Opinion from my friend the doctor!

[ohthegoats]

I have a friend who is a high up anaesthetist. We were just out for lunch with her and a group of others, most of whom have kids already.

The doctor's advice on birth is:

If things go early and seem easy, then all is fine - go for the natural option. If you are overdue and they start talking about induction, then do the following: don't turn it down, they are suggesting it for a reason. Go in for the induction sooner rather than later, have an epidural as soon as they will let you. If things work OK for you at this point, then go for the 'natural' option. The minute they start talking about interventions because something has slowed it down, or you're not progressing etc, refuse the drip to speed you up, refuse forceps or ventouse and just ask straight away for a C-section, before things get too far along. Put your foot down on the issue. The epidural is already in, you're not already massively knackered, and often a calm, non emergency C-section is easier to recover from than a failed induction/ natural birth/ forceps tear/ cut. That's what all doctors would do.

So... what do you reckon to that suggestion? Oddly, as she was telling this story I remembered another friend's birth story - she's in obstetrics somewhere, not sure detail of her job, and that was her exact situation.

"I didn't make the assumption that inductions were only offered if they were medically necessary."

Well, OP does say "If you are overdue and they start talking about induction, then do the following: don't turn it down, they are suggesting it for a reason."

Of course women who are offered inductions can and should ask "Why?".

Cote: I don't see the word 'Why?' in the OP's post though. It came across to me a bit like, be a good girl and do as you're told.

I can see that from the anaesthetist's point of view a protocol of not messing around when things start to go pear shaped and go straight for a CS seems a good rule of thumb.

Whether such advice is good for the individual woman, I have my doubts. A woman pregnant for the first time, will often go along with what she is told. It's often only subsequently that you realise that maybe that wasn't the best course of action for you.

I'm intrigued by this as I recently had a 2nd çs for prolonged rupture of membranes when I had been hoping for a VBAC. I was offered an induction but I turned it down as I didn't want to risk it going pear shaped. I did ask though if I could try the gel and if possible breaking my fore waters to see if that kicked things off but not have the drip and I was told that wasn't possible. Do you mean your friend said to say no to the drip being turned up or the drip all together. I know I could have just said I no longer gave them permission to put the drip in when we reached that stage but they didn't seem to think things would stay without it even though I was having some contractions. I do still wobder if I made the right decision but I was very scared of the idea of forcrps etc.

I think the thing with induction is a bit off. the risk associated with going past say 40 +12 don't start to really increase until about 43 or 44 weeks. At 42 weeks your risk of still birth is the same as prior to 37 weeks.

But you do need to always weigh up the options.

It's why if I was having an induction I wouldn't consent to ARM. ARM adds the risk of infection and places a really large time constraint on you. Lots of pressure to get things moving.

I refused augmentation with DS2. The consultant wanted to start the drip (which I thought was contraindicated with a previous section anyway) and I pointed out that I'd agreed to a trial of labour, which I'd had and could I have a section now please.
She agreed and after the section came to tell me it had been the right decision as he was 8lbs 8 (I'm 4ft 10) and he was in an awkward position.

thecircle - do consider it. It was expensive, but was the best money I ever spent. I was in tears if I sat for more than five minutes, now I only notice when I have a bad chair and have to sit a long time (such as airplanes). And even then it's just minor discomfort.

I even had DS2 a year later, with no similar complications!

I went to the Sayer Clinic in London, saw Michael Durtnall who specialised in coccyx. They also do sciatic pain, although I can't vouch for that because I didn't have trouble with it. If you can, I absolutely recommend it.

And if childcare is an issue, I just brought the DC along and the receptionist watched them!

I don't agree, and I'm pretty sure my dh (who is a GP but worked in 0&G) would back me up. Not that it's not right for some people, but it would certainly not have been right for me!

I never saw an anaesthetist in labour, not in any of them (3dc).

Labour1 - back to back from the start, augmented by drip and arm after 24 hours, ventouse delivery of a 9lb12oz dd after 37 hours.

Labour2 - perfectly straightforward 10hours, no interventions.

Labour3 - induced at 36+6, took 12 hours, it was very painful but by the time they were saying "epidural" I was saying "I need to push NOW!!" I'd only been 1cm after 7 hours, then 2cm for hours, then went 5 - 10 - delivery in 25 mins!

