Ten Month Mamas campaign for 'overdue' to be at 43 weeks instead of 42.

[Spidermama]

My friend is a week and a half 'overdue'. Feels fine. Looks great. She went for a scan today and they told her she's low on amniotic fluid so they're going to induce in a couple of days. She really didn't want this.
Then my midwife friend posted this article on Facebook.

I've googled and found, on the one hand, people saying 'Low fluid can have implications for the babies lungs, can mean the placenta's not functioning so well ... etc etc.

Then on the other side women saying 'WHEN will they stop inducing women unnecessarily for this' and talking of how teeny and over exaggerated the risks are.

So what are your experiences and perhaps more importantly how can I best support my friend. My natural inclination (and experience) is that medics overstate risks.

I was under the impression that it was really dangerous to go too far overdue?

There needs to be more research before they change the guidelines so dramatically anyway...

There's a lot that is not understood about child birth, particularly how a baby is ready and triggers labour.

For those mothers who go "overdue" - maybe they werent overdue at all. Maybe genetic factors (I think race plays a part, I don't mean to offend() as in some women have longer gestation periods if they're African American vs say Asian.

Labour may also be delayed or brought on by stress etc.

Basically obstetricians etc should look at the woman as an individual not apply blanket guidelines and rush to induce without fully checking them over.

"But that, too is so variable"

Of course. But they have studies showing what percentage of first time mums with a low Bishops score will have a labour like yours, and what percentage will end up with a 4 day job followed by an emergency c/s. And they should make this information available to women and discuss it with them.

"I was under the impression that it was really dangerous to go too far overdue?"

Yes for some babies but not at all for others. The problem is that they are so crap at identifying which babies need to be born sooner, and which can be left for a while.

So they have a blanket policy of induction at 41 completed weeks. Which means that SOME women are experiencing completely unneccessary inductions, which put them and their babies at risk.

It's the same as with c/s: lots of 'just in case' interventions. (or 'unnecessesareans' as I've heard them referred to in the States!)

So they have a blanket policy of induction at 41 completed weeks

And even this varies depending on the trust/hospital.

I'm a second time mum, and I know that at St Thomas' in London, multips are offered the first of 3 sweeps at 41 weeks, and induction is usually booked for 41+5.

I was going to have my first sweep tomorrow, but spoke to my caseload midwife team today who were MORE than happy to postpone the sweep until Monday.

Individualised care. That is what is needed.

However, to refer back to the OP, what isn't needed necessarily, is to ignore the evidence of a scan that shows low amniotic fluid levels. If we don't use what medical interventions are offered, to our advantage, what is the point of having anything to do with medicine at all???

Research shows that the risk of stillbirth starts to go up more significantly at 40+10, but hospitals just wouldn't be able to cope with inducing all women then so low risk women are left to 40+12.

This is a misguided (and dangerous) campaign.

My PCT has been due date +10 for some time now. which I believe are NICE guidelines. A neighbouring one routinely offers all women over 38 induction on their due date.

Iggly - so you're basically saying that statistics have no place in obstetrics? Really?

Anyone know how long it takes for a placenta to fail? Genuine question.

For that is the catastrophic risk once overdue, and unless there are unmistakeable signs that can be picked up on scan and scans are performed sufficiently frequently to spot the danger signs in time, it strikes me as very unsafe indeed to wait for a more favourable Bishops score as that may not be related to placental function.

No I mean they should take a look at the woman, bearing mind the stats/guidelines but not automatically assume that being 41 weeks = induction. they should do regular checks, monitoring etc (although it's more expensive than an induction in their eyes). I didn't explain it very well in my post.

Iggly - but there is an undeniable link between increased risk of stillbirth of an otherwise healthy child with rising gestational age. That risk increase begins around 38+ weeks.

You can't catch them all with expectant management, as some things you can't even monitor for (e.g. meconium)

What do you suggest would be an acceptable rate of unneccessary stillbirths of otherwise healthy children to reduce the amount of unneccessary inductions?

the statistical risk may be small, but the consequences of that 'tiny' risk are enormous to the family that leave hospital with no baby.

There are statistical risks to induction too of course. As well as risks associated with babies who are induced before they are physiologically ready to be born.

All of this is up for ready discussion with a consultant and/or Supervisor of Midwives, by women who have informed themselves of the relative risks of either approach and are aware the induction is one of two options.

In my PCT, monitoring as Iggly describes, is an option that is accommodated for those women who prefer that route, provided they are happy to meet and discuss things. It wouldn't be offered if consultants and SoMs were not happy with it as a choice.

It seems that expectant management is the option chosen by OP's friend, and it would be my choice too.

My issue is that once you go down that route of expectant management for post term birth, and are going in to hospital for monitoring of placental function and amniotic fluid levels, what is the point of wilfully ignoring evidence that points to a medical indication for induction? OP says her friend has been told that her fluid levels are low. My question is whether further debate about the medical implications of low fluid levels is worth the risk?

I am all for women being given choice, but in the face of evidence there are choices that make MUCH more sense than others.

"It wouldn't be offered if consultants and SoMs were not happy with it as a choice."

