In Australia 25% of labours are induced. The most common reason for induction is a ‘prolonged pregnancy’. That’s an awful lot of babies outstaying their welcome and requiring eviction. I am not going to get stuck into the concept of a ‘due date’ and how accurate or not they are, otherwise this will be a very long post. I also think the EDD (estimated date of delivery) is here to stay – it is deeply embedded in our culture and health care system. You can read about the history of timelines in birth here. This post will focus on induction for prolonged pregnancy and the complexities of risk.
A quick word about risk
I don’t particularly like the concept of ‘risk’ in birth. There are all kinds of problems associated with providing care based on risk rather than on individual women. However, risk along with due dates is here to stay and women often want to know about risks. Risk is a very personal concept and different women will consider different risks to be significant to them. Everything we do in life involves risk. So when considering whether to do X or Y there is no ‘risk free’ option. All women can do is choose the option with the risks they are most willing to take. However, in order to make a decision women need adequate information about the risks involved in each option. If a health care provider fails to provide adequate information they could be faced with legal action. Induction for prolonged pregnancy is not right or wrong if the choice is made by an individual woman who has an understanding of all the options and associated risks. As a midwife I am ‘with woman’ regardless of her choices. It is my job to share information and support decisions – not judge.
What is a prolonged pregnancy?
Before we go any further lets get some definitions clear:
- Term (as in a ‘normal’ and healthy gestation period): is from 37 weeks to 42 weeks.
- Post dates: the pregnancy has continued beyond the decided due date ie. is over 40 weeks.
- Post term: the pregnancy has continued beyond term ie. 42+ weeks.
The World Health Organization’s definition of a ‘prolonged pregnancy’ is one that has continued beyond 42 weeks ie. is post term. I am pretty sure that this was not the definition used when collecting the above induction rate statistics because most hospitals have a policy of induction at 41 weeks which is before a prolonged pregnancy has occurred. Very few women experience a prolonged pregnancy.
The idea of a prolonged pregnancy also assumes that we all gestate our babies for the same length of time. It seems that genetic differences may influence what is a ‘normal’ gestation time for a particular woman. Morken, Melve and Skjaerven (2011) found “a familial factor related to recurrence of prolonged pregnancy across generations and both mother and father seem to contribute.” Therefore, if the women in your family gestate for 42 weeks so might you.
The risks associated with waiting
In theory after term ie. 42 weeks the placenta starts to shut down. There is no evidence to support this notion and Sara Wickham gives a great critic of this theory if you ever get the chance to attend her workshops. I have seen signs of placental shut down (ie. calcification) in placentas at 37 weeks and I have seen big juicy healthy placentas at 43 weeks. There is also the idea that the baby will grow huge and the skull will calcify making moulding (when the bones in the baby’s skull adjust), and therefore birth difficult. Again there is no evidence to support this theory and babies are pretty good at finding their way out of their mothers expandable pelvis.
The concerns around waiting beyond 41 weeks gestation focus on the potential death of the baby (perinatal death). A Cochrane review summarises the quantitative research examining induction vs waiting at 41 weeks or more: “There were fewer baby deaths when a labour induction policy was implemented after 41 completed weeks or later.” However, it goes on to say: “…such deaths were rare with either policy…the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.” Hands up all the women who had a discussion with their care provider about the relative and absolute risks of waiting vs induction… hmmm thought so. The review also found lower rates of caesarean section and meconium aspiration in the induction group but no difference in admission NICU.
So, essentially according to the available research if you are induced at 41 weeks your baby is less likely to die during or soon after birth. However, the chance of your baby dying is small either way – less than 1%… or 30 out of every 10,000 for those waiting vs 3:10,000 for those induced. In order to prevent one death 410 women need to be induced.
Reviews can only be as good as the research they review and there are some concerns about the quality of the research. The World Health Organization recommends induction after 41 weeks based on this review but acknowledges the evidence is ”low-quality evidence. Weak recommendation”. Sara Wickham discusses the flaws in the research on a free MIDIRs podcast you can download here.
One of the main problems with quantitative research is that it rarely answers the question ‘why’, and rather focuses on ‘what’ (happens). It also takes a general perspective rather than the risk for an individual woman in a particular situation.
Anyhow – to pretend their are no risks associated with prolonged pregnancy (in general) is not helpful for women trying to make decisions about their options.
The risks associated with induction
It can be difficult to untangle and isolate the risks involved with induction because usually more than one risk factor is occurring at once (eg. syntocinon, CTG, epidural). I did attempt to create a mind map but it ended up looking like a spider had spun a web while under the influence. So I have stuck to a written version:
Risks associated with the actual procedure of induction
The induction process is a fairly invasive procedure which usually involves some or all of the following (you can read more about the process of induction here). There are a number of minor side effects associated with these medications/procedures (eg. nausea, discomfort etc.) There are also some major risks:
- Prostaglandins (prostin E2 or cervidil) to ripen the cervix: hyperstimulation resulting in fetal distress and c-section.
- Rupturing the membranes: fetal distress and c-section (see previous post)
- IV syntocinon / pitocin: Mother – rupture of uterus; post partum haemorrhage; water intoxication leading to convulsions, coma and/or death. Baby – hypoxic brain damage; neonatal jaundice; neonatal retinal haemorrhage; death. There is also research suggesting that there may be a link between the use of syntocinon/pitocin for induction and ADHD (Kurth & Haussmann 2011)
The most extreme of these risks are rare but fetal distress and c-section are fairly common.
Risks associated with factors that commonly occur during an induction
The Cochrane review (above) found reduced rates of c-section for women induced. This is an interesting finding and does not fit with my observations. However, the review does not separate first time mothers with women who have birthed before. And they are a different kettle of fish. A research study by Ehrenthal et al. (2010) found an increased c-section rate of 20% for women being induced with their first baby. They concluded that: “Labor induction is significantly associated with a cesarean delivery among nulliparous women at term… reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population.” Another study by Selo-Ojeme et al (2010) found induction increased the chance of a c-section x3 for first time mothers. The researchers recommend that “Nulliparous [first baby] women should be made aware of this, as well as potential risks of expectant management during counselling.” It is now well established that there are significant risks associated with c-section for both mother and baby. Childbirth Connection provide an extensive and evidence based list.
Induced labour is usually more painful than a physiological labour. Syntocinon (aka pitocin) produces strong contractions often without the gentle build up and endorphin release of natural contractions. In addition unlike natural oxytocin, syntocinon does not cross the blood-brain barrier to create the spaced-out, relaxed feelings that help women to cope with pain (see previous post). Not surprisingly, first time mothers are more than 3x more likely to opt for an epidural (Selo-Ojeme et al. 2010) during an induction. A Cochrane review found that: “Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever and association between epidural analgesia and instrumental birth.” The review also found an increased risk of instrumental delivery, and c-section for fetal distress with an epidural.
There are significant risks associated with ventouse and forceps birth, both for the mother and baby – RANZCOG lists them here. And the risks of c-section available via the link ‘Childbirth Connection’ above. The study by Selo-Ojeme et al. (2010) also found induction = increased risk of uterine hyperstimulation; ‘suspicious’ fetal heart rate tracings; and haemorrhage following birth. Not surprisingly ‘babies born to mothers who had an induction were significantly more likely to have an Apgar score of <5 at 5mins and an arterial cord pH of <7.0′ (basically not in a good way on arrival). Another recent study by Elkamil et al (2011) ‘found that labour induction at term was associated with excess risk of bilateral spastic CP [cerebral palsy]..’ Remember we are inducing labour to prevent harm to the baby…
The experience of labor
Once again the Cochrane review states: “Women’s experiences and opinions about these choices have not been adequately evaluated.” This is becoming a theme across Cochrane reviews. However, one thing is certain – choosing induction will totally alter your birth experience and the options open to you. Women need to know that agreeing to induction means agreeing to continuous monitoring and an IV drip, which will limit movement. Induced contractions are usually more painful than natural contractions and the inability to move and/or use warm water (shower or bath) reduces the ability to cope. The result is that an epidural may be needed. An induced birth is not a physiological birth and requires monitoring (vaginal exams) and time frames. Basically you have bought a ticket on the intervention rollercoaster. For many women this is fine and worth the risk, but I encounter too many women who are unprepared for the level of intervention required during an induction.
There have been some attempts to find out about womens’ experience of induction. Heimstad et al. (2007) conducted a survey of women randomised to immediate induction at 41 weeks or waiting with regular ‘fetal surveillance’. They found that women preferred induction. However, these were women who were allocated an option rather than chose one. Another survey by Childbirth Connection asked mothers about their experience of induction (not necessarily for prolonged pregnancy) – 17% of those induced felt they were under pressure to do so by health care professionals. The quotes from women make interesting reading too. A study by Hildingsson et al. (2011) found that labour induction was associated with a less positive birth experience, and women who were induced were more likely to be frightened that their baby would be damaged during birth. However, again this research was not limited to induction for prolonged pregnancy therefore the women may have had genuine pregnancy complications requiring induction.