In both labours 1&3 your doctor friend would have had me down for an epidural then a cs. I'm very glad they had nothing to do with my care, because those three events are my hugest achievements, and I'm glad I was able to manage in the way I did.

I agree weegiemum, in anything to do with labour, blanket statements are unhelpful. DS1's labour was 53 hours and still ended in a section so when I got to 16 hours with DS2 and was still only 3cm, I'd had enough!

Seems reasonable...

I had an emergency Section but because I had been stuck at 9cm for 6 hours and my DD's head was bent it wouldn't go anywhere.

I had an epidural and it was quite easy and relaxed to just move to theatre... her heartrate was fine and everything was ok... in fact i walked home 2 days after the section

I agree, but I have a history of things going pear-shaped. If things are going wrong, I think most doctors would err towards medicalising and C-section. One reason for that is they will have seen the more calamitous outcomes that can happen when women refuse a C-section for days and it finally has to be done as a blue-light emergency. They will also have seen a lot of the after-effects of traumatic births - fistulas, horrendous tears, incontinence problems, chronic pain etc.

Most midwives wouldn't, but I think they tend to take a more "what does the woman want" view which is influenced by a backlash against the over-medicalised, patronising attitude to all births that used to exist.

It's a really difficult area because yes, as a woman going through labour and birth you should be listened to, but when women have ideas like only a natural birth will do and a C-section is some kind of failure, which a lot do, then that may actually work against a good outcome in some cases.

MarthaBear I agree with you. I have many years experience as a midwife, both with hospital and home births. Anaesthetists see very little in the way of normality in childbirth. Likewise Drs these days are generally only involved in higher risk births, not normal births, so tend to have a slightly distorted view of what a normal birth actually is.

FWIW I would much rather have my healthy babies and C-section scars when I know about some of the things that could have happened - babies being deprived of oxygen, forceps damage, serious tears, long-term damage to me.

I had a horrific labour and EMCS first time round, and was offered ELCS for the second. The consultant said "You obviously have big babies and problems giving birth" which I had no problem with because it is true. But when it came to it, I went into labour early and the midwives were all suggesting I try for a VBAC anyway, "you can always have forceps". No chance thanks very much.

There is a big divide between doctors and midwives in this.

Based on my personal experience I agree with your friend. I had a long latent phase (baby actually early), then no progress, hooked up to drip and epidural. I asked for a c section as I had been labouring for three days and was exhausted (and had an infection). I was refused. I asked over and over again and was refused.

It turned out that baby was stuck coming out forehead first. By which stage I'd had hours of being on the max dose of drip. So doctor prepped me for a section but decided (against my wishes) to try forceps and ventouse. It was horrendous. It took seven pulls (yes, I know that's over the limit but both DH and I counted), the ventouse popped off so back to forceps. I was left with significant blood loss, a third degree tear, baby had bruises on her shoulders and was very distressed, bruised coccyx for me. Almost five months later and I still cannot poo without pain.

I would have preferred a section but was refused. I now have pnd which I think was linked to the traumatic birth. What made it worse was that I repeatedly asked for a section when things started to go wrong but was refused and belittled. If you want a section, you need to push it from the start.

iloveyou I really hope you complained, that is a horrendous experience and one that you (and no one else) should ever suffer. It's assault if you did not give consent.

With the benefit of hindsight, that sounds sensible. I went into slow labour with DS1 at 11 days overdue. Labour was augmented (syntocinon / ARM), I had an epidural, it took hours to get to fully dilated, I pushed for 2 hours I was so bloody determined to get him out "myself", but eventually ended up in theatre. The attempted forceps delivery failed, and I had very emergency C-section as DS was in a lot of trouble (the c-section involved one doctor literally shoving DS back out of the birth canal while the other one pulled him out of my uterus). It was clearly all going that way from the point where my labour was doing nothing and I needed a drip. It would have been far less traumatic to have the C-section 12 hours earlier, for both baby and I.

