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

[EldritchCleavage]

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.

[EldritchCleavage]

OnEdge-blimey, you are well-named. I'm not sure what in all of this merits such rattiness. Repeating that I am stupid may be satisfying for you, but it is not elucidating for the rest of us. But there we are.

My previous experience is of marginal relevance to the current difficulty, which is one of not being properly advised. None of the HP who have advised me this time were aware until I told them of the previous induction, so their initial recommendations to induce were not based on it.

In my opinion, you put your baby's life at risk: you seem very ready to make judgments on a slim to non-existent evidence base, which is probably why you don't appreciate my dilemma in the first place. In fact, it transpired my DS was not in danger. He was born hale and hearty, and my placenta was not compromised-his lack of movement was just one of those things, but as responsible parents we erred on the side of caution.

My age is the one single factor relied on as indicating induction. The evidence base for that does not appear to be strong, hence my hesitation.

Do you practice in OB/GYN, by the way? Please do cite the research to which you refer, because I would be very interested to read it. The NICE guidelines do not canvass this issue at all, which is interesting in itself, and so do not provide references to relevant research.

To the others, thank you for your posts. I started this thread to find out if anyone had helpful information to help me make up my mind. I'm very grateful for all the kind and thoughtful responses.

[gailforce1]

Induction itself is not without risks, especially in overstretched maternity units. Have just been reading about a still birth attributed to an overdose of prostain. And the Horizon programme recently featured a woman who died after being induced.
If it were'nt for the pressure to get down the cs rates I wonder how often HCP would rather skip induction and go straight to theatre?

[Jill72]

I include a post I made recently that I think applies to the discussion here. I am 39, and have mentioned a home birth. Again like OP I feel little discussion is going on and I am not being given the opportunity to have an intelligent discussion where risk factors are openly discussed. It is as if you are expected to just sit there and not dare to question the consultant. What is worrying is the vast range of differing advice that is given to women on here about all sorts of things and that DOES make me want to question and delve further!!!! I suspect that as mothers become older, health professionals are encountering experienced and confident women who have the balls to stand up and demand intelligent and engaged discussion. I don't think it is a brigade of women spoiling for a fight and determined to go against medical advice but a cohort of women savy enough to look deeper into what is being laid on the table to help them understand things more fully and with correct facts make the right choices. It is a shame that the only medical professional on this thread represents her professional with rude, immature comments that are clearly getting the backs up of the rest of the posters! And she wonders why we are all questioning what they are saying to us!!!! Any way - here is my post from another thread!!!

^"My concerns are that when you look into some of the statistics they don't seem to add up. Here is an example:

There is another small but serious risk to the babies of more mature mothers. More babies die in the uterus right at the end of pregnancy in mothers aged over 40. Figures for 2006 show that the rates of stillbirth were steady at around 5 to 6 babies per 1,000 births for women aged 20 to 39, but increased to just under 9 babies per 1,000 births for women aged 40 and over.

YES - the statistics show an increase but that is only of 2-3 babies per 1,000 births. Is that really statistically significant enough to be telling older women that they are more likely to have a stillborn????? If the increase difference here was significant then fair dos but to me the difference is so minimal that I think it needs to be explicitly pointed out how slight it is. Instead you have older mothers running round imagining swathes of older mums are giving birth to stillborns!!!

Shoulder Dystocia - from the Royal College of Obstetricians and Gynaecologists website and guidelines:

^How common is shoulder dystocia?
Shoulder dystocia occurs in about one in 200 (0.5%) of births. (note that there is no demographic brake down of the 0.5% !!!)

Can shoulder dystocia be anticipated?
At every birth there is a small risk of shoulder dystocia. In most instances, it is not possible to identify who it will happen to or why it occurs.^

So why are older mums / higher BMI being scaremongered that they are at higher risk of this??????

I completely accept that there are higher risks of different things for different women right across the board - what irritates me is the fact that clearly sometimes these risks are VERY small but represented as being MAJOR issues - not fair!!

