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...?

Even if the risk genuinely is 1 in 486 at 43 weeks...then it would mean 485 unecessary inductions to attempt to prevent one baby dying.

So that one baby's life isn't worth the inconvenience?

I'd not have been happy to take the 1 in 486 ris myself, but I don't think induction is always the right answer either.

What's the alternative to induction, breatheslowly? Sorry, I genuinely don't know.

Marie ^Even if the risk genuinely is 1 in 486 at 43 weeks...then it would mean 485 unecessary inductions to attempt to prevent one baby dying.

So that one baby's life isn't worth the inconvenience?^

Surely that's a decision the individual woman has to make for herself though, and induction should be presented as a choice rather than 'we induce at 40+X days here'.

Induction isn't just an 'inconvenience' - there are real long term risks to the mother's health.

Increased chance of instrumental delivery (leading to increased risk of lifelong continence issues - both urinary and faecal), EMCS (major surgery with an increased risk to the life of the mother, as well as impacting on any future pregnancies and births) - now, of course none of these are as traumatic as a stillbirth, but they're not just an inconvenience, and this information is generally not presented to the mother at the same time as information about the risk of continuing the pregnancy.

Surely that's a decision the individual woman has to make for herself though, and induction should be presented as a choice rather than 'we induce at 40+X days here'.

Yeah, I agree, but do you not also think that the woman should be told "your baby has a 1 in 483 chance of dying if you don't induce"?

they do tell you that, or they did me anyway, i wnet overdue with all 5 of mine and with ds3 i went to term plus 18, according to my dates, it was term plus 21 according to hospital dates, but i was very sure of my dates.

i still ended up being induced with all 5, and thankfuly with no2, 3 and 4 had good experiences. no 1 was a nightmare took 3 days and he was quite clearly not ready to born.

no 5 was also harder work, required the syntocin drip, with no 2-4 i just had my waters broken and that was fine. as it was the midwives checked my placentas after the births and in each case they said the placenta was fine, had lots of fluid and my babies were still vernixy and didnt look remotely overdue.

my mum also went to over 3wks late with meand my sister and we all ahve a longer menstrual cycle so i think i am just meant to cook babies for longer. however having waited so long with ds3 i decided to be induced at plus 15 with ds4, and with dd (no 5) i had had alot of stress at the end of pregnancy, serious illness of one of my children and i was run down and ill msyelf so was induced at term plus 10, bizarrely they didnt want to induce me then sa policy was plus 14. yet when i had ds1, ds2 and ds3 the policy had been plus 10 and i had to fight to go to term plus 14 and they went on about the risks etc, yet they had changed their minds by the time i had dd. as it was i had low fluid levels (got them to scan me) so they were happy to induce but my gut feeling with dd was that she needed to be born, whereas with my boys i knew they were well and all was fine, her labour was harder than the others tho and i think that was partly becuase my body needed another few days to be ready.

btw i actually had it written on my notes in BIG BOLD LETTERS, PATIENT HAS BEEN INFORMED OF THE RISKS OF STILL BIRTH when i went to term plus 14 with ds4, but by the time i had dd, 2yrs later THEY wanted me to go to term plus 14, despite me saying no i am worried about babies movements etc!

I was induced at 43+ weeks with ds1 who is 17 now as the consultant at the time liked to wait as long as possible.

Ds1 weighed 11lb2 and the birth was difficult due to his size. I've had problems with all subsequent pg, the latest being incompetant cervix with ds4. The consultant thinks ds1 weight was probably too much for my cervix causing weakness that has got worse with each pg resulting in it failing at 20 weeks with ds4.

I'd never even thought that leaving induction till later might effect any future pregnancys.

moomins :( so sorry for you loss :( were your other babies big? mine were all big, 9lb through 10lb 13oz, i have never heard that being used as a reason for problems with a cervix before, interesting theory, i would think the extra weight must put pressure on the cervix?

wishing all the luck if you go on to have another xxx

Marie as far as I'm aware, that's pretty much the information that women are given if they choose not to induce by 42w though, or even (as some will testify) that their baby absolutely WILL die if they don't induce at that stage - ONLY the risk of not inducing is given, not any information on the risks of the induction process.

