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Induction on grounds of maternal age: what do you all think?

(50 Posts)
EldritchCleavage Tue 16-Aug-11 15:27:02

I am 43, and at 34+2 with my second child. As before, i'm due to give birth at Queen Charlotte's Hospital in London. Just as in my first pregnancy, my notes have been annotated to say 'induce at 38 weeks'. Last time I refused, but I was induced at 39+2 after DS stopped moving for 48 hours. At that point, both DH and I felt that induction was very much the least of the evils on offer. It was very painful, but essentially fine. As a result, I'm not alarmist about induction nor against it per se. However, the pressure on me to accept an induction at 38 weeks is even greater this time around. It is literally the only thing anyone seems to want to talk about at my hospital appointments.

I'm not completely ruling it out, but I am very annoyed that, like last time, the level of debate and information about it is so very poor. Beyond airily telling that it is because of the risk of placental insufficiency in older mothers, no one (midwifes, registrar, senior house officer) is prepared to discuss it in detail. No one is offering detailed explanations of risks vs benefits, nor explaining why this policy is routine at QCH but not a NICE guideline or a routine practice at other hospitals. No one is offering a care plan running up to induction, e.g. doppler scans of placenta, nor a rationale for why it should be done in the week suggested.

I am someone who tends to the brisk and stoic where medical matters are concerned. I don't generally make a fuss and I am not lentil-weavery about childbirth at all- I just want to have things properly explained so DH and I can make our decision on a fully informed basis.

So, I'm due back at my 36 week appt. for another brow-beating. Please come and help me educate myself about age-related induction so I can ask the right questions next time. Any one actually had it properly explained? I am doing internet research (I've forgotten all the stuff I looked up last time) but thought I'd glean as much MN wisdom as possible too.

minstrel75 Tue 16-Aug-11 17:37:14

Hi. I am also 43 and now 36+2 and have had similar discussions with midwives and obstetricians at Chelsea and Westminster. I am coming at it from a different perspective than you though in that I am the anxious one and would happily be induced earlier because I am so concerned about my placenta failing. The midwives basically said there was no problem and that they see lots of older women. The NHS obstetrician said that she would consent to an induction on my due date because of the evidence of placental failure beyond 40wks. I also talked to an ob on the private kensington wing to find out if my anxieties were just me being neurotic or there are real issues and he basically said there is a good chance that everything will be OK (esp given that I have given birth to 2 children already with relatively straightforward labours) but that the risks are higher of something going wrong. He suggested me going in, in my 39th week to either have a caesarian or a controlled induction (ie with lower threshold for proceeding to a caesearian than there would be on the NHS). He basically said you really don't want to be 43 and having an emergency section (odds of which are greater following induction) because that was when the age-related risks really started counting against a successful outcome.

This is a much wanted third baby and I am feeling v v risk averse because of a previous termination and problems in this pregnancy so I am going for the private option where I feel like I have more control and it will be a calmer experience. I haven't decided whether to go for a CS or the induction yet but to be honest for me it couldn't come soon enough.

Sorry for the really rambling response but hope it helps a bit!

owlbooty Tue 16-Aug-11 17:48:27

Ah, the joys. I've spent the last week or so trawling through NICE guidelines, every research paper I can lay my hands on and grilled my community MW and the hospital MWs. Not because I am over 40; just because I had some rather dubious bp readings a while ago which made everyone leap up and down and threaten me with Immediate Doom if I wasn't induced at 39 weeks. When I asked for evidence I was met with blank stares and then some waffling. I am now 41+2; baby still in residence. Ahem.

<gets off soapbox>

They absolutely should be making a care plan with you right now if induction is already being suggested. You're right that it isn't in the NICE guidelines - I'd be asking why on earth they want to do it so early instead of waiting til you are 40 weeks at least - at 38 weeks your body and your baby may not be ready for induction which in itself is likely to lead to EMCS/interventions - the odds of that seem to be 1/3 as far as I can see. These interventions obviously carry risks of their own. There does seem to be some evidence that being over 40 is a risk factor for placental insufficiency post term (i.e. 40+) BUT tbh there seems to be a serious lack of high quality research on this subject generally which is very disappointing given how many women give birth every day! Other recognised risk factors are a BMI over 30 and smoking so it may be if you're ticking other boxes like those they're twitchier than they would otherwise be but if that's the case they should tell you that. However, the overall absolute risk of something going properly pear-shaped (as far as I can find out) is still pretty tiny. The longer this goes on the more I suspect it's a primarily a case of the hospital trying to cover their arse if something goes wrong.