I think it is an intelligent approach to question and research what you are being told - there are plenty of examples of professionals, (in all kinds of disciplines), getting it wrong or not always behaving in your best interest. I am not going to blindly accept everything I am told or asked to do without good reason."^

[EldritchCleavage]

Exactly Jill72. I'm not even out to be challenging-I just want to say, "Help me understand why you consider induction my best option".

Anyway, I had a good chat with DH last night after re-reading the thread and decided I'll ring and ask to speak to my consultant on the 'phone to get the information from the horse's mouth and come up with a plan.

[Jill72]

EldritchCleavage I think that there is a real 'gap in the market' as far as older mums go!!! We are are a growing minority and I think perhaps new and more up to date information and statistics need to be gathered. I am at the end of my tether with it all and feel like I am going round in circles - I suppose that at the end of the day you just have to go with the best educated guess that you feel happy with. I keep reminding my self that thousands of older mums DO have normal straight forward births!!! Good luck!!

[EPPP]

Yes Jill 72 thousands of older mums have straightforward births, dc2 was born when I was 39 and was described by the mw as a 'textbook delivery', quick calm and totally undramatic in any way. dc3 same but I was 43. My plan was to agree to monitoring for dc3 but stick to my plan for homebirth and only agree to induction if the monitoing suggested it was a good plan. I was told that 'they' would like to induce labour at 40w, dc3 turned up before 39w so it never happened.

[MoaningMcMyrtlepants]

I have three children, the first I had at 37 and the other two I had in my 40's. During all three pregnancies I had vRious health problems. At no point did anyone say to me I would have to be induced at all. Everyone assumed I would give birth naturally and a couple of MW's suggested i have a home birth if I wanted to. DC3 was actually back to back when he arrived. This attitude of your HCP seems really strange to me.

[EggyAllenPoe]

here's how these threads go

1. concerned poster questions guidelines - in search of evidence or experience that may help them understand the advice given
   
2. some people offer that advice, or related experience
   
3. some people just sympathise
   
4. totally unreasonable poster pops up and accuses the op of endangering the life of their child by questioning (yes, how very dare you question) the advice given by the HCP/HCPs
   
5. various posters politely point out what the facts are
   which does not probably remove the initial shock caused by 4) to the op

[EldritchCleavage]

Was a bit taken aback, I must say!

But I have been on MN long enough to know there is a certain type that pops up with inexplicable levels of aggression. It's the MN equivalent of people who start shouting at their imaginary friends at the bus stop.

[ShoutyHamster]

Agree with EggyAllenPoe - what a pity (but perhaps sadly not that unusual) that the poster pouring scorn on the OP's simple request for the evidence base behind the medical choices she is being asked to take... is the health care professional. Do as we say and don't question, indeed!

All posters like OnEdge achieve is to undermine the authority of HCPs, essentially. Because there's nothing which appears more untrustworthy, uneducated, and down right dodgy than someone who can't give you a straight, intelligent answer to a question concerning something they're supposed to be an expert in. Sorry, but the logical response from a normal, sensible person is 'I'm sorry, but your behaviour isn't exactly inspiring trust. I'll take my gut feeling, or a second opinion, thanks.' How counterproductive.

Perhaps OnEdge is tired of patients who persist in ignoring her professional advice. I would hazard a guess that if she has a tendency to talk to them as if they're the shit on her shoe, as she's done here with someone seeking a medical opinion, then that's probably the reason for it.

OP - I would continue questioning this - it sounds bizarre. There are a whole host of risks to induction before term. There are terrible consequences for placental failure too, but that can be monitored. Quite simply, I would say that if they have neither the ability nor the courtesy to treat you as the person who has to live with the outcome of these decisions, and to be able to present you with an intelligent, evidence -based argument why a VERY early induction is necessary, I would decline, and ask for placental monitoring from 38 weeks.

[Portofino]

I would think it very strange as I had my first and only child at nearly 36 and with complications they would not think of doing anything before 39 weeks. I thought the risks for being older still were to do with the BABY not with the way you gave birth. I could be completely wrong on this. But I am 43 next month and still toy with the idea of one last go at it, so please feel free to inform me.