Alternatives to waiting or medical induction
Before labour begins the uterus and cervix need to make physiological changes ready to respond to contractions. It is now thought that the baby is the controller of the labour ‘on’ switch. So, the baby signals to the mother that he/she is ready, oxytocin is released and the uterus responds. In comparison to other mammals, humans have the most variable gestation lengths. This suggests that other factors such as environment and emotions (eg. anxiety) also influence the start of labour. This would make sense considering what we know about the function of oxytocin (see previous post). It is also something most midwives are aware of – a stressed out mother is more likely to go post term than a relaxed and chilled out mother. Having said that, post term is probably the normal gestation length for many women regardless of what is going on. Creating anxiety and stress around due dates and impending induction is probably counter productive to labour.
There are a number of ‘alternative’ or ‘natural’ induction methods available (BellyBelly covers most of them here). However, an induction is an induction. Trying to force the body/baby to do something it is not ready to do is an intervention whether it is with medicine, herbs, therapies, techniques… or anything else. Interventions of any kind can have unwanted effects and consequences. However, ‘interventions’ (massage, acupuncture, etc.) that are aimed at relaxing the mother and fostering trust, patience and acceptance may assist the body/baby to initiate labour.
In Summary
A significant minority of babies will not be born by 41 weeks gestation. Whilst the definition of a prolonged pregnancy is 42 weeks+, induction is usually suggested during the 41st week. Women need to be given adequate information about the risks and benefits involved with either waiting or inducing in order to make the choice that is right for them. There is no risk free option. The risk of perinatal death is extremely small for both options. I know women who have lost a baby in the 41st week of pregnancy, and women who have lost a baby as a result of the induction process. For first time mothers the induction process poses particular risks for themselves and their babies. Each individual woman must decide which set of risks she is most willing to take – and be supported in her choice.
Further resources
Maternity Coalition information sheet for parents.
Stories of birthing beyond 41 weeks
A news article: ‘I was pregnant for 10 months’
I’m really loving your blog. I’m so glad you decided to start one up. The way you present information is awesome and I love how you add in subtle touches of humor. I hope you find immense popularity!
Thanks – I’m pleased you like it.
Great post! I was all set to fight with my provider about post-dates induction because I just knew that my daughter would be “late”, but she came right on her due date, much to my surprise. I wish that every pregnant woman would read this blog and really think about what it’s saying; they might have a very different birth experience than the majority of women do today.
Thanks. Some may find the information a little confronting but women need to consider the risks of induction before jumping in. I have spent too much time de-briefing women who ended up with the full induction ride but had no idea that it was a possibility. I have heard an obs describe induction as a ‘gentle’ pessary to help you into labour.
Hi, great blog, I just found you through a post on the UK midwives list. I am a US-based CNM (nurse midwife) and am really curious about the term “post-dates.” I graduated from school about 2.5 years ago and NEVER encountered this term while in school or in any of my written education materials. It is widely used where I practice, however, by both nurses and midwives, and is used exactly how you say: someone past the “due date” but not yet at 42 weeks (though some people seem to use it for 41 weeks or greater). I really don’t like this phrase, I actually thought that it was sort of made-up until I saw it here. I much prefer the WHO definitions–preterm, term, or postterm. (I do use “near term,” mostly in acknowledgment of the potential feeding problems in near term kids). Does anyone know where “post dates” comes from? I feel that it just saddles women with another negative label and am not sure how it is useful. The pregnancy is still term until 42 weeks! (Again leaving aside the problems with dating, a big issue in my current practice where many women present late for care with unsure or unknown LMP dates).
I don’t know where ‘due date’ came from. It is a symptom of our need to know and control that which is unknown and uncontrollable. In my own practice I write down EDD according to LMP and scan (if they have one). But I ask the mother to choose a ‘due date’ for documentation purposes whilst pointing out that the only person who really knows is the baby. I also watch the moon because most of the births I attend happen on or near a full moon (I keep stats).
So what qualifies as a good reason to induce?
That is up to the individual woman once she has the full information regarding the options and risks in her individual situation. For some they want inducation at 38 weeks, others will only agree if their baby is in significant danger ie. severe pre-eclampsia. The ‘good reason’ is up to the woman who is being induced.
I love this answer. When I first got interested in birth, I continually encountered this attitude that a woman must do her research and then she would inevitably chose The Right Way – because there was only one. It should be freeing and empowering to every woman that she can do research to chose the right way for herself and her baby, which may be very different from someone else’s right way. I love how you said that no choice is without risk so every woman must decide for herself which risks she wants to take. Such a great point, and surprisingly one that I rarely see in any discussion of birth.
Another great post! I have a question for you about calcification. When my daughter was born, on her EDD, I had calcification in(on?) my placenta. Had she waited and arrived at 42 Weeks or later, would that have made for an increased risk for perinatal death? Is it correct to assume that this may not happen this early with my next pregnancy, because every pregnancy, birth, and child is different?
Your daughter was born when she needed to be – who knows what would have happened if she waited until 42 weeks… because she didn’t. Every baby is different. My son was born at 40 weeks (41 according to my dates) and his placenta had no calicification. My daughter was born at 38 weeks and had a very calcified placenta and she was scrawny. She knew it was time to vacate and get some breastmilk. Your next baby will be born when he/she needs to be. Trust your body/baby : )
My bub was delivered by c/s. I had severe GD with polyhydramisis( not sure if this is the correct term, but tons of excess amniotic fluid). U/S showed decreased movement. Once she was born she needed to be in the special care nursery and was on NG feeds. She was not engaged hence the C/S rather than induction. So she didn’t know she needed to be born did she? It’s truly scary to hear you say that bubs know when to be born. Seriously poor advice.
This post is about induction for post dates (ie. prophlyactic) not about pathological complications such as yours. For your information I am attending an induction (in a private hospital) of a client next week for GD. And I don’t give advice. I think you are interpreting this post though the lens of your own experience. You had a complication, it was identified and your baby was delivered appropriately. You had not simply gone past a prescribed date.
You just said your baby was born at 38 weeks as it knew when she needed to be born. I would have thought a placenta calcified at 38wks would also be classified as a complication. Stop contradicting yourself.
Calcification of the placenta is fairly common epecially in smokers (which I’m not). It is not a complication just a sign that the placenta is beginning to reduce function as vessels ‘die’. It only becomes a complication if enonogh to compromise placental function severely… Which I have never seen (perhaps because the process initiates labour before this happens?). My daughter was a healthy baby born at home – 6lb 14 but not a lot of fat. If a placenta has reduced blood flow due to calcification it may not cope with an induced labour which makes greater demands on the placenta to provide oxygen.
I am not contradicting myself. I realize you had a complicated (and perhaps traumatic) experience and are therefore sensitised re. these issues. You want to hear that I am saying all babies should be born a particular way and that there are no complications or risks in birth. This is not me – this is who you want me to be to fit your agenda. Perhaps find out a little more about my work/philosophy?
No, I am not traumatized. Nor am I wanting to hear “that all babies should be born one way” as you suggest. I just think your belief that babies know when it’s time to be born is poor advice and not evidenced based.
Bloody excellent work Rachel, I am getting heaps out of the clear explanations and explorations of the post topics.
I started a job this week as a plain homebirth midwife (no VBACs, no twins, no breeches at term) – just as you described last year. Its a wonderful and complete change. I am already focussing on self-care and preservation, and have witnessed my first birth – at home, in the pool, in the caul. 4.6kg. Delightful.
Please keep up the great work.
Thanks Laura. There is no such thing as a ‘plain’ midwife – and you certainly aren’t! Ha ha. I’m so pleased you are enjoying it. I know that it annoys hospital midwives (and I used to be one) – but you really get to learn about birth by attending homebirths.
Last year I was looking at the cdc stats on neonatal deaths. It did in fact show an increase of deaths for those over 42 weeks ,but this is what I found interesting: babies that were born smaller after 42 weeks were more likely to die than those that were born large. What I’m wondering here ,then ,is if iugr is playing a role in both the time the babies are born and the reason for the deaths. It was just a thought I had. Rachel
Hi Rachel
Thanks for that info. Very interesting. It would make sense that an IUGR baby has a compromised placental circulation. Also if the baby triggers labour perhaps some congenital abnormalities prevent this normal response = those babies are more likely to go post term? Hmmm. What were the figures for 41 weeks by the way? In the UK we were not ‘allowed’ to induce for post dates until Term + 13 days. It was considered that the risk of induction out-weighed the risk of post dates therefore we had to wait until post-term occurred ie. 42 weeks.
http://wonder.cdc.gov/controller/datarequest/D31
Here’s the site with the data set I was looking at…
Here’s just some interesting figures. At the weight of 3000-3499g…at 39 weeks the mortality rate is 1.9 ,at 40 weeks it’s 1.97 ,at 41 weeks it’s 1.91 ,at 42 weeks it’s 2.09(it goes down to 1.79 in the next highest weight group) ,at 43 weeks its 1.99(it again goes down to 1.81 at the next highest weight group) ,at 44 weeks its 1.78.
It appears the increase in deaths comes with the higher gestation and lower weights. That’s were the differences are showing up. Of course, this is just me looking at data, not research ,but I would love to see something done on this. I agree with your assessment of what might happen with an iugr baby.
