where is the evidence for inducing "post term" pregnancy at 42 weeks

[Banjogurl]

Hi, I'm a first time Mum and am 41 weeks today. I'm feeling under pressure to have an induction but believe the official date is one week off and that I am only in fact 40 weeks today.
I'd like to look at the scientific evidence for not going over 42 weeks (I have a background in science) and wondered if anyone could point me in the right direction?

I was induced with my first baby at 42 weeks. In retrospect a spontaneous labour was much easier to cope with than an induced one - so that's one adverse factor for a start. Induced labour is as unpredicatable as any other sort. Some women will cope very well, have a pessary and that's it. Others will need waters breaking and a drip. You may be continuously moitored - I was most of the time and I found that very uncomfortable and I hated being stuck in one place. I know now from my spontaneous labours that I labour better standing up. Then you may well need an epidural - and that's when the cascade effect kicks in. Induction can be a fairly harsh medical process and some babies handle that better than others. I know from my own experience that when they talk to you about the induction process they also talk to you about c-section because that's the only place to go if you and/or the baby are struggling.
Induction is vital if medical circumstances dictate - as with Lougle - but for post dates women that is the question - what is medically required - and it's not an easy question to answer.

Regarding the spoon/precious debate I have only this to say - if you post something that one person finds offensive then they may be misreading. If several people find it offensive then you're better off apologising rather than justifying and saying 'what you meant was..'

Yes, I have no problems with induction, and I'm sure it is vital in certain circumstances. But there seem to be risks, as NL has mentioned. I don't know the details. But if it were relevant to me I would look into the risks of both and make a decision based on the evidence and taking into account the recommendations of the professionals. I wouldn't take kindly to emotional blackmail from those who do not understand the concept of risk assessment and management.

joyfull i had a similar experience with my 1st 4 babies i had to push to be allowed to go to +14 as the policy was to induce at +10. the ironinc thing was with my 5th i wanted to e induced at +10 as i had concerns about her movements (and various other stressed in my life including a very poorly ds3 who had had kawasakie disease) anyway they didnt want to induce me as policy was now term plus 14, oh the irony! as it was i insisted on a scan which showed fluid levels were low, so had a medicaly 'good' reason for induction and then they were happy to do it at term plus 10!

re induction, i have no doubt that it is helpful and necessary for some babies, going overdue and the fact that it is a lottery depending onwhere you live as to what they calss as overdue (i had all mine in the same hospital but they changed their policy inbetween no 4-5!) means i wanted to look at all the info before making a choice.

my circumstances, induced with ds1 and we discovered i am actually allergic to the gel they use! bery bad reaction, hyper stimulated uterous, which meant unhappy baby and nearly ended up in emcs.

so with my others (have been induced with all 5!) i waited as long as i could/felt comfortable with, with monitering etc. in the end i was induced and was ok as breaking my waters worked and then had 4 natural births. interestinlgy with dd who was induced earlier than the boys i needed the drip which i didnt in the pregnancies i waited longer for. i wonder if those extra few days meant i was more 'ready'? but dd was also back to back and that can influence things.

but yes cascade of interventions, my family history is of longer pregnancies, i knew my dates with some of the boys think only had sex once in a month! yet the hospital insist on 'their' dates which are not an exact science.

there are risks to both i went with the info availalbe, the extra monitering and scans for reassurance and the fact that my boys were very active and i knew they were ok. with dd my gut feeling was different so i pushed for the induction.

i think eveyr woman has the right to make the choice that is right for her personally.

My first (spontaneous) birth seemed smooth until he was born with the cord around his neck x3 and with an apgar of 2 IIRC faint pulse and decelerating heart rate.

2nd was by scan dates 41 weeks gest and my (accurate) dates just 40 weeks. I was induced with 2nd. Very quick very straightforward. I appreciate other womens experience of induction will be different.

After my experience with my first DS I wouldn't want to take any chances_thats my view from a personal perspective.

I am also interested in what are seen as risks with induction?

NL has mentioned some of them. I suppose what I'm asking is would people just assume there weren't any and proceed to be induced or would they attempt to find out and make a decision based on knowing the risks of both?

what has the cord being round your babies neck got to do with induction? that can happen at any point in any pregnancy and then birth? fwiw i know someone whose baby was stillborn due to cord entanglement, she hadnt even reached her due date yet.

the risk are that you can end up with interventions and the fact you areintefering with a natural process, being induced means higher chance of c section etc, and does NOT guarantee a good result. you can have a distressed baby due to intervention which can lead to poor apgars and complications after birth. there are risks assoctiated with a c section, more so if its an emcs (more likely with induction) but this has all been said already on the thread.