Marie - if I had a proper discussion with a consultant (taking in to account my whole medical history) then I think that I might have been offered a CS as an alternative. I think that CS can be an alternative to induction and just being put on the hospital conveyor belt for induction isn't the right answer for all women.

Thanks 4mad no the others were early, 35 weeks and 32weeks. Although they were quite big for their gestation at 5lb15 and 4lb4.

I too am sorry for your loss Moomin . Again it illustrates all too painfully, as I said above, that all courses of action have risks associated. From what you write it sounds like it was more your consultant's decision than yours? I think that's the part I struggle with. All good doctors should be capable of communicating the pros and cons of the various options (induce, motnitoring and wait, do nothing at all, elective c-section...) and enabling a mother to make an informed decision about what is the best way forward for her as an individual. It is perfectly fine to explain that "this hospital's policy is XXX because of Y, Z & Q", but that alone is not sufficient for informed consent and the GMC are clear about that in their consent guidance.

"Yeah, I agree, but do you not also think that the woman should be told "your baby has a 1 in 483 chance of dying if you don't induce"?"

If that is indeed an accurate assessment of the risk of allowing a pregnancy to continue past 42 weeks, then YES, all women in that particular position should be told this. And women with additional risk factors for stillbirth should also have the implications of these explained to them. As Flisspaps has said, many many women are told nothing much except the risks of stillbirth. Options are not presented. 2 separate medical professionals implied that to me personally that if I didn't follow their instructions my baby would die (not might and no actual risk given). They were lying or badly informed on the subject and badly trained in informed consent. They should also have explained that induction itself carries risks, however remote, of both fetal and maternal death, as does c-section. This needs to be explained at the time of discussing booking for induction, not once the woman has been admitted and the pessary is poised to go. For planned and emergency c-sections the risks of those things and other adverse consequences are quantifiable (e.g. RCOG consent advice). The risks of induction should also be quantifiable and explained as part of the consent process. I have never ever come across a woman online or in RL who said that their doctor actually did this going through the options, explaining the actual risks etc without focusing just on stillbirth. One doctor explained to me that in my situation the risk of stillbirth doubled. However, he failed to mention the absolute risk, which I would still have considered tiny.

A risk of 1 in 483 to you is totally unacceptable and I absolutely respect your view and your right to make decisions about your body and baby in whatever way you see fit. For me, a risk of 1 in 483 is small (RCOG would descibe it as 'uncommon' and a risk of 1 in 1000 or less they describe as 'rare'). For me personally in my assessment, that risk, in the absence of other complications or risk factors, does not outweigh the risks of induction or elective c-section.

flisspaps you are totally right they went on and on about the risks of going overdue but NOT once did anyone mention the risks of being induced, that is all 5 times it was simply never mentioned, even when i questioned being induced, i got lucky, tho ds1 birth was long and drawn out i managed to avoid c section or forceps (only just tho 3hrs of pushing with ds1) then no 2, 3 and 4 were easy and no 5 was ok despite syntocin.

there was no mention of alternatives to inductions and i had to INSIST on medical management ie extra monitering and checks etc once i got past 42 wks they werent offered to me and the consultants were annoyed that i wanted it, saying it wasnt a service they offered and it was my own risk to go overdue and is holdnt expect any extra monitering! thankfully at my hospital they have a PAWS unit, (pregnancy and wellbeing suite) where you can go at ANY point in your preg if you ahve any concerns, you can self refer tho my midwife arranged appointments for me, and they will moniter you, arrange scans, do all the usual tests etc, this unit is lovely and the midwives were great and very reassuring. the consultant didnt even TELL me this unit existed yet it was just downt he corridor from where he saw me!!