Just another interesting thought on our birthing mentalities: as you can see from this data ,bigger babies do better for the most part no matter what gestation ,so why do bigger babies scare the medical community. Also ,the total death rate for 38 weeks is 2.67(where I work, having a woman go into labor at 38 weeks is no big deal). This same death rate is not seen even up to 44 weeks….why is there the saying in the medical community that nothing good happens after 40 weeks, when the death rates are lower than at 38 weeks which seems to be no biggy(sorry just another tangent:)).
Thanks Rachel
The other thing to consider is whether some of the smaller babies were a twin? Small babies (true IUGR not just genetically small) are associated with mothers who are less healthy – poor nutrition, smokers etc. so again this could be a confounding variable
I did read some years back talk of inducing at 37 weeks to avoid the spike at 38 weeks. I am hoping that stupid idea was buried.
It was also to see in the data pregnancies up to 46 weeks!!! Either way the death rate is extremely small in any term group.
Just seen on a birth discussion board-
“I had to have a c-section because I went 42 weeks and didn’t go into labor”. Seriously. argh. her siggy announces that her babe had to be “evicted” at 42 weeks…
She probably believes that. I have heard of women being told that if they haven’t gone into labour by 42 weeks then their body is unable to labour and they need a c-section. I guess it’s a creative excuse for a c-section…
Perhaps you could clear something up for me, because I have done a lot of reading about this topic and there is something I am not clear on. If term gestation is 37 to 42 weeks, is everyone talking about 42 completed weeks? Like 42 wks and 6d? Or at the beginning of Week 42? Or is there even a consensus?
It is unclear but basically term pregnancy lasts up to 42 weeks. Once over 42 weeks and into the 43rd week it is considered ‘post-term’. Not many induction happen at or after 42 weeks. Usually they happen in the 41st week before the pregnancy reaches ‘post-term’.
Hope that makes sense.
great post! I would like to translate this into spanish… is that alla right to you?
thanks!
Of course – I would be honoured!
While I am agreement with the idea that postdates pregnancy can be safely managed, and generally try to avoid inductions, I cannot disagree more with the idea that every baby knows when it needs to come. In my opinion, this is nonscientific magical thinking nonsense, and has no place in medical advice. Many babies deliver at completely the wrong time. Some deliver quite premature, and some wait so long to deliver they die before they come. Did they know when to come? Individual anecdotes do not change the statistical knowledge that we have, or justify dangerous practice.
The reason postdates is a concern is exactly what you are saying – there is a risk of fetal demise. 1 in 200 is really a pretty high risk, and I’m pretty surprised you would minimize it (though honestly I think your numbers are high, 2/1000 is closer to correct from 42-43 weeks). But still, would you get on a plane that had a 1/200 risk of crashing? Is that actually a risk you are willing to rationally take?
Of course you would say no to this, but I suspect you would say yes to the continued pregnancy because you have an innate trust in pregnancy that makes you believe everything is going to be OK. As an obstetrician, I know that everything is not going to be OK if we wait for every baby to deliver. Some babies are going to die avoidably, and that is unacceptable.
Randomized trials have shown that routine induction at 41 weeks does not increase our cesarean delivery rate compared with expectant management, hence the typical practice pattern of induction at 41 weeks.
Another thing worth adding is that we can likely eliminate post dates fetal death through appropriate antepartum testing. As postdates fetal demise is almost certainly due to uteroplacental insufficiency (old placenta), we have a reasonable expectation that that fetal demise will be preceded by an abnormal fetal heart rate tracing. By employing fetal nonstress testing in women who prefer to await natural labor, we can likely identify those infants at greatest risk and recommend induction. However, if folks choose to await labor post dates without monitoring, they are taking the risk of a rare fetal demise that likely is avoidable.
In my opinion, your views of the dangers of induction are clouded by a pre-existing bias against the practice. The risks you list for pitocin are alarmist and completely unrealistic in real practice, as are those for the use of prostaglandins, which have been shown to be safe in induction in scores of studies.
I appreciate your blog and your passion, but cannot read your post without posting this information. Your readers deserve to have another view, and perhaps one that is a little more evidence based.
I appreciate your comments Nicholas but I think you have made a few assumptions about me. Of course I am aware that allowing nature to unfold can occasionally result in adverse outcomes. This is usually one of the main reasons women hire a midwife. We can identify deviations from the norm; carry resus equipment and oxytocics; have skills to manage emergencies; and have appropriate transfer plans. Modern medicine has saved many women and babies. I attend births expecting the best but prepared for the worst if necessary. But, I guess from experience I really do trust women and babies to get it right most of the time and I encourage women to trust themselves because empowered women birth better. To be fair, when I worked in the hospital setting I had far less trust of women because I witnessed them (although it was us) stuffing it up so regularly. So I do understand the lack of trust many have.
As for evidence… I have included links to the ‘gold standard’ Cochrane review and the risks of medications are directly from the manufacturers not made up by me. The dangers of pitocin are often underplayed. I worked with an obs who referred to it as ‘lethal’ in an attempt to get midwives to take the risks seriously and not to be so blasé about asking him to prescribe it.
I am sure you are aware that unless we fully disclose the risks of any procedure (regardless of how insignificant we consider them) we are liable for legal action. I am sick of counselling women who tell me ‘no one told me that if I was a induced…’
It is not our (mws and obs) risk to take, or not take as i have clearly stated – it is the woman’s. I have supported women who have chosen induction (and epidural before pitocin), and those who haven’t. All I ask from women is that they are fully informed and take responsibility for their birth choices. My job is not to make their decisions or judge their choices.
Some of us might get on a plane that had a 1/200 chance of crashing if we considered that staying in our current location was also dangerous.
Though I don’t have a thorough medical knowledge, however, what I have studied so far in this arena tempt me to agree with you on many accounts
Cochrane is nowhere near a gold standard. Meta analyses, of which Cochrane exclusively consists of, is a useful tool, but it has huge potential for bias in its construction. Many Cochrane analyses are deeply flawed, and often they make no conclusions at all, based on a lack of good data to work from.
There is no question that pitocin can be used in a dangerous manner, and in that sense you could consider it a lethal drug. The same could be said for just about any drug, as most drugs are dangerous if given improperly.
I agree with you completely that inductions have risks, and should not be undertaken without clear indication. Postdates is a reasonable indication, and in randomized trials doesn’t seem to increase the cesarean rate. That being said, this is randomized obstetrical care, and some midwives have expressed that they believe that they might have a lower cesarean rate had the expectant management group been randomized to midwife attendance in labor. Perhaps.
I think OBs and midwives often are working with very different populations of patients. I just came on as attending to a full labor and delivery, 75% of which is patients having inductions around 40 weeks or for questionable conditions like mild hypertension at 37 weeks. I don’t like it either.
I wrote ‘gold standard’ tongue in cheek. As I said in a previous post – meta analysis is only as good as the research reviewed. Research is usually flawed and always biased. Even the questions asked are biased and influenced by the researcher. Unfortunately, quantitative meta analysis of RCTs are considered to be the best available evidence and practice guidelines are written based on them.
I am a qualitative researcher and my bias is wanting to know about women’s experience of birth. I doubt my findings will find their way into practice.
Regarding indications for IOL – I actually think ‘woman’s request/choice’ is the only indication whether that is based on medical information eg. Postdates, pre-eclampsia, etc. or nothing at all.
Pingback: The curse of meconium stained liquor | Midwife Thinking's Blog
Hello
LOVE this blog and recommend it to all of my friends as I believe that you give the ‘other’ side of the story, from the side of baby and mother rather that the one-sided view that you seem to get thrust at you from hospitals, in my experience anyway.
Anyway, could I just ask a question? I had gestational diabetes with my son in 2008 and the hospital led me to believe that I needed to be induced at 38 weeks and refusing this would basically endanger my child. They told me the placenta would cease to be as effective and there was a strong possibility that my baby would grow too big to deliver naturally if left any longer.
This was my first child and I must say I never even thought about questioning their recommendations.
I was induced at 38 weeks and after two days and some very painful interventions and whilst strapped up to several IV lines including insulin, antibiotics and an epidural I gave birth to a 7lb 14oz boy. He wouldn’t feed, grunted on each breath and spent the next 2 days in NICU.
Looking back I fully realise that he simply was not ready to be born.
I am now pregnant again and may again have GD. Do you have any thoughts on whether babies born to mums with GD NEED to be induced at 38 weeks? From the research I have done in the last couple of months the evidence seems very thin and looks as though it may well be the hospitals covering their own back. I would so love to have a natural birth with minimal interventions at a time when my baby is ready but will the GD compromise this dream?
Would love to hear your thoughts
Carly
Hi Carly
I can’t comment on your individual situation and technically gestational diabetes is outside the scope of midwifery. Babies of gestational diabetics statistically are at more risk of morbidity and mortality. However, not much is know about the particular risks for particular factors ie. between insulin dependent and non-insulin dependent, well controlled, poorly controlled, etc. The individual woman and her situation needs to be considered rather than a blanket policy. The Cochrane review re. elective delivery is inconclusive (http://www2.cochrane.org/reviews/en/ab001997.html) about the benefits of induction whereas the NICE guideline recommends delivery after 38 weeks: http://guidance.nice.org.uk/CG63/NICEGuidance/pdf/English. Also check out Michel Odent’s perspective: http://rixarixa.blogspot.com/2008/01/michel-odent-on-gd.html.
