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. We choose the option with the risks we personally are most willing to take. In order to make a decision we need adequate information about the risks involved. 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.
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 definition of a ‘prolonged pregnancy’ is one that has continued beyond 42 weeks ie. is post term. I am pretty sure that this is 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. However, 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.
However, 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 and 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 risks associated with waiting
Essentially the main risk associated with waiting beyond 41 weeks gestation is the death of the baby (perinatal death). A Cochrane review found that: “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.
I am also going to fail to clarify the absolute and relative risks for you. I am a qualitative researcher by nature and find numbers difficult to grasp. Therefore, I contacted a couple of statistician colleagues who attempted to explain the differences in simple terms. The end result = they got a little frustrated with me and told me to forget relative risk because it is not helpful and to stick with absolute risk. So here goes:
The absolute risk of perinatal death was: 0.03% for the induction group and 0.33% for the waiting group. Either way we are talking about a less than 0.5% risk of perinatal death whether you induce or wait… or a 99.5+% chance of a live baby.
Sara Wickham discusses the flaws in the research on a free MIDIRs podcast you can download here.
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
A woman having her labour induced is more likely to end up with a c-section. This is particularly significant for women having their first baby. A recent 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. 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). First time mothers are more than 3x more likely to opt for an epidural (Selo-Ojeme et al. 2010). A Cochrane review found an association between epidural analgesia and instrumental birth. There are significant risks associated with ventouse and forceps birth both for the mother and baby – RANZCOG lists them here.
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, but I encounter too many women who are unprepared for the level of intervention required during an 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.
As a midwife I don’t personally recommend methods to encourage labour for women who don’t want induction. Instead I encourage them to trust their body/baby and to ‘look after themselves’ ie. relax and eat well. My general approach to birth is – trust, patience and acceptance. However, I know that many women want to try something to start their labour and there a number of alternative methods in use - BellyBelly covers most of them here.
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 (less than 0.5%). 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. Each individual woman must decide which set of risks she is most willing to take.
For further information: NICE clinical guideline (UK) for professionals on ‘induction of labour’; 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 : )
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.
As I said I am not a numbers researcher and I am sure my colleagues who are would be halting our conclusion jumping with confounding variables and statistical talk (spoiling the fun). I recently did a joint study with quantitative researchers on assisted conception and breastfeeding. When I looked at the figures I thought certain things looked obviously linked. Then they explained why they weren’t at all : ( Think I’ll stick to words. It is all very interesting though!
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.
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.
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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.
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.
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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’.
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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
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.
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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.