I think inductions have become so routine now that they are "undermedicalised". In my 3 day long induction I saw a doctor (excluding the anaethestist for the epidural):
Once when a very junior doctor was wheeled in to tell me about the risk of stillbirth (the junior doctors had just switched jobs so I think she had probably been there a couple of days). She didn't say anything else about the risks of induction. This bit isn't done unless you question the need for an induction.
Once when the pessary didn't have any effect (a registrar).
Once to do ARM (a consultant).
Once to see how dilated I was (the MW could have done this as he didn't seem to be making any decisions, she did).
To do the forceps.

In between the MW spoke to the doctors about my care but they didn't come to speak to me. I never got the feeling that I was actually under the care of the doctors and given that it is a hefty medical intervention with real risks, I think that they should have a similar level of consultant/senior registrar input as an ELCS would have with the doctors running through all of the risks and getting fully informed consent. And I think it should be done sitting in a consulting room rather than in a hospital bed to return some of the balance of power to the patient.

breatheslowly The first time in my induction that I saw someone other than a MW or an anaesthetist was at about 10pm on Friday night (I was admitted at 9am on Thursday morning) when they first mooted the suggestion of a CS if I hadn't progressed any further since 8pm (I had).

By then I'd had ARM, 9 hours of syntocinon and 4 hours of epidural.

The registrar didn't return again until about 6am when they got out the forceps.

Fliss - that is crap. I know more medical input would be expensive, but the personal cost to me of my experience has been very significant (not to mention the actual £ cost).

I was induced with DD and never realised that I could refuse (well, I knew I could refuse medical treatment but assumed that I would left on my own without any monitoring). The induction was very hard and it was clear to me that neither my body nor my baby were ready. It really did feel like they were throwing all the drugs they possibly could at us to force it to happen.

I have no medical training or knowledge so I can only speak from my experience but I certainly don't think it helped the breastfeeding problems that we had. I wouldn't be surprised it was another sign that my body just wasn't ready.

However, not sure what I would do if it happened again. I know the risk of stillbirth is small but...well....it would be so unthinkably awful that I'm not sure if I could even cope with a small risk.

I was induced at 38 weeks. And my labour was only 1hr 23 minutes long after active labour started. I only had co-codamol an a puff of gas and air. It was an amazing birth.

I had an induction following SROM at nearly 42 weeks and it was fine. Well, fine in the sense we both went home alive and I recovered after a few months.

I know induction has its risks, but my understanding is that the NHS really only intervenes where it feels risks of mortality are raised. The NHS has no vested interest in paying out for inductions where women would labour naturally. I know that there are women on this board who have had terrible experiences with induction and with cs and I would never undermine any woman's experience or right to choose how she gives birth, but I do feel induction is often described very differently on MN to how I have heard my women friends describe it in RL, which makes me wonder if the women who post on these threads have had very negative experiences that inflate the risks of induction somewhat. I think we all make our decisions on our own experiences to an extent, if I had lost a child after term I wouldn't let myself go overdue either. Risk is a terribly relative sort of thing. A one in a million risk is still a tragedy for that one person who experiences it. In the same way, as my induction was okay really, I would have another one regardless of what research said, because the only thing that seems certain to me about birth is that it is uncertain and so I think many women either go with what they know (if it worked well) or avoid what they know (if it were traumatic). Research seems, well.. not pointless, per se.. but difficult to generalise from wrt childbirth when it really varies so hugely from woman to woman.

my understanding is that the NHS really only intervenes where it feels risks of mortality are raised. The NHS has no vested interest in paying out for inductions where women would labour naturally

so why does policy differ so much from hospital to hospital and why is it when you actually question the policy, and why there is a difference you don't get a satisfactory response. The NHS has no vested interest in treating patients as individuals with individually calculate risk. They have a vested interest in maintaining a factory conveyer belt of treating people as its less effort and work for them. To hell with patient experience.

The NHS also has no vested interest in treating elderly patients with dignity and respect either...

My point is, you shouldn't blindly be believing the NHS myth that it knows best. We are right to question policy.