It is about you weighing up the risks of your individual GD + ongoing pregnancy with the risks of induction and early delivery. Only you will know what is right for you and your baby – you don’t ‘NEED’ to be induced. It is one of your options but you choose your birth. Good luck and let me know how it goes.
You’re upset about being given insulin?!
I am currently 3 weeks and 2 days overdue. I have been offered induction, and refused. This is my 10th baby, my 7th was also 4 weeks overdue, although I did not labour effectively and needed pitocin to regulate contractions. I am checking movement and having CTG tra ces done, but am healthy, have low BP, no swelling e.t.c.
I am hoping that labour will happen in the next week, but am a little anxious, as a friend went almost 6 weeks over and then had to be induced.
Wow – your friend went 6 weeks! Did the baby appear post-term? Did you have a ‘dating’ ultrasound in your pregnancy? I wonder if this was more common before we were able to ‘diagnose’ pregnancy so early and use u/s to predict due date. I would love to hear how/when this baby arrives. Good luck x
This was a vary informative blog, I enjoyed reading it. I am a young mom of 23 years old and I induce my first two children let my third one come on her own and am planning on letting my fourth do what ever she wants. I wanted to just comment that as a person who had two inducements with pitocin, they weren’t as hard on my body as letting my daughter choose her own time did. My daughters labor went really fast for me ( 4 hours compare to the previous 8 hours) and was really hard it was when I opted for a epidural. all three are healthy weights 8lbs 6 oz, 6lbs 8 oz, and 8lbs 8.2oz.
Great post! Thanks for the update. Women really need this information so they can make an informed choice. Health professionals need this information so that they are able to ensure women have an opportunity to choose in an informed way.
I thought that the definition of term was 37 completed weeks of gestation. It almost reads at the moment that it’s during the 37th week. What’s your take on that?
Term is ‘from 37 weeks to 42 weeks’. Not the 37th week as this would be ‘from 36 weeks’. Having said that most babies in their 37th week ie. 36+4 etc are perfectly fine on the outside. Maybe it is unclear in the post.
Pingback: December Favorites « Birth a Miracle Services
Hi there
Both my children were ‘late’. The first at 41 weeks. The second at almost 42 weeks. With my second I had a great midwife who told me that hospital procedure required her to book the induction for 42 weeks, I advised her that I would not attend this appointment but would be happy to continue coming in for regular monitoring (every 2 days at that stage). Luckily he came along at 40+10 so I didn’t have to fight the system. With both pregancies I had a ‘stretch and sweep’ (with my second pregnancy I had THREE!) – how do you feel about those as a method of ‘induction’?
Hi Janet
Stretch and sweep can help to release prostaglandin and encourage labour to start IF the body is ready to respond. How do I feel about it? If a woman wants me to do it I will, but would want to explore why she wants to encourage her baby/body to do something that will happen anyway if left alone. Maybe there is a reason for the wait that we don’t understand. If we didn’t have due dates and expectations that babies arrive within precise timeframes there wouldn’t be such dramas over ‘late’ babies, nor the need to kick start labour. Doing a stretch and sweep is not my decision or choice – the cervix involved belongs to the woman and the decision is hers. I’m pleased you managed to have your babies within the prescribed time frame and avoid the hassle of ‘post-term’.
Pingback: Induction,why so bad? - Pregnancy - Third Trimester Forum (Page 3)
hi, i am currently in my 41st week and am trying for an unassisted VBA2C at home. unassisted because the country that i live in does not support VBACs of any sort, and no no doctor, hospital or poly clinic is willing to give me a trial of labor.
my question to u is about the risks of going post date. my EDD was april 28th by earliest scan (at 8weeks) and april 14th by LMP (july 7th). if we assume i conceived 2weeks after my LMP, i am in my 41st week now. im hearing that going post date for a VBA2C can be highly dangerous. wat is the truth in that? do u think i should wait more or go ahead and schedule a c-section?
I don’t give advice only information. You must do what feels right for you. Going postdates is not highly dangerous. It does not increase your chance of uterine rupture. However, according to research being postdates reduces your chance of a vaginal birth – but the reasons are difficult to determine. You are still most likely to give birth vaginally without problems. I am hoping you are already in labour – or have your baby in your arms. It would be great if you could update us with your decisions and outcome.
thanx for this… since yesterday afternoon, ive been in pre-labor apparently (or watever term u guys use for it!) .. irregular contractions lasting close to a min, and some bloody mucus a couple of hours back. im in touch with a midwife in the US (u probably know her as she is the one who sent me ur links in the first place) and she is trying her best to monitor me from afar. i also have a doula who is abt an hours car ride away from me, and will come once active labor starts. i am really really hoping to have a vaginal birth this time around. will let u kno the outcome of this trial
thanx for responding. i find ur posts highly informative.
How exciting! Let us know when your little one is earthside
x
i had an unassisted home birth on may 3rd at 6:45am. it was really a very crazy experience! hubby caught our baby girl. alls well and we are both doing fine.
You have made may day! Congratulations you amazing birthing mama
Welcome earthside baby girl x
Thank you for your blog! I happened upon it last week and it is wonderful. I am a doula and childbirth educator, and spent some time as a homebirth midwife’s assistant, so I am nodding in agreement as I read along.
I am so happy to see your post about induction and “prolonged” pregnancy and to see birth beyond 42 weeks discussed as simply a variation of normal. It’s a topic I try to cover thoroughly and carefully in my classes because IOL at 41 weeks is definitely the norm around here. I will also admit that it’s my particular soapbox because my own babies came at 41 weeks + 6 days (induced in hospital), 41 weeks + 2 days, and 44 weeks (both homebirths).
If you don’t mind, here is a link to a short version of my 44 weeker’s birth story, in case any other mamas need encouragement as they wait for their little one to arrive!
http://www.theunnecesarean.com/birth-stories/taras-story-9-lbs-13-oz-home.html
Thanks Tara – I’ve added a link to your story in the post. It is important for women to hear/read positive birth stories from other mothers.
The link to “big babies” by Claire Hall is’nt working for me. Is there any other way for me to get to it? Thanks…btw great post
Hi Erica – I just checked and the site is no longer available
Thanks for letting me know. I will try and get around to writing a post about ‘big babies’ in the future.
I just came across this post and your blog generally and I think your analysis is very sharp and respectful of the complicated issues involved in pregnancy and childbirth. I particularly like the way you discuss risk, since nothing is risk-free and women must make choices based on the risks they are most comfortable taking on. Hope you don’t mind if we link to your blog every now and then.
Thanks Beth. Just checked out your site. It’s a great resource for women!
We are publishing statistics collated from all the hospitals in Ireland next Monday and I am trying to write a bit on our induction stats. Would you mind if I posted a link to this blog at the end of my piece please?
Of course you can
If only I had read more, and perhaps been informed by the medical team on waiting vs induction….
I am still emotionally ruined, nearly 6 years. Fear from the medical team in a hospital who gave me no support or options. They told me what was going to happen, they lied and when I questioned it, I felt like a fool…
Emotionally I have not been able to allow myself to get pregnant again. I wish for another child, but my fear is so huge and haven’t been able to shift this….I urge women to read this……If only I knew I could have waited.
My waters broke ’2 weeks early’…..with no natural contractions. I was ‘high risk’……They gave me 1 day to have natural contractions, otherwise I had to be induced. The fear started there, and ended with an ‘emergency c-section, epidural pethidine and 52 hours later I had a c’section. I didn’t see my baby for an hour whilst I was stitched up, I was so drugged and out of it. I got golden staff and was in bed for 2 months on anti biotics with a hole and puss oozing from me, my little girl was jaundiced, not to mention the anti biotics in her system.After 2 courses of antibiotics, the wound hadn’t healed.The Doctors then suggested that I should get my cut re-opened and done again…
I said no, I cleansed my system, bathed my wound, started on homeopathics and my wound closed over with in 3 days..
I sit here and cry and want so much for my fear of birthing to dissipate. I wish someone had of just told me that I could of waited up to 3/4 days at home and trusted myself as a woman to birth the way I was meant to Birth, in my power!….x Thanks for this site…x Em.x
Em I am so sorry. What you went through was awful. Please access some help to talk it through – can you talk to a local midwife or doula? *hugs*
I have, I have 2 very special friends who are midwives……No matter how much talking I do, this feels cellular and instinct has kicked in.. It’s too late now…I have had a healing with a beautiful woman, I have cried in the safety women’s circles with my friends. It still sits imbedded within me…..I never want to feel that invaded or out of my power again.x I am so blessed to have my little girl. x .
Grateful for this site and will pass this onto women I know.x Thanks again, great information, with love.x
It is so sad that the care you got (or don’t get) during birth has had such a devastating effect. A lesson for all practitioners
hun i really think you should see a maternity hypnotherapist for emotional release work. it’s great stuff and very safe and healing. it’s something i do when helping traumatised women approach their next labours (i’m a hypnobirthing teaching) and i’ve seen disempowered, frightened women become amazons, and have beautiful easy births.
If only I had read more, and perhaps been informed by the medical team on waiting vs induction….