OP every doctor we know would second your friends opinion. Sadly there appears to be something of a conspiracy theory about this on MN that manifests itself as a general belief that evil medics interfere for no reason purely for the pleasure of denying poor mothers the birth they want.... We have fetishised the idea of a natural birth to the point that people genuinely believe that options like induction aren't being offered on any real basis.

But then I'm probably one of those that drank the koolaid because I'm going for an elcs right from the word go...

Having worked in O&G and seen several births and some of the situations where sadly things do go wrong, and also seen the repairs women have to have afterwards, I would have to say you friend is spot on IMO. I would refuse an instrumental birth, and if there was any hint there would be any hiccups I would go for an epidural as it is much easier to do it early on than to get an epidural/spinal in in an emergency situation.

I am a junior doctor btw.

Minifingers - induction is offered according to increased risk of stillbirth and is evidence based. They do still happen unfortunately.

I agree with some of that, but not all. I'm answering assuming it is a first child, as there are obviously extra considerations if not (e.g. I would have been more keen on avoiding a section third time because of the difficulties it would pose caring for and doing the school run with the older ones).

I don't agree that induction is obviously being suggested for a reason. For example, different areas have policies of routine induction anywhere from 10 to 15 days 'over'. So, if you are in an area with 10, it is pretty random that they are suggesting induction at that point. And I disagreed with my dates, so was utterly sure I wouldn't be 14 days over when they thought I was.

On the induction, especially for a first baby I thought that a drip was needed a lot of the time. So I don't understand why you'd agree to induction, but not the drip. That seems odd to me - as opposed to pushing for a planned section at that stage if you want to avoid the drip. I probably do agree somewhat regarding instrumental delivery. I would have refused high forceps.

It also doesn't make sense to me that if you are induced by just ARM or pessary that automatically means early epidural whereas she recommends natural labour if things kick off on their own. Those are basically the same labour. Nothing against epidurals, but I don't understand that distinction. I would see if you need/want one in either case.

I also don't quite get 'induction sooner rather than later', as, as I understand it, induction is likely to go more smoothly the closer you are to going into labour naturally. Earlier inductions tend to be tougher.

So a lot I don't quite get about that advice really.

Anaesthetists will probably have seen plenty of births of all varieties during medical school and foundation training. Far more than the average lay person. And let's not forget they may have had a couple of births themselves.

I'm an anaesthetist. An obstetric anaesthetist at that (with a side helping of intensive care).

I have been involved in hundreds of normal births, some with epidurals and some without (because sometimes it's too late for an epidural and when my hand is being gripped in the vice like hand of someone pushing a baby out it's not that easy to excuse myself - besides, someone needs to give the im synto).

When I site epidurals, I pop back frequently during the labour to make sure they are working and to troubleshoot problems. All patients who have had any form of anaesthetic input get followed up the next day on the ward regardless of the type of delivery.

I agree with most of the OP. I wouldn't request an epidural as soon as possible however because it's perfectly possible to be induced, labour and deliver without one and epidurals come with their own risk of complications. I'd also be augmented with the drip - but then I'd want the epidural first. However I would refuse a forceps / instrumental delivery in favour of straight to CS for the reasons stated.

(DS1 - induction for prom, epidural after 24h of contractions had got me to 3-4cm prior to syntocinon drip, born 6h later by ventouse in room. Which made a straightforward vaginal delivery with DS2 more probable, and what I had).

Super, a voice of experience! Interesting to know, thanks.

Hazchem said, "I think the thing with induction is a bit off. the risk associated with going past say 40 +12 don't start to really increase until about 43 or 44 weeks. At 42 weeks your risk of still birth is the same as prior to 37 weeks."

That's really not true. The risk of stillbirth increases significantly the longer a pregnancy continues.

www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf

Look at Table 4.2:

In the UK, the risk of stillbirth at
39 weeks: 0.5/1000 (0.05%)
40 weeks: 0.9/1000 (0.09%)
41 weeks: 1.3/1000 (0.13%)
42 weeks: 1.6/1000 (0.16%)
43 weeks: 2.1/1000 (0.21%)

Also worth linking to this because someone else above thought that induction didn't reduce stillbirths.

Induction for post-dates reduces perinatal deaths and, less intuitively, reduces emergency sections.

www.ncbi.nlm.nih.gov/pubmed/22696345