MNHQ here: new NICE advice recommending induction at 41 weeks - what do you think?

[RowanMumsnet]

Hello

NICE has today published a new guideline on the use of induction in labour, and one of the changes they're making is to recommend that induction should be undertaken one week earlier than has previously been advised.

NICE says (bolding added by MNHQ):

"Inducing women in labour earlier than previously advised will make birth safer for them and their babies, according to draft guidelines published by NICE today (25 May 2021). The updated recommendations strengthen previous advice in the light of new evidence on induction timings."

"The draft guideline, an update of the 2008 version, recommends that women with uncomplicated singleton pregnancies should be offered induction at 41 weeks and the induction should take place as soon as possible. Previous guidelines advised induction between 41 and 42 weeks, and that women who had chosen not to be induced should be monitored after 42 weeks. If women choose not to have induced labour their decision should be supported and their care options discussed with them."

"Recent research which compared induction times and outcomes showed higher infant mortality after 42 weeks if the woman had not been induced."

You can read the full draft guideline [https://www.nice.org.uk/guidance/indevelopment/gid-ng10082/consultation/html-content here]]

We're being asked by the media what you all think about this - so do let us know - we know induction is a topic that concerns a lot of you.

Thanks
MNHQ

I technically had this due to circumstances I was experiencing. As babies are typically getting bigger, it's definitely better for the health and welfare of both baby and mother.

I was induced and it’s pretty awful. It leads to the cascade of intervention - more chance of instrumental delivery and c-section.

The false hormones from the hormone drip cause harder, faster contractions that in my case gave my baby fetal distress and resulted in EMCS.

I’d love to know the stats on infant mortality beyond 41 and 42 weeks compared to the risks for women of being induced. It would be interesting to hear how a baby’s chances improve by being induced early, compared to how a woman might receive significant damage (either to her vagina or surrounding organs or the damage done by c section).

I don’t think enough consideration is placed on the damage done to women’s bodies by inductions and instrumental delivery. If inductions earlier result in reduced infant mortality, that’s the right thing to do. But additional help and support should be available to women to make it the best experience possible and to deal with any birth damage.

I've been induced with 3 out of 4 so far.

1st aged 21, 42wks. Awful experience, back to back, 3rd degree tear and episiotomy and minor pph. This caused the most damage to my pelvic floor and rectocele.

2nd at 30 was my only spontaneous labour at 41+3 So would have been offered induction under these new guidelines.

3rd aged 31, 42 wk induction, great bishop score so waters were broken and she was born 2hrs later.

4th (age 40) was induced at 40wks due to size. He was predicted to be over 5kg if left to his own devices. Not such an easy birth as 3 and needed drip and therefore epidural again but not awful like 1. Like DC1 the drip caused me to contact 6 x in 10min, no break at all.

5th is due in 2.5wks, aged 41. My trust has booked me to be induced bang on 41wks due to my age.

Things I would have liked to see in the guidance is more information on older mothers and the risk of prolonged pregnancy for them.

My trust say 41wks for the over 40s. But weren't concerned with my 4th until he was huge and would have let me go to 42wks, because I was only a few weeks over 40. Whereas the neighbouring county offers from 40wks. Who is right? It makes me feel anxious tbh that it differs according to area.

Also regarding sweeps and subsequent pregnancies, they should be offered at 39wks to all mothers not just FTM (unless I've read wrong!) Some of us 2/3/4/5 timers don't go any earlier with subsequent pregnancies and maybe sweeps earlier would help.

I also think letting women know and understand their bishops score would help. I might have made different choices with DD1 had I had any information, same with dc4.

Took them an age to get the epidural done and then find a dr for the inevitable interventions which was dreadful for me & the baby. I was in a nappy for six months from tearing and scarring. Induction is often unbearably painful and needs to have the people on standby to administer the correct treatment ASAP.

@inthekitchensink this is very true. It's acknowledged in the document that induction is likely to be more painful.

Dc3 I wanted an epidural but none was available. Luckily she was only a 2hr labour and didnt need drip etc but neither the MW or I knew that at the point they told me I couldnt have one.

Dc4 I refused the drip until I had an epidural in, but that meant waiting from about 4pm until 11pm for the aneathetist to become available. Which was fine, I wasn't in pain, but luckily having been through drip first with DC1 I knew not to let them near me without an epidural again.

Delivery at 41 weeks will save babies' lives - I'm really pleased. But PPs make valid points about how inductons can be stressful and traumatic, especially if adequate pain relief isn't in place - so I suspect this should be accompanied by an increase in maternity unit staffing (especially anaanaesthetics) in order to work well...

Controversially, I wonder if ELCS should be offered to women who aren't labouring naturally at 41 weeks and who are nervous about induction.

I'm not sure.

My first was induced at 42 weeks, he eventually arrived at 42+2. He was absolutely perfect, placenta was healthy and he was 8.5lb so not massive either for my dates.

Some babies just need longer than others. I wouldn't recommend unnessary induction. It's an unpleasant thing to go through and massively increases your risks of intervention.

Have the antenatal units got the capacity to deal with all these additional inductions? What about obsteric theatres as your more likely to require a visit to theatre from an induction.

It seems like an awful lot more intervention and medicalisation of a very natural process.

@StoneColdBitch i agree re sections.

I've had 3 subsequent vaginal births after dd1s birth but actually my body was just not ready with her and she was in a back to back position. We were taken to theatre, ex scrubbed for c section etc, which was scary. She was ventoused out and as I say i was left with a 3rd degree tear and episiotomy and minor pph. The tear itself healed ok but I've lasting pelvic floor issues and a rectocele.

I think if the body is really unready, or just maternal choice then that should be an option.