This is just another thing on a very long list within maternity care that seems to be about what the doctors/nurses/midwives feel is the easiest option and not about whats in the patients interest.

Inductions can (and are) used to smooth out the demand on delivery units. I was told so many times during my induction "we will examine you and then if there is room on the delivery unit we will move you up for ARM and the drip". Apparently if I fannied about not going for an induction then my baby was at risk. If they didn't have room on the delivery unit and my induction had to be delayed then it was just hunky dory. The reason that I was given for induction being at 40+12 at my hospital is that if you got bumped off the list because they were busy then you still had a few days leeway on the magic 40+14. None of that is really about the woman and baby. It is about an overstretched service that really can't cope with peak demand.

I was induced with my LO at 42+3 weeks. At the 40 week midwife appointment they booked me in. I, like others, did not know of the risks of the induction and were only told about the problems if I went overdue.

In the end I was induced twice and then she eventually turned up. Like another post, I do not think the baby or my body was ready and I hated it.

I did feel panicked when told about the risks of going overdue, untill I confided my fears to a friends mum who was visiting from Greece. Oh, she was wonderful and insisted I spoke to her niece who had had 6 children all at 42 weeks. Both happily informed me that 42 weeks was term and she (mum of friend) had been slightly shocked about how early she felt babies came here.

I'm not sure I would refuse the induction myself, but I do think you need to be informed and make a choice based on that. However, you have mentioned that you have some medical concerns. If it was me, I would be demanding a c-section (yes opening a can of worms) or what ever else I could get, just so I could have a healthy little one.

They wanted to induce DD1 when I was 3 days overdue (13 years ago now). I refused. They said, "Why don't you want to, you could come back later with your stuff and have the baby later today." I said, "Extra-strong contractions, increased risk of caesarian." They asked where I'd heard that (couldn't rememember!) and got a senior doctor in. He had a look at me and said, "Fine, come back in a week."

So I went from desperately needing to be induced to "Come back in a week" . A week later DD1 decided time was up and came of her own accord .

With DD2, at one antenatal appointment they booked me for an induction at 40+1 week. I said, "I'm not coming." They said, "It's ok, if the baby is born earlier, we'll cancel the appointment." I said, "You can cancel it now, I'm not coming!" (don't think they did...) Anyway, what on earth is the logic of that, making an induction appointment so far in advance, when I hadn't even reached due date! Bit over-keen on their inductions I think!

There are lots of interesting observations in this thread, and everyone has a different experience and viewpoint. Based on the research I've been able to do - and it's very difficult to find any good studies available to non medical professionals - the concern with being overdue is indeed an increased risk of stillbirth. However, whilst it's established that there is a strong correlation between being more than 2 weeks overdue, there are a couple of important factors to keep in mind.

1. Whilst the risk is increased by something like 2-4 times depending on which study you're looking at (they vary alot), the absolute risk is still very low; something like 1-2 in 1000 seems to be the most consistent number
2. Correlation and causality are not the same thing, and none of the studies is forthcoming about what the causal relationship is. So, the delayed delivery itself may not be the cause of the increased risk of stillbirth. For instance, there could be underlying medical factors which make both delayed delivery and stillbirth more likely - in which case delayed delivery is an indicator of increased risk, not the cause. As cause of death is not covered in the studies I've been able to find, it's not possible to draw clear conclusions from the data. I've also been unable to find any data to show the post birth mortality rate for babies that were successfully delivered through induction compared with non-induced babies. This data is significant, as it could tell us whether a baby that was stillborn would in fact have had an increased risk of death shortly after a successful induced delivery.

Randomised studies on pregnancies are incredibly difficult to do, because of the inherent ethics issues - and as a result it seems we're really only able to make best guess efforts as to cause and effect. However, what does strike me is that for a naturally occurring event like child birth, the rate of intervention through induction is staggeringly high in the UK, where it's consistently at somewhere between 20 and 25 percent.