See I think that's where I struggle to understand. Even before we lost dd2 I would rather have taken the risk of induction with a cascade of intervention/medicalised birth than the risk of my baby not surviving/suffering brain damage from lack of oxygen in the last few days.

But then I've never viewed birth as an experience but as a means to an end and hopefully a healthy baby. The birth is such a tiny part of a baby/child/adults life.

My other niggle with assessment is that sadly things can change so so quickly. Since we lost dd2 i've been much more exposed to baby loss and have heard so many tragic stories like fm's where the baby was fine one evening on a scan/ctg and gone by the morning. I accept that my viewpoint will be skewed as I've been more exposed to this.

But intervention also carries risks to the mother and baby's health. It's not all about the natural birth dreams.

My question still stands, would people assume, or would they make some attempt to find out the facts? Lots of fingers in ears and la la la on this thread, because people have made up their minds. Which is fine, but I find it worrying that so many people cannot grasp the concept of risk benefit assessment.

but the risks of intervention can include those same risk, just through the induction process, it doesnt eliminate it.

and with regards to going overdue the evidence is not conclusive that it is always necesary or that it produces better outcomes, if you showed me a review that said it did or strong evidence to point to more favrouable outcomes then yes i may reasses but as it is, BOTH have their downsides and having experience 3 nightmare days of labour with ds1 and a cascade of intervention, a distressed baby and various consultants in the room who found me an 'interesting and unusual case' and argued over the best course of action as they didnt know! meant i didnt want a repeat of that process for my others. we were lucky with ds1 that things settled down as they were prepping me for section.

there are just so many factors, esp with dating being debatable and then the benefits versus pros for induction, yes it can and does save lives in some situations going post dates is not necessarily one of those.

stillbirth is a horrible thing and sadly we dont even know the causes for some of them, its an area that needs more research and more monitering and awareness.

as an aside ctg are fine for telling you your baby is fine then, but obviously things can and do change quickly, a scan and a doppler scan can pick up more problems ie low fluid, check the blood flow from the placenta and they can see how effectively its being transfered through the umbilical cord etc. which is what i had, with the boys it showed all was fine and could tell they were fine. with dd i had to PUSH to get that scan i shouldnt have had to push to get it, there were concenrs over babies movements and i wanted one! it showed reduced fluid levels which is a sign the placenta isnt working as effectively, then they induced me, but had i not pushed for that htey would have happily left me another 4 days (very ironic given in my other pregnancies i had to FIGHT to get those extra 4 days!) the cut off are very arbitary and in most hospitals it has changed to +14 as induction at +10 showed no increase in a good outcome but did show more negative otucomes/experiences for mother and baby. past 14 days and the evidence is not clear, partly as not many people choose to go past that. i think and i could be wrong that the stillbirth rate rises once past 33wks? but again the numbers are limited.

but we all do have our own personal issues that we bring to these situations, and did i worry?! hell yes, i worried MORE with each of my pregnancies as i KNEW more each time about what could go wrong and flet i was pushing my luck, i had met more people who had had problems both in rl and via parenting forums. but i did try to look at it objectively and with the evidence that in MY situation i was ok to go to term plus 14 and with ds3 as i knew my dates i went to term plu 18days iwth daily monitering, scans etc and a VERY active baby who let me know he was fine, i had the full support of midwife as well.

i think this is a we are all different and we all risk assess differently and its totally understandable :)

i think whatever have made a perfectly valid and understandable risk assesment for HER circumstances actually.

but yes the risk of induction are to mother and baby and they do include death, interestingly the drs etc are no so keen on sharing hte risks of induction with you, they happily quite the risks of not inducing but they will NOT mention the risks of inductoin without you really pressing them and even then they are vague and dont want to! or that has been my experience at least.

Poor OP hasn't come back. Hope it's because you have spontaneously gone in to labour banjogurl!

Stealth I think it is inaccurate to say that people who don't agree with you have grasped risk benefit assessment. It's just that presented with all the facts some people on the thread agree that they would rather wait it out and some people have said they wouldn't. Two different opinions and frankly there's no right or wrong answer which is why it's such a hard decision. Both decisions could be disastrous, perfectly fine or somewhere in the middle!

haven't grasped

what has the cord being round your babies neck got to do with induction?