The problem is, I suspect that no matter how carefully you phrase your questions, (as I tried to), they won't be willing/able to actually give you a proper answer. I think sometimes they're just too used to people accepting they know best without questioning it.

At the end of the day I've decided all I can do is go with my gut feelings (which is that induction is not right for me right now) and keep going for monitoring as often as they suggest (ctg, dopplers etc) - I too am not anti-induction but I am anti the idea of being railroaded into something without good evidence. I really hope you get some decent answers. Good luck!

cookie9 Tue 16-Aug-11 18:02:52

At queen charlotte's too. And they said at 16 weeks they wanted to i Duce me at 40 weeks. Now considering whether to go for induction or c section if haven't gone into labour by then. As first baby believe they are quite often late. Don't want to run risk of induction leading to emcs. If bishops score is low when they induce then not likely to work so could end up with emcs. Believe planned c section much less risky for older mother than an emergency one. L
OP who is your consultant as I am wondering if it is a consultant thing rather than hospital policy?

EldritchCleavage Tue 16-Aug-11 18:06:59

Thanks, both of you. It really helps to be able to talk about it, rather than just be arrogantly expected to bob and curtsey then agree.

My current instinct is that 38 weeks is too early. I was told inducing at 40 weeks is too late as it could take a long time to work, so that I would end up going over anyway.

Given my last induction was quite fast, I don't currently see why another should be particularly long, but I will ask.

My present instinct is to say I will agree to induction at 40 weeks with an interim care plan of scans etc from 38 weeks. I know my DH is quite nervous about this and would rather err on the safe side. My concern is whether induction at 38 weeks really is the safe side, as I am being asked to assume.

EldritchCleavage Tue 16-Aug-11 18:09:01

Cookie9, as with last time, my consultant is Mr. Edmonds. I did dredge up an old thread on here (well, last year) in which someone else at QCH said it varied from consultant to consultant, so perhaps Mr. E is very much of the 'whip it out' brigade. Who knows?
I do dread ending up with a Cesarean, I must say.

cookie9 Tue 16-Aug-11 19:41:50

We do have different consultants as mine is Ms Akmel. If I am going to end up with a c section would prefer it to be a planned one. There is a 25% risk of emcs following induction but haven't found statistics relating to induction before 40 weeks.

fifitot Tue 16-Aug-11 19:49:00

WTF? I had my first at 43 and my second at 47. I was induced at 10 days over for the first just because 10 days was what the local hospital let you get to and noone ever mentioned anything about induction last time round even at my advanced age! Just that if I went 2 weeks over they would induce. I was 1 week over but went into labour naturally.

I can't believe what I am reading above. Either your consultants are very antsy about this stuff or mine was negligent!

mejon Tue 16-Aug-11 21:01:28

Same as fifitot. I'm 43 and had DD2 in February following an induction at 40+12. No mention was ever made about needing to get the baby out on time or early due to potential placental failure. I agreed to an induction then as I was getting fed up and thought it was time she arrived and because the MW was concerned that DD was going to be a large baby (she wasn't!)

Policy here is that induction is 'offered' at +10 I think.

Not only was I of an advanced age, but my BMI is over 30 (though I'm not a smoker) so judging by what owlbooty mentions I should have been a prime candidate if this is normal practice. I was under consultant care all along and all my ante-natal appointments were text-book with normal BP throughout.

tallulah Tue 16-Aug-11 21:20:31

I had DD when I was 43 (almost 44). Nothing was mentioned about induction- in fact we were planning a home birth with the full backing of my MW until we discovered DD was breech at 38 weeks. I ended up having a CS just because she was breech (6 days before due date because the only other slot was the due date itself and they didn't want to chance me going into labour). I had asked the MW prior to that if I was "high risk" being so old and she looked at me as if I was mad.

EldritchCleavage Tue 16-Aug-11 22:21:14

Very interesting. I should say I am a pretty young and fit non-smoking 43 with no ongoing medical conditions, very good blood pressure and absolutely no complications in this or my last pregnancy. In other words, even among my age cohort I wouldn't have thought I was a prime candidate for such an intervention.

I can't help thinking, especially after reading these last few posts (for which, thank you all) that if the evidence base for this practice were really good, the medics would just explain it to me. The lack of elaboration makes me wonder how clear the rationale for doing this really is.

