Why are so many women now induced when they are classified as 'overdue'...?

[babysaurus]

More of my friends than not have been induced when they have got to 41+ weeks, none of whom made it to 42 weeks. This got me thinking several things:
Firstly, the EDD is just that 'estimated'.
Plus, isn't the gestational period in France considered 42 weeks rather than 40 - so going up to 42 weeks there would not be considered the wrong thing to do? (I read this on MN so apologies if this is actually wrong!)
Lastly, have inductions been responsible for a massive improvement in sucessful births in this country?

Are they really as crucial as you may be led to believe...?

Sorry PML = LMP

The reason I have been looking into this so much is because as a Type 1 diabetic I have been 'told' I 'have' to be induced at 38 weeks at the latest.

I have been looking into this more and more and the main reason for this is due to the potential size of the baby. I am currently measuring right in the middle of the scales they have, and have no blood sugar issues going on which is likely to make the baby balloon in size so this sounds like a hospital 'one size fits all' policy. The other reason, which I intially took more notice of, is that the placenta can fail post 38 weeks - turns out this risk is both tiny, especially with blood sugar control as good as mine has been, and is also a gradual rather than sudden thing which makes it seem far less of a big deal as it was initially portrayed.

So in short, my PCT think it is a more sensible option to induce labour early (epidurals are 'strongly recommended' - that a tube full of anesthetic into my spinal cord is a preferable option to being induced without one doesn't sit well with me!), and then there being a high chance of needing interventions such as the hideous forceps or even a c-sec (these seem to be very high with diabetic patients) rather than running the tiny risk of the baby being large (despite evidence to the contrary) or even tinier, the placenta failing.

I am starting to get a bit wound up about it as it does look more and more like the medical back up behind these policies is not neccessarily relevant.

Please don't think I would put the baby, or myself, at risk due to sheer bloody mindedness. I would never do that, but I cannot help but question the reasoning behind procedures which may well be both traumatic and damaging.

With regards to non diabetic women, I came to the conclusion long ago that birth has become more and more of a medical procedure for everyone and I am still not completely convinced that that's always the right way to go.

Am interested to hear others thoughts and experiences, and thanks for your replies so far!

I think if there are any other factors like your diabetes that may affect the pregnancy that it's best to have a chat with the consultant so that they can explain everything in detail and provide you with evidence.

It seems like sometimes mothers are patronised by being told what's best without being told why. It might be that induction is the best thing for you and your baby but you ought to be given all the information before you decide.

Would you be able to book an appointment with a consultant to discuss this in more detail?

The discussions I have had so far have resulted in the two risks (the large baby and the placental failiure) being the reason behind, if there are no other issues such as blood pressure to take into consideration. Neither of these two risks are, now I look into it properly, especially risky (or at all) to me as things stand at the moment, and I don't plan on suddenly reducing my insulin or living off Mars Bars now (these would result in high blood glucose and the baby putting on weight)! I am starting to think that the reasons behind 'all diabetics must me induced' is to cover all diabetics, those with both good and bad control. (I have also been told by the diabetic nuse that a significant number of their diabetic patients are badly controlled.) The risks which come with induction seem significantly more substantial to the risks of not being induced at 38 weeks from where I am currently standing .

I am 25 weeks this Friday so have only just started to look into things properly, with a view to discussing them with the obs / diabetic consultant - hence me picking brains on MN and also doing a lot of Googling! I have another appointment tomorrow at the hospital (a diabetic one) as well as a midwife one so am trying to get info together now.

I agree that sometimes mothers are patronised by being 'told what's best' without the evidence behind it, and I also realise that their policies are often to be on the safe side. I will not refuse induction on principle, but I do think it's important to weigh up the real risks on both sides of the argument.

MrsMicawber - exactly, in some women this deterioration can take place as early as 37w, other women have big 'juicy' healthy placentas at 42w+. That's why I think it would be sensible to offer all women regular monitoring from 37w.

The cost financially to the NHS would surely balance out with a possible reduction in inductions that were clinically unnecessary as there was no sign of placental failure (as induction often involves a variety of interventions up to an increased EMCS rate, and longer hospital stays than spontaneous births) whilst hopefully reducing the stillbirth rate for those babies who suffer placental failure or deterioration even before induction is suggested.