Nothing. Did I say it did? I was explaining my experience.

Knowing just 5 more mins in utero would have meant my first DS being stillborn did mean my attitude towards induction was very different with my 2nd pregnancy.

I'd heard people saying inductions were 'bad' and I was anti induction due to reading about them leading to a higher chance of possibly more intervention.

My experience was a good one luckily.

Whatever, I don't think you understand my post. I have no problem with people deciding induction is the best thing, they're most likely right. But to decide that without even considering the other options and the risks and benefits is imo misguided, tho I agree people are perfectly entitled to do it. The attitude seems to be "there are risks to not inducing, therefore I want inducing", not "there are risks to both, however on balance the risks are greter for not inducing". Just realising there may be risks tk both and finding out more before making the decision would be a good idea.

firslty ((whatever)) hugs as i think you are very brave to reading/posting on this thead, it must be hard for you.

secondly re the cord round the neck, the implication in your post was that you were happily induced the second time partly as you didnt want the same thing to happen again? forgive me if i am wrong, but cord entanglement is something that can happen at any time and induction will not stop it.

one of the risks of induction is prolapsed cord, which is very dangerous, they often have to break your waters (they did with all of mine) and i was lucky as they were all well engaged etc, but it IS a risk and will mean emcs, that may mean all is well but baby still has a risk of oxygen depravation and death :( odly enough drs dont tell you that your risk of cord prolapse is higher with induction (certainly didnt in my case) so to me the risk of waiting a few more days was better than risking an induction at term plus 10.

and as i said its arbitrary the cut off date changed between me having my babies so havin ghad to fight to go to plus 14 with 4 then with dd i had to push to get the induction at plus 10! despite having concerns about the baby!

But the OP wouldn't even be 42 weeks by her dates for a whole week after the hospital dates. More than a whole week after the hospital recommends induction. So the whole placentas failing after 42 weeks argument is irrelevant as by the OPs dates she has not reached that point. Normal pregnancy is 37-42 weeks, 40 weeks is just a convenient point in between those gestations. Some women and babies need the full 42 weeks, others don't, it annoys me greatly that we (I count myself as part of the system in this case) presume to know better than women when they conceived, presume that our machines know their body better than they do and so squish them into the maternity machine that is the hospital, regulated by our arbitrary timescales and interventions based on the hospitals needs. Don't get me wrong I believe there is a place for induction but this should be in conjunction with women and the babies best interests, not inducing blindly at T+10 just so you can fit everyone in without going over the magic 42 week Mark.

secondly re the cord round the neck, the implication in your post was that you were happily induced the second time partly as you didnt want the same thing to happen again? forgive me if i am wrong, but cord entanglement is something that can happen at any time and induction will not stop it

No I was happily induced the second time because after my experience with my first my mindset was whatever risks induction may bring (at that time my understanding was a higher risk of intervention) I'd rather that than wait it out and risk stillbirth.

I know cord around the neck can happen at any time.

This seems to be one of those subjects where if you state a view that you base your decision on someone with an opposing view takes it as a judgement on their decision and around it goes!

I had no idea that there is a higher risk of cord prolapse with induction and though I know now about hyper-stimulated uterus all I was told when 'consenting' for induction at 42 weeks was that 'if the baby was struggling we would bale out and go for a c-section'.
I've always viewed birth as a means to an end. Still want to be informed and make choices though.

Gemma -regarding the BMJ link that you say demonstrates the sharp increase in stillbirths after 40 weeks, you are absolutely correct. That graph appears to show a sharp increase in something (difficult to say what without title or the context of the paper, as the link just takes me to an image of part of a graph and I can't work out the citation to look up the paper -it looks like intrauterine deaths, but could be unexplained intrauterine deaths or even something else?). It seems to show that at the peak of the increase at 44 weeks the risk is less than 1 in 10,000. i.e. for 9,999 babies out of 10,000 that risk will not materialise. It also appears to show that all of us will endure a greater level of risk earlier in our pregnancies. Indeed the 44 weeks level appears to be roughly comparable with 33-34 weeks.

A sharp increase is of course relevant, but many of us also will look at the absolute risk and see that it remains an extremely rare, albeit tragic, event. These risks are actually lower than what I have seen quoted elsewhere, so I would be cautious about using this to base any decision on without reading the rest of the paper.

