Induction - you want to book IOL WHEN? Anyone managed to put this off or done expectant management?

[LionRock]

I'm looking for some moral support really as I will be having what I expect to be an uncomfortable conversation about induction this week... basically to put it off for a while. If anyone's had a similar experience I'd like to hear about it.

Situation:
First pg, MW-led care, no issues
They suggest have booked IOL at 40+4
No reasons why (though I just turned 40 this month)

I have one MW appt before the date for IOL. I plan to question the date for IOL (I've read the NICE guidelines). At least until after 40+8 if that's the ave length of a first pg and there are no health issues prompting an earlier date. Does anyone have any info about when's appropriate to attempt membrane sweeps? I believe they only work if things are almost happening anyway... also if anyone's done expectant management I'd be interested to hear how that went.

As an aside, the community MW that I see are a bit variable but all moan about how busy they are etc etc. So I don't expect them to be particularly supportive of anything that means more work for them e.g. more appts for sweeps / expectant management. The appt I have for this week was a cancellation and otherwise, the next available appt was for after the date for IOL, 3 wks away...

No advice really, as only on my first baby and due next wk sorry....But I am really surprised that they want to book you in for induction at 40+4?! Really never considered the possibility, that due to the lack of available hospital appointments that may mean either going in soooo soon for IOL or having to wait until after the recommended cut off point at +3 wks...?

I don't see why they won't offer you a sweep at least?? Have you pushed your MWs for this? They shouldn't be so trigger happy re full blown induction.

At the time of booking the IOL (38wks), the next available MW appt was 41wks. IOL booked at 40+4. I got a cancellation for 39+0 and it's unlikely there's any other appts available before IOL, unless they "squeeze me in" somewhere. At the 39+0 appt this week I'll be having the conversation about not being happy with an IOL so early.

So, I'm not convinced that IOL is appropriate at 40+4, don;t know if it'd be useful to even request a sweep at 39+0, and expect them to push for the easiest route for them rather than what's best for me as an individual.

Certainly worth asking for a sweep if baby is well down. Agree 40&4 seems
v early for Iol if no other reasons for it. Maybe local policy due to you being 40? They don't do IOL here till term&12!!

DW was induced at 41+5 and with hindsight would probably have waited even longer.

Loopy - thanks - do you know of any evidence to induce at 40w post-40? I'm trying to get the full picture here but everything I've seen says reasons for induction should be based on medical risks and I've not seen age mentioned as a risk. As an aside, I did ask about this a while ago and the consultant said with increasing age comes increased risk of pg-related issues but that age itself wasn't a risk. (I'm MW-led care and saw the consultant by chance the way appts work.) I was a bit when IOL was mentioned but want to be better prepared for the next chat.

In case this helps anyone else:

Lamaze advice on IOL www.lamaze.org/ChildbirthEducators/ResourcesforEducators/CarePracticePapers/LaborBeginsOnItsOwn/tabid/487/Default.aspx

NICE guidelines on IOL: guidance.nice.org.uk/CG70/Guidance/pdf/English

Also, I have literally just turned 40 days ago

LionRock,
This recent thread addresses similar issues and may be of interest/help if you haven't already seen. Good luck.

www.mumsnet.com/Talk/childbirth/1189863-Older-Mum-pressure-to-be-induced

I am assuming IOL means induction of labour.

I had my first baby when I was 34 years old but was finally induced when I was 12 days late. No mention was made of it prior to this.

At 37 years old I had dc2. He was rather large (had growth scans at 37 weeks) but they did not induce me and I went into labour and he was born 11 days late.

DC 3 was born when I was 42 years old. No mention of an induction at all despte me being late again. Finally had to be induced for a medical reason though at 6 days late.

Can you just ot turn up for the induction? I think that is what I would do unless they give you a good reason to do it.

Thanks Katherine that thread was relevant.

cace it sounds like the advice to induce (yes, IOL = induction of labour) varies according to the area / unit / consultant. Which is fine, but it'd be nice if they said as much so we know what's going on when making decisions. All the research I can find online compares risks and benefits of induction at 41/42/43 weeks vs waiting. The idea of inducing before 41 weeks seems non-standard.

I plan to refuse the induction until at least 41+ weeks unless I'm given a good explanation why it's appropriate earlier. I just feel like I'll have a job getting the MW team to fit me in for whatever appts should be offered while giving the baby a chance to arrive spontaneously in the meantime.