I know that I, as a type 1 diabetic patient, would be offered weekly (or more if needed) monitoring from week 36 so this is good news from the placental failiure point of view.

I refused induction at 41 weeks because I wanted an active birth and didn't want to be hooked up to monitors and having to lie on a bed. I was also quite scared of the cascade of intervention. Lastly, I thought the hospital dates were a bit out, and didnt actually think i was all that late.

I eventually went for induction at 42 weeks and had my DS at 42+5!

I was induced. I was fairly reluctant and went in to discuss it. They wheeled out a junior doctor to give me a lecture on it (I assume this is protocol) but she appeared to know very little and I just asked the MW all of my questions. I was really reluctant but in the end went for it. DD was obviously overcooked and was a bit skinny (I am convinced this was because she was overdue). My induction started at 40+12 but DD wasn't born until 40+15 as the pessaries and gel did absolutely nothing for me.

The main issue I have with the whole process is that I ended up with the typical cascade of intervention and quite significant damage that has needed surgery once and it likely to require further surgery later as the result of forceps. The risks of not inducing were very clearly presented to me, but the much higher risk of an instrumental birth (and associated risks) was not explained at all. I was aware that I wanted to avoid an instrumental birth and would prefer a CS if an instrumental birth was likely. I think that the stats on CS and instrumentation should be presented to women undergoing induction (split by 1st time and subsequent babies and just gel/ARM & drip) so that they can make clearer choices about the risks to their own bodies. I don't think that the cost (when factoring in complications such as follow up surgery like mine) would make inductions much cheaper than CS. I think that we should be presented with more information to make a choice rather than just a lecture on "your baby might die".

I wasnt induced in the end (went into labour on my DD, despite looking like I really wouldn't), but I had quite a long discussion with my Obs about the possibility. She said she would only induce if the cervix was ready as if not, risk of emcs huge, and she'd rather monitor and do a planned c-section if nothing happened. Apparently risk of placenta failure is higher in older first time mothers (I was 35) and as someone said upthread, can happen very fast, so daily monitoring required. Therefore, I imagine for the NHS there's also a cost consideration.

I will be 37 when DC2 is born, and definitely dont want to go over 42 weeks.

Really great thread, babysaurus. This is also on my mind at 37 weeks, as an older first-timer. I gather there's also some indication to suggest there's a genetic link to carrying your babies for longer, and my mother was induced for three of her four labours.

My NCT instructor did say that she thought that some of the studies that considered the 'overdue' stilllbirth risk were old or problematic, or that new research had refined the findings - but could anyone with more knowledge than me link to some studies? Thanks.

I too have found this thread very interesting.
I went to 42 weeks with DS and DD before they would start induction but was being scanned weekly to check the fluid levels around the baby.
Induction was hideous and took 3 days of pessaries before they could even break my waters. Was even given pethidine to help with the pain of the false labour pains at one point.
DD was skinny and also had really dry skin which I was told was due to her being so overdue.
I was told by a midwife who was induced with all 6 of her children that it does have something to do with your cycle length and if it is long then you're likely to cook babies for longer.

Dreading it with this one, hence my eager research into natural induction methods which to be honest seem to be a bunch of old wives tales based on coincidences!

I would never allow myself to go overdue and this is why...

I used to belong to a local group of women who had lost babies shortly before or after birth. The overwhelming majority of women whose babies were stillborn had died after their due date.

Marie -that is very sad and I'm sorry to hear about your loss .

Without wishing to seem insensitive, how many of those were after 42 weeks? Stillbirth is of course a dreadful and tragic event for anyone who experiences it. Even with the existing research the risks of going past 40 weeks are not considered significant enough to recommend induction for everyone that reaches their EDD, so I'm not sure how helpful an anecdote it is to be told that in your experience stillbirth is usually after 40 weeks. Do you know what research shows about the distribution of timing of stillbirth and why?

Also, my understanding is that for a large number of stillbirths very sadly the cause is never know. The recommendation to induce by 42 weeks is related specifically to the risk of sudden placental failure. Sadly, there are of course many other reasons why babies die suddenly and unexpectedly before they are born, including during labour itself.