I am still emotionally scarred and it’s nearly been 6 years. My Fear is from the medical team in a hospital who gave me no support or options. They told me what was going to happen, they lied and when I questioned it, I felt like a fool…….They were very neglectful in terms of my well being, emotion, spiritual and physical being…x
Emotionally I have not been able to allow myself to get pregnant again. I wish for another child, a sibling for my little girl and perhaps a boy, for my partner. Unfortunately my fear is so huge that I haven’t been able to shift this….I urge women to read this……If only I knew I could have waited.
My waters broke ’2 weeks early’…..with no natural contractions. I was ‘high risk’……The Doctors said If I didn’t start having natural contractions soon, I would have to be induced. When i refused, the Dctor told “not to be silly, do you want your baby to die”. The fear started there, then the Oxytocin started, WOW…..there was no gradual welcoming, it was on and it didn’t stop, no breaks, or time to rest…I had plugs and, a fetal monitor on, a drip..pethadine up to the eye balls,to deal with the oxytocin ( only intensified it)….. I ended up having an ‘emergency c-section with an epidural. I didn’t see my baby for an hour whilst I was stitched up, I was so drugged and out of it. I ended up contracting golden staff from hospital, where my c-section wound oozed puss from the hole that wouldn’t close. My little girl was jaundiced, not to mention the anti biotics in her system.After 2 courses of antibiotics, the wound hadn’t healed.The Doctors then suggested that I should get my wound re-opened cleaned out and stitched up again.. I could of punched the Doctor.
I said no, so I cleansed my system, bathed my wound, started on homeopathics and my wound closed over with in 3 days..
In the beginning,Imagine when my waters broke if the Doctor had of said ” it’s all fine, go home relax and give us a call and let us know how you are feeling, you are safe and in good hands…You aren’t high risk and your baby isn’t going to die”….perhaps I would have had the pleasure of a gentle slow movement into labor, rather than forced and help in a state of agony, with an outcome only known by Doctors…
I sit here and cry and want so much for my fear of birthing to dissipate. I wish someone had of just told me that I could of waited up to 3/4 days at home and trusted myself as a woman to birth the way I was meant to Birth, in my power!….x Thanks for this site…x Em.x
I love that you went into detail on all of this stuff ranging from induction of labor and the how it works to the risks of it. Particularly helpful was the risk of infant death. I had an awful experience with my midwife during my last pregnancy continuously encouraging me to go in for an induction because I was 42 weeks. I had three fetal stress tests taken and had high scores for all of them. I felt physically great, besides wanting to get the baby out. lol The baby was still very active and I felt sure that God wouldn’t allow someone to be pregnant forever. Surely. That was my hope. It was a really scary situation I had my midwife telling me that my baby was in danger and the doctor at the hospital telling me he would die after 42 weeks.
In the end, I went with my gut and I also found this study by Gulmezoglu Am and held onto that for dear life. It wasn’t that comforting though since I was under immense pressure from my healthcare providers and everyone that I knew to induce. I successfully went into labor on my own when Peter was ready to be born at 42 1/2 weeks.
Thank you so much for making this information available to moms! I wish that more healthcare providers knew it too.
Pingback: Seeking support online – pregnant with twins « Gifted Birth Support
Pingback: VBAC: making a mountain out of a molehill | Midwife Thinking
The best time for induction is 41 weeks of gestation.
I think the best way of induction is Misoprostol. Here what is required is approach on how to insert to posterior vaginal fornix.
I am currently 40 weeks and 2 days pregnant with my first child. I am 38 years old. I live in California, just for further info. My baby is healthy and the pregnancy has been fine with zero complications. My OB/GYN started to talk about induction at the 38 week mark. I’m not exactly sure why. At 40 weeks she said to come in for a Non-Stress Test and was really pushing the idea of induction. (In fact she said it is far more likely that I’ll have to be induced than not be induced- her reasoning- I am effacing but not yet dilating) The NST test was this morning. The baby looks great, the heartbeat is strong. The placenta is healthy and working efficiently, the baby is moving and kicking just fine, amniotic fluid check- fine, etc…. So they want to give me another NST next week. Fine. I myself was 2 weeks late back in the 70′s. I’m in no hurry and it seems the baby wants to cook a little longer. I will resist induction as long as I can and am comfortable with. But when she uses phrases like “fetal death” it feels like she’s using guilt to get me to have an induction. Why does she care if I wait longer? This person barely knows me. The whole thing makes me want to hide out at home and deliver my own baby in my bedroom with my doula. (I won’t. Sadly I can’t afford to have a midwife/home birth even though I desperately want to) My baby is healthy! Why is she tormenting me!? This is such a stress-filled way to end what has been a beautiful pregnancy.
Thank you for your article. I don’t feel so isolated now.
Your obs is a bully and I am sorry that you are not being given evidence based information or being supported by her. I cannot believe that even an obs would suggest a stress test at 40 week… more like a stress inducing test. I really hope you can stay strong and do what feels right of you and your baby. Please let us know what happens. You are the expert on your body and baby – not your obs.
Hi, this blog is an amazing find – thank you! I am almost 35 weeks pregnant, and planning a home birth. I have been advised by my midwife that because of my age (42), I “won’t be allowed” to go over 41 + 4 for fear of my baby’s placenta not working properly after this gestation. I have been unable to find any info about this online but was recommended your blog……..I really want to avoid induction unless my baby’s life is at risk. Can you advise at all?
I can’t offer advice… only that nothing can be done to you without your consent ie. it is not a case of ‘allowing’ you to do anything. I would be worried about your midwife’s understanding of the physiology of the placenta. You can do whatever you want. Risk is a fact of birth which ever option you choose. You need to decide what type of risk you want to take
Hi again and thanks for replying. I have a good awareness of the risks of induction but it’s the risks involved in not inducing in particular at age 42 that I don’t know and am finding decent info hard to come by.
Rachel – the risk is an statistically increased chance that your baby will die while waiting for your labour to start or that complications will arise during labour. However, you are not a statistic and it will be difficult to identify your personal risk. Humans are more complex than stats. For example, is the statistical increased risk because of the interventions women who go postdates are subjected too?
If I was caring for a woman who went past 42 weeks the kinds of questions we would be working through include ‘why’ has she gone post dates… is this normal for her or is there something else going on (emotional, physical). What has her pregnancy been like. Is she really post dates – how was the due date worked out. Has the baby grown well, is he/she moving well. What does the women feel – what does she know. There is the option of a biophysical profile where they assess placental blood flow and fetal well being – for some women this is reassuring, for others it increases stress and prolongs the pregnancy further.
As for your age. This again is totally subjective. An individual 20 year old may be less healthy than an individual 45 year old. You are not a number and to be honest your age should not be an issue in itself. You really need to connect to yourself and your baby and allow your intuition and embodied knowledge to direct your regarding what is right for you. You will never find concrete answers outside yourself
Reblogged this on Mommy Baby Spot and commented:
This is a must-read if you’re considering induction due to your due date having come and gone. She’s also included some really great links for more information. Don’t succumb to the medical pressure to schedule your baby. Trust your body.
Thank you midwifethinking for a great article!
Pingback: Examining the Contract « Spirited Mama's Musings
Pingback: Asynclitism: a well aligned baby or a tilted head? | Midwife Thinking
I am currently 38 weeks pregnant, I’ve had 3 children but my 1st was 2 weeks overdue and induced and then ended up delivering by emergency c-section. My two subsequent children were natural births but each time I had my waters broken and not good experiences. As I am now 40 and have had a previous section, (16 years ago), I have been told that I can go over due up to 10 days but need to decide whether I would prefer to be induced at the end of that time if need be or opt for an elected c-section. The reason has been presented as far as I understand mainly on the basis of possible rupture of the uterus due to more intense contractions resulting from induction. Also my age has been raised as cause for caution. I’m now confused and anxious as to what would be best (apart from obviously hoping and praying that I go into labour naturally before a decision needs to be made!). To elect for major surgery and all the possible risks that presents seems crazy, but the thought of risking rupture of the uterus and all the other undesirables that can potentially arise from induction is also really worrying me. Chances are I could quite likely end up with an emergency c-section anyway! Any advice??
Hi Janet – I don’t give individual advice. Some issues to consider: If you haven’t already read: http://midwifethinking.com/2010/09/16/induction-of-labour-balancing-risks/; induction will increase your risk of uterine rupture, however the risk is still small and lots of women have inductions with c-section scars… and elective c-section also has risks; you have done and can birth a baby vaginally; age is individual – some 20 year olds are less healthy than some 40 year olds; You can go as far as you like past your ‘guess’ date – no one can do anything to you without your consent.
So, you basically have 3 choices:
1. Wait until your body and baby are ready to birth – regardless of what the guess date is.
2. Opt for an induction which involves: http://midwifethinking.com/2011/07/17/induction-a-step-by-step-guide/
3. Have a planned elective c-section
All of these options hold risks and very small risks ie. we are talking less than 1%. You need to do what feels right for you. Let me/us know what happens
I wish I had found this back when it was posted (funnily enough my daughters EDD). I was induced at 42 weeks for her and it ended in a c-section, which I think was more about the length of time that I had been in labour for than anything else since she wasn’t distressed and they came in to discuss surgery within 30 minutes of my epidural…
Now I find I’m fighting an uphill battle to be “allowed” to have a vbac. The hospital are fine with it in principle, but want to place restrictions on me that aren’t exactly conducive to achieving a vbac, and I’m worried the stress of arguing with my healthcare providers is going to up my adrenaline and prevent labour from coming on
I hope you can find a way of de-stressing the situation because it is counter-productive. It is such a shame that the hospital creates such unnecessary stress around a simple birth.
