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.

The point is that I don't think any consultant would advocate induction at 37 weeks just to the statistical risk of stillbirth, therefore why advocate it at 42 weeks.

And as with every single decision made in pregnancy, it should be that of the expectant mothers with informed consent, not dictated at all. And I know too many consultants who automatically say "you are risking your child dying" by going past 40 weeks (I've had this), which is scaremongering.

IMO, there is a middle ground where induction isn't the automatic choice, but mums are kept informed and managed if that's what they then choose.

Statistically though that's not true (in terms of dates and the risk of stillbirth). The risk is the same and it's safer inbetween. Minuscule though and better managed with more scans and uterine dopplers.

The thing is, if a baby has a failing placenta, then induction and labour isn't really safe anyway. Hence the need for the extra checks regardless. And those extra checks would show if baby was still happy and safe in the uterus.

Also I believe that most trusts induce at 40+10/12 which is not 42 weeks either. And the risk only starts increasing after 42 weeks (again only according to statistics).

As an experienced midwife I see plenty of women who have a induction who cope fine without an epidural.

I don't think that planting the seed in a woman's head that if she has an induction then she'll need an epidural is helpful. Of course she may feel she needs one and if she does that's fine. Plenty of women do. But on an individual basis a woman won't know until she's in that situation. However if a "high ranking" dr ha told her to have one she's more likely to feel she needs one I'd have thought.

I also see plenty of women who have the syntocinon drip who proceed to a normal vaginal birth. I'd wager they're glad they didnt ask for a lscs at the first mention of the drip. And a Dr on a labour ward should know that putting your foot down mid labour and insisting on a lscs is unlikely to get you one unless there's a medical need. Such decisions aren't up to the anaesthetist, its up to the obstetrician who is likely to say no ime.

I didn't say that the risk only increases after 42 weeks, just that it is at this point when the risk is higher than 37 weeks. I'll try and find my evidence to confirm that.

I'm also not advocating an induction at 37 weeks, rather I'm not advocating any sort of automatic induction purely based on dates alone. I have known too many women have to fight against induction at an already difficult time, just because they have reached an estimated date not always compatible with their own dates.

The risk is managed better, as if late term scans (32, 36, 40 weeks) are introduced, it would show any loss of growth, and a uterine Doppler shows the blood flow through the placenta which would help to identify how it's still functioning. Plus there needs to be a greater focus on kick counting and movement awareness in this country.

Having said all that. I would choose expectant management to a point that I was comfortable with, (while not anticipating anything other than information from my medical team, rather than scaremongering and lack of choices), at which point I would go on to have an induction when I felt ready. I would accept a foleys catheter, pessary, drip, and ARM. I would go to a CS before using instruments.

But I have done loads of research into birth choices, and I have experienced it all going wrong therefore I believe I will always choose baby's safety over birth method. I think not all women are as lucky to be so informed as some consultants can be very difficult. I have also come across some mothers (vbac) who seem determined to put birth method above all else, not believing that in 21st century uk we could lose a baby through childbirth.

"The risk is managed better, as if late term scans (32, 36, 40 weeks) are introduced, it would show any loss of growth, and a uterine Doppler shows the blood flow through the placenta which would help to identify how it's still functioning."

I'd be interested if you have any evidence for this as I am not aware that there is any at the moment.

I mentioned the POPS study in Cambridge earlier which might answer some of these questions, but doctors/midwives have to work on actual evidence, which currently states that induction for post-dates after 41 weeks reduces stillbirth. The "scaremongering" is based on scientific research and statistics.

There is a funny idea of Mumsnet that doctors and midwives just want to interfere for the sake of it. It is because they think it is safer (based on that research) for mother and/or baby (depending on when and why they are advising a particular intervention). It would be far easier for them to let everything happen naturally but that would have a significant cost in terms of lives and damage to mothers and babies.

I would agree with most of this, except agreeing to induction. I would go for a natural birth, including refusing inductions and waiting for labour to start naturally - but I agree with refusing any intervention such as drips to speed up etc, and would go straight for the c-section in case of any complications during labour. This is exactly what I had in my birth plan, and infact what happened. I always knew I would refuse instrumental delivery, and therefore decided to refuse any intervention that might lead me in that direction. I laboured at home and then in a MLU but when things stopped progressing at 8cm and they transferred me to hospital as they wanted to put me on the drip to speed up contractions I refused and opted instead to go straight to C-section. It was calm and a lovely experience and most importantly I was in control of my own birth.

I don't think it's a funny idea. If you look at the sort of things that were happening to birthing women that lead to formation of the NCT and other bodies there has been a long history of unnecessary medical interference with birth and not all of that is based on evidence.
The Friedman curvy for instance is one tool that is used to managed labour. part of the evidence that the curve is based on 96% of the mothers being sedated including many in twilight sleep. The Friedman tool is still in us int he developed world.
So no I don't think it's a funny idea that women question what doctors and midwives are telling us. It's part of trying to be informed so we can actually consent.

Dino - I don't, this is based on entirely anecdotal evidence, however it often forms the basis of the plans for keeping rainbow babies safe (again anecdotal) which makes me wonder why (other than cost) it isn't the standard.

I don't disagree that induction reduces stillbirth, I just wonder if there is a better way (management) to try before taking that route. As of course, not all babies which are inducted post dates would have been stillborn.

As you say, the research needs to be done.

As for doctors (not midwives) wanting to interfere for the sake of it, I can only go off my own personal experiences, which is that the consultants over medicalised all my pregnancies and birth experiences (induction at 36 weeks for my rainbow) without it being necessary. At the time I had neither the information nor courage to request something different.