MonaPomona Tue 16-Aug-11 22:49:52

Hi - I was under care of Kingston Hosp at the start of this pg,, my 2nd. They said it is our policy to induce at 40 weeks if you are 40+ in age (I am). We moved house 4 weeks ago and I am now under the care of Epsom Hospital; when i told my Epsom MW about the Kingston policy - she said they were 'nutters'.

When I was booked in at Kingston I did ask why induction was offered at 40 weeks if you are aged 40+ and was told it was due to some studies indicating placental failure was more common but I was told the evidence was not substantial. On that basis I decided I would not be induced at 40 weeks just because that hospital wanted to cover their backs.

I agree that if there was good evidence you would be told. The fact that you have not been told clearly what the risk is speaks volumes. And 38 weeks does seem a bit over eager in my view.

OnEdge Wed 17-Aug-11 16:32:38

Message deleted by Mumsnet.

fifitot Wed 17-Aug-11 22:06:52

Jesus - nice post OnEdge. The OP wants an informed choice about how she gives birth - not too much to ask is it?

Induction is not without risk to the baby and the mother. The OP is concerned because no HP has explained the risks or benefits of induction or why some hospitals want induction and some don't. How is that mad?

Or are we all supposed to blindly follow medical professionals as if they are gods?

The 'evidence' of placental failure due to maternal age is very sketchy. The least they could do is explain their reasoning.

OnEdge Wed 17-Aug-11 22:17:05

EldritchCleavage Asked what we all thought, that is what I thought when I read her post.

fifitot Wed 17-Aug-11 22:20:38

'Pathetic, time wasting idiot'. Nice.

OnEdge Thu 18-Aug-11 00:18:03

It seems to me, from what you say EldritchCleavage, that you want to glean information to take with you to the appointment with which to formulate an argument against the advice that you have been given by several professionals who specialise in Obstetric care. They are trying to manage the care of someone who has a history of reduced fetal movements at 39 weeks. They are recommending that you are induced at 38 weeks. Its common sense. You would be devastated if you were to ignore their advice and went on to deliver a stillborn baby. This is why I think you are mad.

spudulika Thu 18-Aug-11 09:27:40

OneEdge - there are risks to both the OP and her baby of inducing labour at 38 weeks.

She wants a clear picture of what the benefits to her and her baby may be before making a decision.

"They are recommending that you are induced at 38 weeks. Its common sense."

Perhaps you're not aware of the fact that there is a RANGE of opinion amongst doctors as to the best protocols for managing this sort of situation. There is not consensus that inducing at 38 weeks is the best or the only option.

"Or are we all supposed to blindly follow medical professionals as if they are gods?"

Yes I think OnEdge thinks we should. After all, they know everything, we know nothing. And they obviously care more about our babies than we do. hmm

spudulika Thu 18-Aug-11 09:31:59

But I see from OnEdge's profile that she's a nurse.

Which maybe explains why she puts the needs of the institution to process patients quickly ahead of the needs of the individual to understand the medical treatments they're consenting to.


knockedupagain Thu 18-Aug-11 10:54:41

Well... I'm not at all sure what my opinion is on this one, other than OnEdge should have been nicer! I'm 50 and have (obviously!) had IVF to be currently 27+6. My blood pressure is "perfect", my BMI is fine, and I have no underlying medical conditions. I do, however, have a nasty tendency to have retained placentas (this is my 5th birth) and have been known to have a massive PPH requiring 6 units.

My consultant had written "induce at term" on my notes without so much as mentioning it to me, let alone discussing it! I ticked him off the next time I saw him, and pointed out that the PPH was after the only time I was induced (I was 41+5 so really needed to be induced that time), and I'd rather not repeat the experience. I went over my dates the other three times too, but only 2 - 5 days over so was allowed to go naturally and apart from the dratted placentas requiring either a manual removal or a splendid midwife who had a very hard time but managed it, my births were otherwise uncomplicated. Admittedly, as soon as I appear in labour, they do open up a vein and stick me on a drip for ease of pouring in some blood swiftly if necessary, but this doesn't stop me from moving around and giving birth on all fours, so that's fine with me.

I negotiated with my consultant that I should be induced at 40+5, which gives me a very realistic chance of going into labour naturally, and also acknowedges the slightly increased risk of placental insufficiency. I am happy to be monitored on a daily basis from term, and am in any case being scanned every two weeks at present as I have anti kell antibodies (similar to rhesus factor), in case my baby is kell positive. So I know that my baby's growth is excellent, and that the blood supply to the baby is currently healthy. All indications are that the baby is kell negative, but I find the extra monitoring very reassuring.

