Reducing post-dates induction numbers with post-dates complementary therapy clinics

In 2012/2013, over 23% of pregnant women in England underwent induction of labour (IOL) (Birth Choice UK, 2013a). Across 11 trusts in Anglia in 2013, these rates ranged from 18 to 29% (Birth Choice UK, 2013b). The majority of post-dates inductions are performed with no other indication than gestation being past the estimated date of delivery (EDD) despite the increased risk of induced labour leading to instrumental births and caesarean sections (NHS Information Centre 2012a; 2012b), especially in primigravidae women (Vrouenraets et al, 2005).

The National Institute for Health and Care Excellence (NICE, 2008a) recommends induction for women with uncomplicated pregnancies between 41 and 42 weeks. Furthermore, NICE (2008b) recognise that an ability to identify those pregnancies most at risk, could avoid unnecessary induction for all.

Women's experience of induction is not always a positive one. Gatward et al (2010) highlighted women's concerns about the physical and emotional effects of induction. Further negative emotions and the ‘loss of the ideal’ were found in a subsequent qualitative analysis (Gammie and Key, 2014).

Induction pathways usually commence at 41 weeks gestation with a membrane sweep (NICE, 2008a) despite a highlighted lack of evidence for the clinical benefit (Boulvain et al, 2005). Even studies advocating membrane sweeps to reduce post-term pregnancy note the discomfort and concerns related to uncomplicated vaginal bleeding associated with the procedure (De Miranda et al, 2006).

The use of prostaglandin is often the next step adopted by most NHS Trusts in their management of post-dates pregnant women. The forms of prostaglandin used often differs by Trust; with some using either a Prostin E2 gel or a sustained release version. A review of IOL highlighted that the sustained release vaginal prostaglandin E2 (PGE2) is superior to PGE2 gel; however, the sustained release gel is considerably more expensive (Kelly et al, 2009). Without data from cost analysis many Trusts are now exploring the benefit of outpatient induction clinics. Such change in practice is likely to be a response to research demonstrating the negative effects of hospital admission for post-dates inductions whereby hospital admission was associated with illness and discomfort. Women report not being able to do what they want, eat what or when they want or being able to sleep because of noise (Reid et al, 2011).

In a study comparing intravenous syntocinon to placebo or expectant management, induction by intravenous oxytocin, was found to significantly increase the use of epidural analgesia (Kelly and Tan, 2001) indicating that women find intravenous induction a more painful process. It was also associated with a less positive birth experience (Hildingsson et al, 2011).

Establishing need and about the clinic

Acknowledging the increasing evidence for women's negative experience and a desire to facilitate choice, opinion was sought from service users. A unanimous response from a small antenatal survey from 6 women about the feasibility of a post-dates pregnancy complementary therapy clinic resulted in its implementation at Hinchingbrooke NHS Trust in November 2012.

Women are booked into complementary therapy post-dates clinics around T+7 gestation of pregnancy. A routine antenatal check is performed and a membrane sweep offered; not all women opt to have this and the decision is recorded by the audit tool.

If all is satisfactory and the woman meets the set criteria (Table 1), the following complementary therapies are performed; acupressure, reflex zone therapy and aromatherapy massage in accordance with the regimen advocated by Expectancy (2014). Expectancy is a course trainer accredited by the Royal College Midwives (RCM) which highlights the importance of safety in the use of complementary therapies. The treatments are carried out as a combined regimen, and as such it cannot be said that one treatment has been found to be more efficacious than another. Following completion of the appointment, the local policy of induction is discussed along with the woman's options. If the woman consents, she is booked for low-risk outpatient induction using slow-release prostaglandin at T+12 gestation.

Finding funding

In May 2013, the lead author was awarded a national research grant to help fund this service. The application described the aim of this service, which was to reduce post-dates induction numbers and improve women's choice. The grant will enable further extension of the service by training more midwives to allow more clinics to be available for women and more data to facilitate further evaluation of the merits of such a service.

In July 2013, 11 additional midwives received training from Expectancy, which enabled the service to be extended from once a week, based within the hospital, to five clinics a week—four of which are community based. Four of the midwives already had Diplomas for Maternity Complementary Therapies and the 11 new midwives took part in a 2 day course. The practice development team also devised a package to ensure updating of complementary therapy skills, latest evidence supporting practice and identifying training needs, and a live register to define roles within the service.

Collaborative working has been suggested as key to making maternity services and children's centres a success (Vincent, 2013), so meetings were held with children's centre managers and venues were established, enabling women to access a clinic nearer to their home settings. Some centers hosted purpose-built low lighting designs for ‘sensory rooms’ for children, these were used to create a low lighting, relaxing ambient environment.

Weston and Grabowska (2013) audited their service and found that 67% of primiparas and 78% of multiparas went into spontaneous labour following attendance of their clinic using the same combined technique of complementary therapies.

Results

Data from audit have enabled the comparison of the number of post-dates inductions performed in the year prior to and year following the set up of the clinics. There was a notable reduction (5.3%) in the numbers of medical inductions performed on post-dates pregnant women (Figure 1; Table 2).

Some months (March, July and September) had more IOLs than the previous year. This may have been due to disruption in the service as there was a change of clinic day and location, which occurred in March 2013. Furthermore, staffing changed in September 2013 when the service was expanded into the community. The benefit both to women from a patient experience perspective (which we are further reviewing) and to Trusts from a cost reduction perspective, when medical inductions are reduced should not be overlooked. In the first year of the service (from November 2012–October 2013) 192 women have been seen in the clinics.

Future exploration

A further research project is underway to explore complementary therapy clinics and psychological measures of fear, stress and anxiety and physiological stress in post-dates women. Birth outcomes as a secondary measure will also be explored. This research project has applied to be adopted onto the Clinical Research Network Portfolio and awaits ethical approval.

Anecdotally, the clinic has been well received by all stake holders and the authors are planning to further review data collected over the past year with a view to inform practice and possibly extend the use of complementary therapies within the unit. Part of this review will also involve a more formal patient feedback, which up to this point has been by verbal submission to our practitioners. Our obstetric consultants are also supportive to consider extension of the service to help more women, who are not within the current low-risk care pathway; however, careful evaluation of the service needs to be undertaken first.

Key points