Induced not inducted!

DinoSnores - it depends what is meant by scaremongering. Presenting facts isn't, 'playing the dead baby card is'. This is speaking as one who was told 'well, if you don't care for your baby', by a very junior doctor when I dared to question her.

Such comments are completely unacceptable.

I'm not against induction btw!

With this baby (3rd, 2nd rainbow) I'm trying for a vbac and want to be 'allowed' (hah!) to go full term. When I told the consultant I didn't want an elective section at 38 weeks, he replied "so you want to risk your baby's life".

Some are like that, and it's disgusting.

There are complex reasons for stillbirth risks and these need to be explained better to women.

I know for example that when I come off anti-coagulants prior to giving birth, my placenta will start to be compromised after a while, certainly earlier than normal women. For me, therefore, it is extremely risky to go 'overdue'. Raw statistics don't show these variables.
Junior Doctors who explain things glibly or guilt-trip women without thinking further muddy the waters.
When I explain my scenario to non HCP they sometimes cannot understand, because in their mind there's a straightforward healthy window for all and I'm risking myself and a 'medical birth judge judge judge by agreeing to induction or C section 'early'.

Agree completely Squiz.

I think because there is a fear that consultants over medicalise birth unnecessarily too, that some parents take it too far the other way and disbelieve them when sometimes, the medical route is the only safe option.

There needs to be a greater trust in the consultants that they are giving correct information and making suggestions truly for our benefit, so that when things like early c sections are offered, we know it's the right thing to do.

Yes, squizy, I agree about a fear of medics. I know many women on here have had difficult times and did not trust their hcp's - but in general, I find it hard to believe that the majority of doctors and midwives aren't making decisions for their patient's benefit. They won't be advising an early CS because they think they might be bored next Tuesday, or an induction at 42w because they are worried the ward will start looking a little empty.

I'm not saying that overall policy shouldn't be challenged in some areas, or that a patient also shouldn't be allowed their own say in their treatment. But the negativity some people have towards hcp's involved in birth is hugely surprising to me.

I think part of the problem is that most women will engage with quite a range of HCPs during a pregnancy. Even if only 1 in 20 is a bit rubbish in some way, if you meet around 10 HCPs during the pregnancy and delivery (that's pretty conservative. I reckon I far exceeded that with DD1: off the top of my head about 5 different antenatal midwives, 2 sonographers, 4 midwives, consultant who dropped by on ward rounds, registrar, anaesthetist, paediatrician, and that's excluding many peripheral people and a straightforward forceps delivery) you have quite a chance of encountering them and that encounter sticking with you.

I also think that there is a lot of protocol in birth. For example, both I and a friend had our due dates brought forward at the scan when we knew it would have needed to be immaculate conception for the change to be correct. My MW was massively supportive when I said I would not agree induction at +14, because I knew it was absolute max +9 and I would want to allow another few days. My friend was guilted to the max about dead babies and agreed to an induction she didn't really want at +10. It was hospital policy and that was that. I don't deny that the hospital thought that they were doing it for her benefit and her baby's safety, but they weren't responsive to personal circumstances. I think that's where a lot of the distrust creeps in.

"DinoSnores - it depends what is meant by scaremongering. Presenting facts isn't, 'playing the dead baby card is'. "

The risk of going post-dates, which is why induction is offered, is "a dead baby" sadly. That isn't scaremongering.

"Raw statistics don't show these variables."

Indeed, which is why population-based stats need to be used alongside the individual patient data. The problem is that with things like induction for post-dates, it is impossible to say whether Baby A would have been fine until 44 weeks or if Baby B would have been fine if induced at 40+10 rather than a bad outcome at 40+11.

In my own case, following the stillbirth of DC2, I had a lot of scans with DC3. These scans picked up an issue so my consultant suggested an induction at 39 weeks. DC3 was completely fine. So does that mean that induction saved her or wasn't necessary? If I hadn't had the scans, the issue wouldn't have been picked up but would it have caused any problems?

It is impossible to know for individuals which is why these big studies are done to look at big populations. When making policies, doctors need to look at the evidence based on populations to make their recommendations. The plural of anecdote is not data.

Penguins it's a tricky one... I guess HCP would get the flipside... they see many, many patients. It's likely a small amount can't count or believe something odd on google or are doing something unhealthy. So how does the HCP do their best without making prejudiced assumptions - many might feel protocol is the only way.

So for your loss Dino.

I think LaVolcan was really referring to HCPs who act like any delay in induction has the inevitable result of a stillbirth. It is one thing to explain that stillbirth increases after 42 weeks, preferably also by explaining the absolute risk for proper consent. By 'the dead baby card' I would think of things friends have been told like "If you wait until day 16 there is a serious risk your baby will die" (not really accurate since the absolute risk remains very low and the increase in risk is gradual, it doesn't magically double on day 14) and frankly more emotive comments like "You can't put your birth experience over the life of your baby". Yes, I've heard of people told these types of things (though I may not have them word perfect).

Squizita - Yes, but that isn't how we work with healthcare is it? We require consent, even if it is a bonkers decision (short of sectioning) we give people autonomy over their bodies.

I think in part it is an overstretched system. My MW knew me, knew my history, I'd explained my views on my dates from the 12 week scan onwards. My friend was dealing with a rota of Me's.

I was really referring to the sort of language being used - with slithytove's example being worse than mine. How is saying 'So you want to risk your baby's life?' anything other than emotional blackmail and how does it contribute to the woman giving informed consent?