Pingback: The Curse of Meconium Stained Liquor | Midwife Thinking « natural birth resource
Pingback: Dating Scans: A comfort or crime? | Calm Yorkshire Birth
Thanks for this article and the birth stories. All three acurrately summarise my current situation of having a ‘post-term’ pregnancy. While I am convinced that my EDD is (and we already know this is only an estimate), pressure began from 39 weeks (according to their calculations) to begin the induction process.
Both the baby and I are fine, it seems everytime I come into contact with a medical professional (and now that I have passed their 42 week mark this has become a daily occurrence), there is yet another reason given to me, ‘objectively’ of course, as to why I’m putting my baby and myeyself at risk. For example, last week after being given the all clear from a scan of the placenta, fluids, etc, I was then told the baby was at an oblique lie and that he was ‘too humongous’ to move. He was of course deemed ‘humongous’ based on the estimated fetal weight which clearly states is an estimate, is less accurate after 36, and without taking into account previous scan data (at 34 weeks he measured above average and from both the scan palpatation it is obvious that he is very long). So, I was then told that if I went into labour naturally his shoulder and cord would arrive first and he would asphyxiate. Super. Way to frighten a poor stunned woman who only minutes before was given the all clear. I was then told that I would be kept over the weekend and scheduled for an emergency c-section on Monday AM (clearly it was not urgent enough to ask a consultant to perform this over the weekend). I tried to insist that the baby would move as he is still quite active and had been disturbed by all of the poking and prodding, which was of course ignored.
Once in hospital I felt wrongly imprisoned, as I knew nothing was wrong. And sure enough, while being monitored later that evening that I asked for the position of the baby to be checked and he was in the correct position. Once that issue was resolved they began making more of an issue about his weight and shoulder dystocia. I was also told that I wouldn’t go into labour after 42weeks bc I hadn’t and other women
Apologies, I didn’t complete my previous post.
So, as I was saying, I was told women don’t tend to go onto labour after 42 weeks (nevermind the fact that women are generally induced before this point so there is no supporting evidence for this). I wad also then told that they wanted to check for gestational diabetes as this would explain the baby’s size (and warrant the unnecessary c-section now planned for Monday). This suggestion completely threw me! This was being suggested to a woman with none of the associated risk factors, with an extremly healthy diet, had walked, swam as well as practiced yoga 3 times per week up til 40 weeks and has only put on 11kgs. Nevermind, that not a single one of my routine urine tests had showed any positive signs for glucose. Thankfully only after very brief consideration did we decide to refuse the test, to continue with my original plan and to be discharged. They agreed, but this means both the baby and I are subjected to daily monitoring for 30 mins and today I have to see ‘my consultant’ the one who I saw for 3 mins and inaccurately ordered a ceasarian. It is obvious she is very pro-intervention, so I am trying to regain my slightly shattered confidence to go into battle. I can’t emphasise enough how stressful this is and how disempowering it feels to have someone making blanketed decisions about me and my baby without considering our case individually.
But, this article has given me back some of my confidence and I am ready to ask for the evidence, to be informed of induction risks and to have my due date re-estimated. So, many, many thank yous for this!
I have had 4 babies. back then they didn’t do the scans they do now-Thank God! My first was due on Fri, the doc “rimmed the cervix” on monday and said he would see me in hospital in a couple of days. Jason was born 2 weeks later-healthy and 5 hrs from start to finish. I have no clue about the timing of my next, since there was a possibility I had lost a baby. She was either exactly 4 weeks late or right on time-which would be right on time in any case. My third baby was “due” 18 of Nov. and was born 18 of Dec. My 4th was due 3 wks after the “due” date. All my babies were healthy. I was healthy. I am a birh doula and have witnessed obs tell outright fabrications(lies) to get their clients to do what they want according to their schedules. Growing up I had a great deal of respect for the work and dedication I thought obs represented. It is very hard to mesh what I thought with what I have witnessed. I guess that is what happens when you put any person or profession on a pedastal. This post is a wonderful tool to get women to think and help them to know what questions to ask, and hopefully learn to respect themselves, their babies and their bodies. We were not made less that any other mammal on the planet. Our bodies are more than capable of carrying, delivering, and nurturing our babies. On the occasional time we need help, I thank God that we do have the proffessional people there to help, but we need to recognize that they are only people, with lives of their own.
I would love some advice from you regarding my delivery! Your post was very helpful, however, I’m still having a difficult time deciding what I need/should do. My “due date” is tomorrow. I have been at 2 cm dilated for several weeks and I started to thin about 2 weeks ago. I lost my mucus plug almost a month ago. I am considered high risk because I have a thyroid disease. My doctor has been pretty great about meeting my desires and not pushing an early induction. Last week, he suggested that if I had not gone into labor by my next appointment (coming Tuesday) that we would schedule an induction for the following week. He does not want me to carry over 1.5 weeks but he will let me go 13 days. I haven’t argued with him because I don’t know what I feel most comfortable with. Do you have any suggestions?
Hi Brittin
I don’t give advice only information – you need to make your own decision about your own body/baby. I have a number of concerns about your comment…
Firstly how on earth do you know what your cervix is doing and why? I am hoping that you are not seeing a care provider who is undertaking the outdated and invasive practice of vaginal examinations in pregnancy. This practice is pointless as it does not indicate when you will go into labour and it can result in complications… possibly why you lost your mucous plug in the first place. A woman who has previously had a baby can walk about with her cervix opened for most of her pregnancy. This is normal and nothing to do with labour.
“My doctor has been pretty great” – because he has not bullied you into an early induction?? But will schedule an induction if his ‘guess date’ is more than a week wrong (did he discuss the evidence or your thoughts on this?)… “he will let me” NO – this is your body/baby. He does not ‘let you’ do anything. YOU let him do things to you ie. give consent for procedures. He does not need to give consent for you to not have a procedure.
The only suggestion I have for you is to take responsibility for your body/baby/choices/birth and do what feels right for you… and that may be an induction. You are the one who has to experience your choice – no one else should make them for you.
I am sorry, I don’t mean to be harsh with you. I am just deeply amazed and saddened at how disempowered women are within the maternity system.
Not quite the reply I was hoping for, beings this is my first pregnancy and it’s all so new to me. All of the women in my family that I’ve spoken to are pro-induction and pro-epidural, so it’s hard enough just feeling like I’m going against the ‘norm’. I have tried to research as much as possible during this pregnancy and I never read any warnings or had anyone tell me that having my doctor check my cervix would be a bad thing or should be avoided. The way you say it makes me feel as if I’m stupid for allowing this. I was just uninformed, like most women in America. It is hard to find any reliable sources online that are pro-natural births and list warnings of hospital procedures since it’s so common highly promoted. Just recently, 3 of my friends were induced. Each was between 36-38 weeks. When I asked why they chose to be induced, they said it was because their doctor recommended it. They didn’t question it at all. I feel like I’ve done pretty well this far since I made it very clear from day 1 that an induction would be a last resort for me and I will absolutely not have an epidural. I feel a bit deflated after your response.
One of my friends that I reach out to more than anyone had a home birth and her midwife performed several vaginal examines and swept her membranes 4 different times (she is even strep b positive). I did see a lot of research where that was not suggested. I, too, am positive for strep b, so I haven’t asked him if it was something to consider. By saying my doctor was been pretty great, I mean that he has listened to my concerns and allowed me to make my own decisions so far. He has not pressured me to feel a certain way or even to schedule a induction. He made the comment that we would go ahead and schedule it so it’s on the books and we could go from there. He, like most doctors, is concerned with letting me go over 42 weeks. Like I mentioned, since I am a high risk patient, he would like me to only go to 41 1/2 weeks, but has said he will “let” me (if I still “look great” – blood pressure, etc) go up to the 25th of this month, which is 13 days past my EDD. He is a doctor for a reason and while I trust my judgement, I also take his opinion into consideration since he is aware of my medical history.
Thank you for your response, I guess, but I will seek information from other, more understanding and less harsh resources!!
I am sorry you have taken my comments as a personal attack. If you note I state that women are disempowered within the maternity system ie. you are not given access to the information and care providers take a paternal approach to their client relationship. You are not stupid. You are searching for the right answer. My point is that you will find external experts who advocate induction and ones who advocate never inducing. I don’t advocate either. I want you to access the information and make your own decision. I have taken lots of time and effort to put the information out there for women to access. It speaks volumes that you have been unable to explore your options and thoughts with your care provider.
I am aware that homebirth midwives also do dangerous/pointless practices such as vaginal examinations in pregnancy (and worse). This is why I use the term ‘care provider’ to talk about those who do things to women.