[gailforce1]

Is "speaking down" to patients a speciality of those working in obstetrics?
I have seen specialists in other medical fields and have never felt belitttled and have been positively ENCOURAGED to ask questions, bring research to appts etc.
Does pregnancy and birth deprive a woman of her thinking abilities?

[EldritchCleavage]

Thanks all. The current plan is to say I want to go to 40 weeks, with monitoring from 38 weeks.

[7to25]

hi
Sorry to post so late
j was even older than you when I had my last child. I was offered induction at 38 weeks but was very much against this as I had not been induced before and thought that I should go naturally. in the end I was induced at 40+5 with the consultant threatening a section if I didn't hurry up. I did!
In retrospect, I wish I had taken the earlier induction. I spent the last couple of weeks on the day ward being scanned and assessed, really I could have had it all over and done with.

[EldritchCleavage]

That's good to know, and a fair point-the constant assessment could be draining and worrying in itself. It would also be pretty disruptive to family life.

[coffeeaddict]

I am pregnant with no5, aged 41, had last baby induced a week early and probably this one too. I am someone who frets, so the idea of monitoring kicks freaks me out. I would probably be dashing to hospital every two seconds and exhausting my whole family!

(I was whipped out as 'failure to thrive' and nearly died in the womb, so maybe that has affected me...)

Interested though in the perception of 'risk' as I have just been through the whole 'amnio or not not amnio' debate. In that context, 2-3 in 1,000 would be considered to be quite a significant risk, not negligible!!

I find the risk juggling one of the most stressful things about pregnancy. I have no idea what risks I take in every day so it's hard to get it all in context.

[EldritchCleavage]

Coffee I agree that juggling risk is very hard. That's why I've found this question so vexed. Given the stakes are incredibly high, I would have expected to receive good quality information and sympathetic help in doing the risk assessment. But that hasn't happened in either of my pregnancies.

[EldritchCleavage]

I am now 39+3 and babycleavage is still not engaged. I am going in on Wed, but there is now a distinct possibility I might have to have a c-section. Bugger. Anyone with good ideas about how to get babyc's head in my pelvis?

[Gwlondon]

Hi, I was induced one week early because of suspected placenta insufficiency, not due to age but gestational diabetes.

One point that my obstetrician made is that the better the placenta is functioning the more oxygen the baby gets during the birth (spontaneous or induced). Also the greater the energy/oxygen reserves the baby has in the lead up to the birth. He also said that during a contraction the baby doesn't get as much oxygen so is reliant on their reserves.

The obstetrician didn't want to wait until the placenta was definitely failing but wanted to err on the side of caution by delivering the baby early.

In my experience (limited-gave birth once!) you get poor explanations by people that either don't know why or can't communicate effectively the issues. I gave my doctor a lot of questions but in the end did everything he said. He was very good at communicating what he knew.

Good luck.

[Gwlondon]

Not sure if bouncing on a birthing ball might help engage the baby. Or walking? Sorry didn't see your last message. Good luck. Hope it goes well.

[EldritchCleavage]

Thanks, both of you. I think babycleavage may just have dropped a bit, after some porno writhing twice a day and a good walk this afternoon. Will repeat Monday and Tuesday and hope for the best!

[EldritchCleavage]

My final update: induction with prostaglandin failed, but the baby was an unstable lie anyway, and eventually breach, so I had a Caesarian on Saturday. daunting, but all went smoothly. Little DD is very cute, and DS is smitten!
Thank you all for your generous advice.

[cookie9]

Congratulations! Have my 34 week appointment this week so will be interesting if they bring up the induction again.

[EldritchCleavage]

Thank you!

Note when the ante-natal and labour ward staff -from midwives to SHos and registrars heard why I was being induced they uniformly rolled their eyes-all the pressure in antenatal clinic for these inductions clearly does not represent any kind of consensus.