Of course for every family that loses a baby it is a huge and lifelong personal tragedy. The risks, however, are thankfully small and most babies are born healthy, even at 40, 41, 42 or more weeks.

Pesto, I think most were between 41 and 43 weeks, although I remember at least one was at 39 weeks. This was years ago, in the eighties. Also at the time, the trend was for as little intervention as possible. I had a scan about 12 years ago whilst pg, and the sonographer showed me how the placenta was beginning to fail. It wasn't a problem as such, he was just showing me out of interest as it was towards the end of my pregnancy.

I would be very interested to read any studies that have been done on this, but in the meantime I would never allow myself to go beyond my due date. And yes, I have based that view on entirely anecdotal evidence.

... OK, I have had a quick look at a BMJ study, and the risk of stillbirth goes from 1 in 2,039 at 39 weeks, to 1 in 486 at 43 weeks. A four-fold increase.

Shit. That is worse than I thought .

Hardcheese This is a good paper looking at the various research evidence.

There's another paper here with lots of useful info and references, although it looks like it wasn't peer reviewed.

Marie can you link to the BMJ paper you refer to please?

There is also lots of info on this page aboutt homebirth with references that can be followed up. It's especially helpful on dating of pregnancies.

Sorry for the multiple posts. There's also a campaign going to alert women to the importance of keeping an eye on their baby's movements in late pregnancy: Count the kicks

Thanks a lot, Pesto - just starting to read the BJOG one now, very interesting.

Also here are the National Institute for Helath and Clinical Excellence Guidelines on induction of labour. They go much broader than just reasons for induction, but are relevant.

"the risk of stillbirth goes from 1 in 2,039 at 39 weeks, to 1 in 486 at 43 weeks. A four-fold increase."

They don't know exactly what triggers labour, but it's suspected that the baby plays a role in this. Perhaps the factor that's involved in the stillbirth is also that involved in a failure to trigger the start of labour? Just a thought.

One day we'll get much better at identifying those babies who need to be born sooner than later. Until then I think the system will tend to advocate for mass induction for post dates, to save the very small number of babies who benefit from it. But at a cost to the majority of mothers and babies who subject themselves to this intervention.

And subsequent babies born to first time mothers who have c-sections for failure to progress following induction, will carry some of the risk.

There could well be something in what you say Shagmund . As with all these things to do with the decisions we make in pregnancy, there are no right or wrong answers, just a balancing of the various risks sprinkled with our individual experiences and viewpoints. Even if the risk genuinely is 1 in 486 at 43 weeks, which is not a figure I've seen before, then it would mean 485 unecessary inductions to attempt to prevent one bay dying. That is a lot of consequences for 485 women and babies, given that induction carries its own risks, as you have highlighted.

For some people, any measure is acceptable to try prevent even a 1 in 1000 risk or less that their baby might die. For others, a likely unecessary intervention with all the associated risks is totally unacceptable to attempt to mitigate what they perceive as a tiny risk. Every woman needs to factor into her decision-making her own personal risk factors, including age, BMI, health in pregnancy etc too.

What I personally object to is this attitude of some in the medical profession that they have all the answers, for example one person told me "my baby would be likely to die" if I went post-dates. That is actually untrue and scaremongering, and demonstrated to me that their knowledge on this topic was not good. I feel strongly proper discussions should be had with pregnant women about all these things and their views and decisions taken into account and respected. Pregnant women are not sausages in a sausage machine, yet sometimes this is how we are treated. Informed consent, which is an absolute pre-requisite to any medical procedure such as induction, means exactly that: informed. The guidance for doctors (and actually the ones for nurses and midwives too) is absolutely clear that doctors must respect patients views and decisions, even if they regard them to be irrational. They must also not make assumptions about the information a patient might want or need, or factors they might consider significant and must discuss treatment options, including the option not to treat.

bay = baby

BMJ article

Pesto - it's so disgraceful that women are consenting to this procedure in such large numbers without really understanding what the risks are. I remember when I had my first and induction was on the cards - I had NO idea what was involved in the process, none at all. And so much coercion going on too.

Fascinating how induction rates vary from hospital to hospital.

Nationally it's 21%. But some hospitals are as high as 29% and other hospitals as low as 13%!

Incredible. And that's hospitals in the London region.....