You asked me to give you advice. I do not know your medical history – your doctor does and is in a position to discuss with you your options and the risk and benefits of each option specifically related to your individual case. To ask me or anyone outside of this relationship for advice is putting them in a difficult situation. You may be able to find some more understanding and less harsh resources on the internet but I hope you don’t find anyone willing to give you advice about what to do in your situation (for their sake and yours).
Again I apologise if you feel that my response is an attack on you. It is not. It is a comment on the state of maternity care and how it works to prevent women from being informed and from taking responsibility for their birth journey.
Also be careful about stating you will absolutely not have an epidural. Induction is not a physiological process and many women require an epidural to manage the pain. You have not failed if you choose an induction or an epidural. It is important that you do what is right for you not other people.
If you are not too annoyed by my honesty I’d love for you to come back and let us know how your birth went
Wow, do you have the same autonomy of your legal issues wrt your attorney? Do you tell your builder contractor how you want him to construct the framework? Do you have that same autonomy in choosing the chemotherapy for a relative who may have cancer? Sounds like if this woman wanted an epidural and wanted an induction, you would take that autonomy aware from her because you want to impress your ideals upon her. POT meet kettle.
Have you actually read the reply and the post and other posts on here? Try: http://midwifethinking.com/2011/04/09/judging-birth/
If a woman wants an epidural and an induction I support her choice… I have cared for many women who chose this option… and elective c-section. It is her birth, not mine – she needs to gather information and make HER choices. I’d like to see where I suggest taking autonomy away. That’s the opposite of what I am suggesting in this thread which is about taking responsibility for ones body/baby/choices rather than expecting others to.
From your comments re. autonomy and building/medical treatment/law – you clearly don’t understand the concept of bodily autonomy or law regarding adequate information for consent.
Hello Rachel,
I am a doula in Ottawa, Canada. I really enojoy your blog. Thank you for writing!
In your opinion, if an induction was necessary for medical reasons at 37 weeks with the first baby. Because of all the advirse effects on the induction drugs to the baby and because it could 3 times more likely turn into an emergency Cesarean, wouldn’t it be a better choice to have one planned?What are your thoughts on this?
Yes – I think that an elective c-section should be offered as a choice in this situation. The mother needs to make the decision as what she feels is the best option for her weighing up the risks and benefits of induction vs c-section.
This is exactly what I needed to read at 42 weeks 4 days. Thank you!
I am still feeling great, my daughter is doing well. My doctor has been great about following what I want, not that he has a choice, until my last appt (42 week). He still made sure I knew it was my choice to make, but made it very clear that he feels I’m putting my daughter’s life at risk. He even asked what exactly my issue is with induction. I explained that once one intervention is introduced that it often causes a domino effect that I’m not comfortable with. He had me start doing NST and she is passing those without issue. I am thinking of asking for a biophysical profile at my next visit as he has mentioned he isn’t comfortable with me remaining pregnant after that date. He said by then he wants me to make a decision. Obviously he’s trying to pressure me into the induction, but back tracked to make sure I knew he couldn’t make me do anything. Thankfully when he tried to play the ‘dead baby card’, to scare my husband I believe, he underestimated my support system. Thankfully my daughters birth will more than likely be attended by a midwife.
Do you have opinion on biophysical profiles?
Hi Penny
Biophysical profiles when done correctly can provide helpful information ie. if they show that all is well. However, they can promote anxiety and stress for some women which is not helpful. Remember this is your body/baby and therefore your choice. Your doctor is not responsible for your choices – only for the care and information he provides. Maybe he needs reminding of this? Good luck, let us know what happens
I went into labor/water broke (the day after I left my comment) on my birthday September 11 at 8 am. I was to 7cm at 10am and my daughter was born at 1:24pm. She was OP and didn’t turn until I was pushing. She weighed 8lbs 11oz 20 inches long.
The head nurse that I had met during a NST (very chatty) informed me that it was in my chart that had I made it to my OB appt that day my OB had planned on talking me into an induction. I explained to her that I wouldn’t have consented and she said “Good! Your baby is doing well.”.
The hospital I gave birth in was much better than I thought it would be. After my last birth I was fearful of hospital policies vs my birth plan. I had one nurse for the entire time I labored. I was her only patient so she stayed in the room and helped my husband comfort me. Suggested a bath, different positions to try to get my daughter to turn, and held the monitor to me so I could continue to move around. She also was our day postpartum nurse while we were there. My daughter was breastfeeding so well when she was put on my chest that they left us alone to cuddle for two hours. They were all wonderful supporters of breastfeeding. All of the nurses followed my birth/baby plan without complaint. Even my requests for no eye ointment and no bath. After the last hospital I was ready for a fight and was so relieved to not have to.
The on call OB was less than pleasant. I had Norovirus and while the nurse explained this the OB looked at me and said “So you took castor oil.”. She was also very angry that I was refusing *routine* pitocin and made a few rude comments about to the nurses in front of me. She was so rude it was actually funny. The nurses kept looking at me in horror. Even they were shocked.
Over all I am very happy with the experience. Thank you for easing my fears. The information you share here is so important.
Thank you so much for coming back and sharing your experience. Congratulations!
I was induced at 41 weeks (EDD based on dating scan) with my first baby in February year. LNP put me at 40+3 but my cycle had been anywhere between 28-38 days in the year prior to getting pregnant. Due to Wednesday 8th February being lucky in the Chinese culture (I live in Melbourne!) I was unable to be induced at 40+10 as all the induction spots at the hospital had been booked! I had the option of waiting until 40+12 or else 40+7 (which I chose). I liked the fact that you clearly outlined the risks associated with induction however I did not face the issues of confinement and limited movement that you suggested. I was given cervidel at 4pm and attached to a wireless CTG that allowed me to move freely around the birth suite. After 90 minutes of monitoring, in which I had already begun contracting, I was allowed to walk down to the hospital restaurant to get food (provided I was back in 30minutes for more monitoring). At 7.30pm my membranes spontaneously ruptured and active labour really began. The wireless CTG allowed me to assume any position I liked and I spent most of the time walking/squatting/standing etc.I had an IV catheter inserted (incase further intervention may be needed) but was not hooked up to an IV line/bag so this did not limit my movement either. I was determined to move as much as possible during labour to really get the endorphins working. After my membranes ruptured I was able to use the shower for pain relief as desired as well. At 10.50pm an internal examination was done suggesting that i was 5-6cm dilated and fully effaced. At this point i decided i wanted an epidural however i had a very good midwife who convinved me to wait it out a little longer (she knew i wanted to keep as active as possible for as long as possible). At 11.25pm I asked for pethidine however again my midwife convinced me to wait 15 minutes to see how I was going. At 11.30pm I felt the need to push and at 11.45pm my son was born on the 5th February. My obstetrician didn’t make the birth (he assumed after the internal examination I’d be at least a few more hours) and I managed to birth my son without any pain relief at all. I guess I wanted to tell my story as everyone told me beforehand ‘that I didn’t want to be induced’/'that I wanted to avoid being induced at all costs if I could’ etc but for me being induced was no-where near as terrible as everyone made it out to be. I am sure it can be awful (as some of the above stories attest) however if a future pregnancy required me to be induced I would definitely do it again. I am sure some genetics were involved (my mum had me spontaneously and naturally in 6 hours and my younger brother in 3 hours and my grandma had my mum in 5 hours and her younger sister in 2 hours) however I am also thankful for my obstetrician, midwife and hospital for allowing me to support my birth plan despite being induced by being able to move around as much as possible and holding me off from pethidine/epidural while in transition when your mind tells you ‘that I don’t want to do this anymore!’. So while there are many risks involved I definitely think that the mindset you take into induction can help you with your induction experience.
Thank you for sharing your experience. Induction can be a positive experience. It seems your body was ready to respond and you managed to avoid the artificial oxytocin IV which is often the source of problems during induction.
Just wanted to say I’ve had 4 children all were past their EDD, one was 17 days past and I was threatened with and Induction but baby decided it was time, I had no calcification of the placenta only thing that was noticeable was he seemed to shed a layer of skin over the first couple of days otherwise perfectly health and he’s 25 now!!!!
Thank you for your article. We have two daughters: one was induced at 38 weeks while the other arrived of her own accord at 40. The oldest was induced and is now 31 months and the younger is 14 months. we have compared how often both girls get sick and found that the daughter who was induced is more prone to catch colds, viruses etc. This trend tends to repeat within our family between children that have been induced and those that have not.
I wish our obstetrician mentioned that there may be potential consequences to our baby’s health later in life. I now appreciate that nature knows what it is doing and we need to listen more to her and where possible we should not try to change the natural process.
Did the daughter that was induced receive antibiotics in the hospital, during the labor or afterwards? That could have an effect on the health of the child throughout her life. I also have a friend with 3 children, and the one that was induced (the youngest) has the most allergies of the three and seems to get sick more often.
As you say, research depends upon who is interpreting it. In regards to the increased LSCS rate in first time mothers who were induced; Was it is the induction process or the pathology behind the cause for induction which led to this increase in caesareans?
