And in fact, what research there is suggests the effects are rather more marked than pethidine.
The effects on the baby are rather bigger.
But I think again, it illustrates this point that the techniques are used and then it is only much later that we discover they have some disadvantages.
I'll remind you of Voltaire's famous remark always being quoted, that medicine seems to consist of putting drugs of which you know little into patients of whom you know less.
I think it very much applies to the situation.
We don't know much about the physiological processes that are going on before, during and after labour.
And we don't know very much about the effects of the rather powerful drugs that are available on the mother and particularly on the baby.
'As long as unforeseen complications are found following induced birth, 'mothers are entitled to ask whether induction is best for them 'and their baby.
'Inducing birth can lead to increased intervention.
'Do mothers know this could happen and why? 'For many women, high-technology birth with contractions 'controlled by a drip and not by them, 'is neither what they want or expect.
'Where there are no strong medical reasons for induction, 'they may agree with the Lancet in thinking it is a pernicious 'practice having no place in modern obstetric care.
'Do we really want this to be the shape of childbirth to come?' Having taken the view that all labours ought to be conducted 100% of the time in hospital, that's to say that everybody should either come into a hospital and wait until go into labour or they should come in and be started off, which is a view that I take, and which I think is a view which nearly everybody will take in 20 years, I just don't think that it can possibly be sensible to conduct careful and comprehensive antenatal care and then let the patient conduct their own first stage of labour.
Once you take that view, then all inductions are medical.
It's just a matter of deciding when to do it.
Women, I think, quite rightly, regard birth as a natural process.
Something which, when they elect to have a baby, they believe is going to be perfectly normal and easy and natural.
Perhaps not without discomfort, but certainly normal.
It does seem that in the present climate of opinion, hospitals and obstetricians perhaps have lost sight of this themselves, and are tending to regard the pregnant woman as somebody who is suffering from a disease.
And this is not the case.
The onus is on the individuals or the clinicians, or scientists, who feel that we can usurp the process of normal labour in normal, healthy, pregnant women by a pharmacological labour to prove that this is superior.
And to my knowledge, there have been no carefully controlled trials carried out to show this is so.
There are arguments about the convenience to the hospital, the convenience to the mother, but to my mind, the convenience to the hospital or to the mother pales before the importance of the life of the baby and we are not entitled to do any procedure which could jeopardise the well-being of the foetus in labour.