What I would do if there is any indication that that things are no longer optimum for the baby, I'm not sure. Most likely instantly crumble and agree to anything that will get my baby out alive. A CS is a particular risk for me given my history of retained placentas and PPH, and an induction does make this more likely. I have not only this baby to consider, but my four other kids, for whom I would like to stay around. I share your pain, OP, but have no answers! I do know of more than one baby stillborn days before they were to be induced, that would have been alive if induced at term, but that does not make any decision straightforward. As others have said, other risks also need to be considered. The ease with which I renegotiated my induction from term to term + 5 does make me think that 38 weeks seems a little early BUT you do have previous of baby not moving at the end so.... I have no idea! Good luck!

EldritchCleavage Thu 18-Aug-11 12:01:25

Onedge, I am very surprised that you are being so unpleasant and insulting about this. If you are spoiling for a fight, please choose a thread in AIBU. Your implicit suggestion that I'd put my baby at risk is unworthy of comment, save to say it is hysterical.

The essential difficulty I have is the lack of good quality information. You say I simply want *an argument against the advice that you have been given by
several professionals who specialise in Obstetric care.*

Actually, I don't want an argument with anyone. I don't go in all guns blazing. More to the point, I HAVEN'T BEEN GIVEN ANY ADVICE. That is the core of my complaint. Obviously my OP did not manage to convey how sketchy the supposed explanations of the rationale for induction have been to date. It really has come across as a box-ticking exercise.

I want a detailed discussion so I and DH can decide what to do (and if that is induction, as it may well yet be, when best to do it and what care plan to have in place in the meantime) on a properly informed basis. It troubles me that you are a nurse, apparently, yet do not seem to understand or value the notion of informed consent.

knockedup, thank you very much for that post. You say you don't have answers but actually, reading about how you have balanced the various factors at play has been illuminating.

That's the point here-it is not a case of 'risk-free induction' versus 'risky waiting game'. Both approaches carry risks, and I need help evaluating them so DH and I can decide what's best for the health of baby and me. Clearly, baby comes first but I do need to think about risks to my health too, not least because I do have another child to look after.

EPPP Thu 18-Aug-11 14:38:10

I had dc3 at 43 and they started off on the induce at 40 weeks but when I said I wanted a homebirth they spent their time fussing about that and my slightly raised bp and it was never mentioned again. DC3 was born at home at 38w or so.

OnEdge Thu 18-Aug-11 18:22:09

EldritchCleavage So, you refused to be induced at 38 weeks last time, and then 9 days later, your baby stops moving, and you then consent to an induction. In my opinion, you put your baby's life at risk. Thats not hysteria, its there in black and white. You are stupid.

Tangle Thu 18-Aug-11 18:51:13

OnEdge - Aren't you making assumptions that induction at 38 weeks would have resulted in an un-compromised baby, though? And that there was no benefit to the continuing development the baby made in the womb during those 9 days? That the baby stopped moving due to placental problems?

Your opinion may be that EC put her baby's life at risk - but I fail to see how trying to understand the issues and ask questions makes her stupid. You are seeing things as very black and white and assuming causative relationships that are far from proven on the back of the information we have. To me, it is not EC that is coming over as stupid.

EldritchCleavage - I sympathise with your predicament. I'm trying to get a straight answer out of my consultants as well - they'll quite happily tell me that the prophylactic treatment they're recommending during this pregnancy doesn't increase any known risks. Until I mention home birth - when I'm "too high risk", but they won't tell me what I'm at "high risk" of. It just leaves me feeling incredibly confused and as though their recommendation is possibly more to do with their comfort zones than any research, evidence or experience. I'm not dead set on a home birth, but I don't understand why they're advising against it so vehemently atm confused and I can't gain that understanding because they won't have a conversation about it.

Have you tried putting your questions in writing? That's the tack I'm going to take next, I think, to try and get an answer rather than a 10 minute diatribe during which I get talked over any time I try to utter a word...

OnEdge Thu 18-Aug-11 19:05:45

The trouble is, what research has shown is that there is an increased incidence of stillbirth in women over the age of 40, but the specific cause/reasons for this is largely unknown. Maybe that is why they are unable to give you answers to your questions.

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