Yes, it is difficult to make clear cause and effect assertions from quantitative research. Both studies cited in my post attempted to control for co-founding variables. The Selo-Ojeme et al. study only looked at induction for post-term pregnancy. In both studies the researchers concluded that induction of labour independent of other factors increased the risk of c-section for primiparous women. That is their interpretation. The same problems crop up with research into post-term pregnancy which demonstrate increased risks for the baby… they don’t provide the ‘why’ ie. are these babies already at higher risk for reasons other than length of gestation. Anyhow, in terms of induction and c-section the findings fit with ‘common knowledge’. In my years of working in a large regional hospital we would have to inform the anaesthetist and theatre staff when putting a primip on syntocinon… because it was likely we would end up in theatre and need them. Either way, I think this evidence should be shared with women to assist in their decision making re. induction.
Pingback: Induction Risks: Know your facts
Thank you for your posts and sharing your knowledge and research! It has been wonderful learning from you! I truly appreciate the time and effort you put into writing about such important issues.
Thanks
Thanks for your brilliant blogs. As a London based Hypnobirthing teacher and clinical hypnotherapist, I’m frequently having to help women ‘fight off’ unnecessary inductions. It’s so often not an ‘offer’ but pressure and bullying. When questioned on risk, many midwives simply don’t know the facts. I work with many women for the first time during their second pregnancy following a difficult or traumatic first birth. I am often de-traumatising before anything else is possible. I think there is an argument to say that an (unnecessary) induction can cause PTSD. Do you know of any research on this? Thanks again.
It is great that women are finding healing after traumatic births and that there are practitioners like yourself to support them in this. Wouldn’t it be great if women had empowering first births instead?
There is a fair bit of research on interventions and a negative birth experience. In summary – the less control the woman perceived she had over the events, the more likely she is to be traumatised. So it is not the intervention, but the way it is administered that matters. I don’t know anything specific to induction – but if a woman did not feel informed and was pushed into an induction with full information… and then endured the associated interventions and complications she may be traumatised. In contrast, if she chose an medically unnecessary induction and was fully informed of the risk, she may feel empowered that she was in control of the events in her birth.
Pingback: Induction of Labour – Balancing the risks | Ripple Effect Yoga
I loved it
A very interesting blog. I am one of the women who does not necessarily mind intervention. Whilst I would prefer not to have any kind of assisted delivery (especially a c-section), if its needed then so be it. I had an epidural with my first child and it was the best thing I ever did, I couldn’t move and was on a drip but this did not bother me, In fact I was glad of the chance to rest and sleep. My labour lasted 12 hours (which I believe is the lower end of average for first time mothers) and I had absolutely no problems. I am currently overdue by 2 days with my second child and would and will do it all again. My baby is also in a occiput posterior position and as I have been led to understand that this can lead to a much more painful labour, I request that they have an epidural ready and waiting! I am not ashamed of this, I am no hero and no one will be awarding me any medals for doing it au naturele! I am happy for women who insist on only natural births and yes I do agree this is the optimal way (for most), but for me, I don’t tolerate pain well, and i don’t want to be pregnant past 42 weeks and if that means intervention then so be it! I am no medical professional, and like you said, any medical intervention for anything poses risk, but I would take an educated guess that the progression of medical technology regarding pregnancy labour and birth, since even 50 years ago, results in fewer maternal and perinatal deaths. Whether or not that means intervention and an inability to move, if that’s means that my baby and me will be ok in a situation that otherwise might’ve meant extreme complications or death in a time when these interventions did not exist, I’d take interventions any day of the week.
This is just my personal opinion of course, but like was stated, as a woman, MY choice would be for the labour and birth choice that is most comfortable for me. But I respect that women should be informed of the risks of all possibilities of birth, but not made to feel any less of a woman if they choose to have pain releif such as the epi, or feel like a failure if they end up with a c-section.
Interesting blog, thank you for sharing a midwifes perspective.
Midwife thinking – you are a star. It’s so refreshing to read your information. I’m not going to ask you anything as I have read a similar story to mine in your blog (42 years old and doc wants to induce me) I’m so relieved. I’m fit and healthy, had a fantastic pregnancy so far and the only thing worrying me was induction. Thankfully just for a week, since I’ve found your site I am no longer stressed and will go back to my doc confident about the questions I want to ask. Thank you so much x
Thank you and enjoy your new baby
Pingback: -2 | Good Families Do…
Hello! i found your blog through a link on Twitter. This is a well written, informative and empowering post. I do wonder if the photo of caster oil was a good idea though – particularly for those who simply skim read posts, and as a result might think you were advocating the use of caster oil as an ‘alternative to waiting’. I’m so happy to have discovered your blog and will be back to read more
Am 40week+3 pregnant and am going to be induced next week thursday ur blog as been so informative. I will keep u post on how my induction goes, but I still pray I go into natural labour before then
Good luck
Great article thanks! I’d love to hear your comments/experience with women in my situation. I have a ‘double’ uterus, ie. a completely separate second uterus with a second vagina (not really sure of the correct term as it seems there are all different degrees of the same thing). I have no kidney on my left side, and my left vagina is the ‘path less travelled’ so to speak, hence I have no chance of conception in that side. I had been told, and was kind of expecting, trouble actually conceiving, as I can only really conceive when ovulating from the right ovary, I was also 36 when I decided to go off the pill after half of my life on it. Surprisingly I was pregnant within a couple of months. I was treated as high risk in the early months because doc wasn’t sure how well my right uterus would expand, and how much room was there. I ended up having an amazing pregnancy, worked hard to stay super healthy and fit, gained only 3kg as I was overweight to begin with. At 40+3 my bp shot up and doc advised induction. I was scared as everyone I know who was induced ended up having emergency cs. But I trusted my doc as she was super supportive of all of my plans, and was highly recommended by (and complimentary of) my doula. She always said ‘women’s bodies know what to do and baby knows where to go, in an ideal birth I’ll only be there to sign the papers’. This attitude is amazing where I live (I’m an Aussie living in Dubai) as birth here is a purely medical process, must happen in hospital with an obstetrician and is full of interventions, most of which seem to me to be for the benefit of the doctor/hospital schedule. I went into hospital the next day and had 3 inductions over the next 3 days, I begged for a 4th in a last attempt to avoid cs, but I just didn’t dilate at all. I also had my acupuncturist come, my doula was with me doing hypnobirthing techniques, acupressure etc, but despite everything I ended up having a cs. I had the most amazing baby boy who I still think of as my little miracle at 19 months old. After his birth my doc said the left useless uterus was pulling so hard on the right one that my right cervix had dislocated and there was no way it could dilate. So I realise I was never going to have had a vaginal birth that time, which is somewhat reassuring as I don’t need to beat myself up over choices made. But I have heard of women with the same physiological setup birthing vaginally. In your experience, would this likely be an issue second time round? Would this be permanent cervical damage, or can the cervix repair itself and function as nature intended next time? I’d love to try for a vbac if I get pregnant again, but I don’t know if there’s any chance at all. I will be ecstatic just to have another healthy happy baby, however they come into the world!
Hi Hannah
I have known women with similar anatomy ie. double uterus have a vaginal birth. As I don’t have your notes, and have not been involved in your care it is difficult for me to comment. However, some questions that jump out = did you have ‘raised bp’ or pre-eclampsia (PE)? Raised bp does not mean you have PE – and blood tests + urine tests are required to make this diagnosis ie. raised bp alone is not an indication for induction. Your cervix is not separate to your uterus, it is just the opening… it is all part of the same structure. The uterus pulls up or ‘absorbs’ the tissue that is called the ‘cervix’ during labour… I am not sure what is meant by dislocate or how that could possibly happen…
Even if you have 2 uteri and 2 cervixes, the hormonal changes during physiological labour would soften them and allow stretch… but then again I don’t know the particulars… just thinking out loud.
Enjoy your beautiful baby boy and I can’t see any reason for you not to be able to birth a baby out of your vagina in the future.
Pretty nice post. I just stumbled upon your blog and wanted to say that I’ve truly enjoyed surfing around your blog posts. After all I’ll be subscribing to your feed and I hope you write again soon!
This may help provide some clarity
Great blog! I was just wondering after reading the comments what are the precise stats of having a still birth after going over 42 weeks and refusing an induction. 1 in 200 or 1 in 1000?
Also, if you choose expectant management then surely the risk must be very low if you’re being monitored every few days? Thanks!
Unfortunately you will never get precise stats for individual women ie. your particular pregnancy/baby/situation. Waiting beyond 41 weeks and declining induction = 30 in 10’000 chance of your baby dying. Being monitored (if that involves a full biophysical profile) can provide an indication of how well the baby is at the time of the assessment… and may indicate a decline in the condition of the baby ie. reduced placental flow. But not necessarily. There are no risk free options. You must choose the risk you want to take.
Do you have any information regarding twins. Specifically, being “full term” at 38 weeks? Actually I have read some sources that say 37-38 weeks is considered full term by most OBs. I have heard that they develop faster (lung maturity, ability to suckle). How could that be? Why is it twins are born so early compared to singletons? Is it because there is so much intervention prenatally, or is it really a physiological reason? Of course I realize there are many twin mothers who have gone 40 + weeks, but that does not seem to be the norm..
Most women birth earlier with twins. Perhaps because of the size of the uterus = triggers labour (spontaneously). Also probably due to the fact that most women are induced or have a c-section ‘early’ with twins due to policies like your OB has. Therefore, not many women get to 40 weeks or over.