I've had 3 post dates babies. First induced at 42, born at 42+3. Nightmare, iatrogenic complications and zero actual signs of post-maturity.
DC2 born at 40+12 without intervention of any kind, and definitely post mature - hardly any water, dry skin, long nails etc.

DC3 I declined induction and had a scan at 42 weeks, then CTG each day. He arrived at 42+3, perfectly healthy and again, no signs of postmaturity. No sign of deterioration of the placenta.

I was very lucky that DC1 was not permanently damaged by the induction. They had not scanned or monitored, there was no need to induce.

There is not enough research, because not enough women are having natural term pregnancy.

I don't recall the detail, but I know the findings are based on a tiny number of babies, like fewer than 10, and that being post dates was not the only factor in their deaths for most of them.

DN was still born at 27 weeks. There is risk at every stage.

Whatever - for me the things that concern me about induction are roughly as follows:

Use of drugs that may interfere with the natural pain-reduction mechanisms of labour (for both mother and baby), for example syntocinon.

Reduced mobility in labour (e.g. because of increased need to monitor, and options that have better outcomes in terms of need for pain relief & c-section rates (for example, homebirth use of pool). I should add this is not primarily about 'the experience', it is about my opinion that interventions in labour, including any drugs, have real physiological effects on both the mother and I am not convinced they are risk free. Babies born following labours where drugs have been used behave differently. They find it harder to initiate breastfeeding themselves and there is evidence that the mother's hormones in the minutes following birth are actually different. the long-term consequences (if any) are unknown. But there is research evidence that method and experience of birth does have lasting effects on the child at a population level.

Likelihood of being stuck in a less than optimal position for both comfort and progression of labour due to monitoring

Intervention cascade -i.e. increased discomfort leading to request for more pain relief, etc etc

Increased likelihood of needing epidural, which may well contain drugs fromt he same family as pethidine and can interfere with baby's post-birth behaviour and breastfeeding

Risk of fetal distress during directed pushing semi-recumbent following epidural

Unknown long-term consequences of all of the above, for both mother and baby.

Perception (not sure of stats) of increased possibility of instrumental delivery or c-section (as compared with homebirth/pool scenario -induction vs spontaneous labour on a consultant-led unit doesn't show difference in c-section rate)

All associated risks of instrumental delivery, including trauma to baby, perineal trauma, incontinence etc.

All associated risks of emergency c-section (which are all higher than planned c-section).

Other known risks of induction, such as hyperstimulation, uterine rupture etc.

Finding info on the level of risk for each of these things in an accurately dated pregnancy with no other complications being induced (by various methods) at 41, 42 etc weeks seems to be practically impossible. My own views are coloured by my experiences of a horrible induction of DC1 at T+10 for no other reason than I was T+10 by their (inaccurate) dates (I was actually more like 40+6).

For me personally, the risk of all the above does not outweigh the increased risk of stillbirth at 41 or 42 weeks, quoted by RCOG as rising from 1 in 3000 at 37 weeks to 1 per 1000 at 42 weeks to 1 in 500 at 43 weeks. Especially not when I have looked at detailed analysis of the studies on which these risks are calculated. The evidence relating to increased risk of stillbirth comparing an accurately dated 40 week pregnancy to an accurately dated 42 weeks does not convince me.

With 3 DCs, I have not had a pregnancy go to 42 weeks yet (though I am 38 weeks with DC4, so that may yet change). I would decline induction before 42 weeks. After that time, I thinkt he discussion I would want with a consultant, based on my own obstetric history would be elective c-section vs expectorant management. I might consider induction purely by rupture of membranes if that were possible.

I totally accept that other people will look at the same info and make a completely different decision . What is so hard, is that no-one knows which pregnancy might be that 1 in 1000 or even 1 in 500, or whatever the figures are. What I struggle with is how many mothers and babies have unecessary negative consequences of induction in the bid to ensure that one baby does not die . Until we can identify which baby that might be, 499 out of 500 or 999 out of 1000 inductions for going 'overdue' are unecessary. That is an awful lot, and not without negative consequences. I know other people will not necessarily agree with me, especially where they have personal experience of stillbirth and that is absolutely their right and I respect it. This is why it is so important we are each allowed to make our own informed decisions for ourselves .