Out of interest, would people usually expect to attend their 40 or 41 week appt before setting a date for induction? I'm not sure how long to do expectant management (or does that not kick in until after 42 weeks anyway?) I could handle this sort of situation so much better if I wasn't pregnant right now

I could handle this sort of situation so much better if I wasn't pregnant right now Ain't that the truth :o!

As I understand it, expectant management would involve equipment not generally available to community midwives - all the stories I've heard have involved women going to hospital and having a CTG trace for an hour or so and/or an ultrasound to measure blood flow through the umbilical cord. Intuitively and logically, expectant management should be offered from the date you decline IOL - but then intuition and logic don't necessarily count for much in these circumstances. That said, I think you could make a strong argument for expectant management from 40+4 - if they were concerned enough for IOL then why on earth wouldn't they, unless they want a medical negligence claim if (in the worst case) something goes wrong? IIRC the NICE guidelines back that position (something along the lines of "if IOL is declined then expectant management should be offered"), but would be worth checking.

How long to continue to take expectant management and decline IOL is another very personal choice. As you've discovered, risks to increase as you go further beyond 40 weeks (and many women have had more than enough of being pregnant by then as well). You may well find less resistance to postponing the IOL if you're prepared to give a date when you will accept it (which you are always free to change again) rather than going for an indefinite option - you'll either go into labour naturally (fingers crossed :) ) or you'll reach a mental state where IOL feels like the better option than waiting.

In general I think you'd expect to go to your 40 week appointment before booking IOL - but then in general they wouldn't recommend IOL before 41+ anyway so there would be time to fit it in. As they want to induce you earlier, booking it in while there are plenty of slots seems like a sensible way to make sure things happen on the suggested schedule - just a shame they haven't managed to convey why you're on that particular schedule...

Do you know the name of the consultant you saw? Has the IOL at 40+4 been driven by a consultant or by policy?

The consultant you talked to previously seems to have been very pragmatic and to have taken a very individualized view of risk (which is what I'd want as well) - I think I'd try and get hold of him and ask for an appointment / telephone consultation to discuss an appropriate date for IOL. The impression I've got is that your IOL date is being driven by policy that states something like "for a woman over 40, IOL should be advised at 40 weeks" and the MW's (who you say are overworked) don't have the head space or authority to want to question that policy.

Sorry that's turned into a bit of a brain dump . Fingers crossed your LO makes a prompt and calm arrival and all of this can become an annoying memory :)

I was monitored at the hospital in the day assessment unit so didn't go to my clinic for a mw appt.

40+4 does seem quite early& will be entirely due to your age.

I don't think you are being at all unreasonable to push very hard for an appointment for a sweep at 40 weeks. I'm now 40+ 9 and when I rang to make my 41 week appointment, ten days in advance I was told they were full. I told them this was unacceptable and they either had to squeeze me in or cancel a booking appointment. They then found a slot. Do not accept this as a slightly older mum, who doesn't want to be induced you should have no problems getting an appointment for a sweep at 40 weeks.

Good luck!

Thanks everyone.

It does seem like lack of MW appts is an issue. In part due to how the MW teams are arranged locally (by postcode so I can only attend one clinic session each week) and also the upcoming bank holidays, but just because they have no free slots for 3 weeks seems a poor reason to induce in 2 weeks without offering sweeps etc. Anyway, I have the cancellation appt and feel better prepared to put my case forward. Also, I spoke to a friend (different health authority) who will try to speak to a MW friend for some independant advice on whether the age 40 / GA 40 wks thing has any validity. Though I suspect not as NICE guidelines etc do not suggest induction appropriate before about 40+10 unless there are maternal or fetal health concerns that outweigh the risks of induction. I will update in case anyone else is interested.

It just seems odd that in any other area of medicine patients seems to have to push for treatment and investigation, but in childbirth it seems a trigger-happy approach is used, even when all evidence is against it. Or (being cynical) the community MW would prefer IOL as it's less work for them, more work for the hospital team

Loopy

thanks, I did see some numbers about the risk of stillbirth. I'll try to dig them out, but IIRC the additional risk added by induction outweighed the risk of waiting until 42weeks. Also there was a question about how many stillbirths were inevitable due to fetal issues e.g. congenital abnormalities, i.e. they were inevitable at any GA .

I suppose this is part of the problem. I feel like the healthcare professionals have given me only a couple of pieces of the jigsaw and I'm looking for the other pieces myself. Informed consent shouldn't be like this!