That's very naive! Sometimes doctors and midwives need to do something to try to minimise the risk or damage, even if they think it is a daft idea. Take the militant home birthers who want to have a high risk home birth regardless of the advice or evidence. The doctors and midwives don't just abandon them and their baby but try to work out something to minimise the risk as much as possible even when they think their plan is bonkers.

The problem with monitoring is that a proportion of placental failure can be predicted, but there is a significant proportion that can't be predicted.

What we need to know is how many babies would die if everyone low risk was left to 43 weeks and how many babies die as a result of induction. A Cochrane review was published on this just a few months ago:

onlinelibrary.wiley.com/doi/10.1002/14651858.CD004945.pub3/abstract;jsessionid=F581E8DD8919245CB3A2F918ABFD9E70.d03t01

BACKGROUND:
As a pregnancy continues beyond term the risks of babies dying inside the womb or in the immediate newborn period increase. Whether a policy of labour induction at a predetermined gestational age can reduce this increased risk is the subject of this review.
OBJECTIVES:
To evaluate the benefits and harms of a policy of labour induction at term or post-term compared with awaiting spontaneous labour or later induction of labour.
SEARCH METHODS:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2012).
SELECTION CRITERIA:
Randomised controlled trials conducted in women at or beyond term. The eligible trials were those comparing a policy of labour induction with a policy of awaiting spontaneous onset of labour. Cluster-randomised trials and cross-over trials are not included. Quasi-random allocation schemes such as alternation, case record numbers or open random-number lists were not eligible.
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy. Outcomes are analysed in two main categories: gestational age and cervix status.
MAIN RESULTS:
We included 22 trials reporting on 9383 women. The trials were generally at moderate risk of bias.Compared with a policy of expectant management, a policy of labour induction was associated with fewer (all-cause) perinatal deaths: risk ratio (RR) 0.31, 95% confidence interval (CI) 0.12 to 0.88; 17 trials, 7407 women. There was one perinatal death in the labour induction policy group compared with 13 perinatal deaths in the expectant management group. The number needed to treat to benefit (NNTB) with induction of labour in order to prevent one perinatal death was 410 (95% CI 322 to 1492).For the primary outcome of perinatal death and most other outcomes, no differences between timing of induction subgroups were seen; the majority of trials adopted a policy of induction at 41 completed weeks (287 days) or more.Fewer babies in the labour induction group had meconium aspiration syndrome (RR 0.50, 95% CI 0.34 to 0.73; eight trials, 2371 infants) compared with a policy of expectant management. There was no statistically significant difference between the rates of neonatal intensive care unit (NICU) admission for induction compared with expectant management (RR 0.90, 95% CI 0.78 to 1.04; 10 trials, 6161 infants). For women in the policy of induction arms of trials, there were significantly fewer caesarean sections compared with expectant management in 21 trials of 8749 women (RR 0.89, 95% CI 0.81 to 0.97).
AUTHORS' CONCLUSIONS:
A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction although no significant differences in the rate of NICU admission were seen.However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction).

well BartletforteamGB I guess I fall into your category of "militant home birthers who want to have a high risk home birth regardless of the advice or evidence".

I've had four at home. No scans. No pain relief. No intervention.
Had I thought there was any reason for concern, I would certainly have welcomed the medics.

As it was, I had two straight forward births and two which took a bit longer and were tougher. It was the best possible start to motherhood. I felt so strong, so empowered ... totally buzzing. For the rest of my life I will remember all my labours and births with clarity and with pride.

I barely ever mention this to other women because I can never find anyone who has had similar experiences and indeed practically every mum I know has a horror story of intervention or terrible trauma.

I wish more women could have similar experiences to me because the sense of empowerment is enduring.

I know I will now be called smug and accused of taking unnecessary risks blah blah blah blah ... but I wouldn't change my incredible births for the world. They made me who I am and it genuinely upsets me that most women have babies extracted in intrusive, painful ways when the vast majority of the time its not necessary.

My friend was fine at 42w, declined induction, everything then went wrong. Inducion is not that bad in the grand scheme of things, i've been induced twice with no complications. depends if you think the small risk is worth it.

Hi,

Just wondering if anybody knows what the chances of putting something in place so that if I was to go overdue I could have an ELCS rather than an induction? I ask because my sister had a difficult birth with induction, forceps etc and as a result of being completely out of control and just worked on (plus other things of course) she ended up with quite severe PND; medicated for 2 years and still receiving counselling after 3 years. I don't want this and I think having a controlled environment rather than lots of escalated intervention which might result in EMCS anyway would be the better option.
Tell me if I'm being daft/if there's no chance etc please.

Im really torn on this!
Ive been induced at well over a week overdue twice. Theres a big part of me that would love to wait, if I was ever pregnant again, and let my body do its stuff. Have a lovely home birth etc. But, on the other hand, by 41 weeks I was ready to try just about anything to get them out! There is also a risk of still birth, and Im not sure that is a risk Id be willing to take.

OP, you've had great birth experiences, that's great for you.

You can't base an assessment of medical risk on your own personal feelings about your own positive experiences.

No one is going to force your friend to have an induction, but you have to consider that she has been advised to have one because of medical reasons. She wants a positive birth experience, but she is hardly going to have that if she ends up with a still born baby. Even if the risk of that is small, in my opinion it is not a risk worth taking. This is her child. It's not about 'feeling empowered', it's about healthy child, healthy mother.