1st son,induced at 42 weeks.

Born with skin peeling off(least of the problems).
Meconium in waters, trouble in keeping temperature and sugar levels stable.
5 points in APGAR scale when born.
Difficult to establish breast feeding as body not ready.

I’m glad I consented to induction.

2nd son, spontaneous labour at 41 weeks,everything was fine.

In my case waiting beyond 42 weeks with 1st baby could have had disastrous outcome.

Each case should be treated individually and mothers going beyond the EDD informed of the choices and possible outcomes.

I've only had one but was induced just after 40 weeks due to being aged 40. Pessary did absolutely nothing. Ended up being on the drop for 18 hours of agony, stuck on the bed and unable to move as they insisted on constant monitoring. Had an epidural after 8 hours. Baby eventually delivered with ventouse for her and episiotomy for me - she had ended up with the cord wrapped round her neck twice. I was completely out of it by this stage.

If I were to do it again I would refuse early induction.

I've no problem with them offering induction one week earlier. But induction is seldom just offered, quite often when a women isn't keen then the behaviour from some healthcare professionals becomes downright coercive.

I almost think it's irrelevant. Virtually every mum I know who got to her due date was offered induction. Everyone who was offered felt pressured to accept so it wasn't really a free choice - threats of dead babies etc. This change just reinforces that

If they want more women to agree to inductions there needs to be more support and pain relief available for women while they are undergoing them.

I'm not sure how I feel about this. Ultimately it should mean better outcomes for babies (if I've understood correctly) but induction can be much more traumatic for mothers.

I have so many friends who had difficult or traumatic births and it really affected their mental health in many cases, I hope that if more women are going to be induced then the NHS is prepared to provide them with the support they need after the birth.

I would certainly want to understand the impact of a planned c section v an induction at 41 weeks on women - particularly around tears and later continence issues as i assume the outcomes for babies would be similar.
For any women reading this who are about to be induced and feeling scared from these experiences- it is a personal experience and for me, my induction at 35 weeks was better managed and caused less issues than the natural birth i had. I know this isnt the case for everone and i do not wish to minimise others experiences. I had good healthcare, an epidural and no ventouse or episiotomy on that occassion.

I absolutely agree that women should also be fully informed of their choices and offered an ELCS if they have a low bishop score and induction is unlikely to be successful.

My cervix was 0cm dilated, still high and far back and I had an EMCS thanks to fetal distress and “failure to progress”. I wish I’d have known I could have opted for the section in the first place and avoided 40 hours of labour.

Also the term “failure to progress” should be put in the bin.

I have three children and had my first induction 11 days ago with my son. I was 41w 6d. As far as inductions go (and I was absolutely dreading having one done) it went well. I had a pessary put in at 1.40pm. Had some on and off pains later on in the evening but nothing to talk home about. My waters broke on their own at 10.30pm and my son was born without any intervention at 11.57pm - a very quick 1hr 27mins labour.

Agree with PPs. Of course this should be recommended if the outcome would mean less stillbirths.

But there must be support and adequate medical care for mothers that are induced. I was left with continence issues and a rectocele after my induction. I wish to god c section had been offered and for me that would have been better than 4 day induction, stitches breakdown, infections and being readmitted, 2 years of physio and DD going into special care and also being readmitted. My injuries were due to inadequate post natal care, felt like no one cared.

Comparing the risks to mum of induction versus the risks to baby of pregnancy going beyond 41 weeks is like comparing apples and... Boeing 747s. It’s a horrible decision to be faced with and with this new guidance many more women will be asked to decide. This means we need more data readily available to women. I also think that ELCS should be a central part of this conversation, as well as immediate and adequate pain relief for any and all labouring mothers.

I had one straightforward spontaneous birth, one induced at 42 weeks which only required the pessary then was also straightforward and uncomplicated. I’m very glad I opted for the induction second time round but I think the birth was so straightforward because I was very ready to give birth - 1 week earlier I may not have been. Also my spontaneous birth was at 41+1 so I honestly do think I cook babies slightly longer than average (she was only 7lbs 6 so not huge). If I’d have consented to induction it would’ve been totally unnecessary.

I can only imagine this new guidance will make women who decline induction subject to even more paternalistic and scaremongering bullshit.

The due date calculated at my scan was not correct. I told them there was no way that it was right. I know when I ovulated. I'd have had to have conceived before ovulated for their revised date to be right. Plus my husband has an extremely long torso and short legs (so it's not surprising that his baby - who is pretty much his mini me - might have a rump to crown measurement that is longer than someone with more even proportions). The measurements at scans are no so accurate nor are foetuses so uniform that they can date pregnancies to the day.

In addition, every single woman in my family has long pregnancies. My mother and her brother were born at 42 weeks. I was born at 42 weeks. My sister was. My other kids were born at 42 weeks. My sister's kids were too. Some people do just gestate babies for longer. So it's not a surprise that I got to what they thought was 42 weeks (but my dates would have said were earlier) and there was no labour.

I had an extremely stressful 8 hours in the hospital (alone, because of bloody covid) with obstetricians and midwives trying to scare me with talk of 'dead babies' into an induction I knew I didn't need. They pretty much forced me to agree to daily monitoring. During the daily monitoring, I actually felt the baby turn himself around and around and around inside me because they make you lie back in such an uncomfortable and unhelpful position for this.

When I finally went into labour I ended up with an EMCS (very close to a general anaesthetic) because the baby had the chord wrapped around his neck several times. If they'd actually listened to me, and given some thought to the actual margins for error in the dates they were working from plus the clear pattern in my own and my family obstetric history, I'm pretty certain I'd have had much less stress at the end of pregnancy and I sincerely doubt we'd have needed the EMCS (at 9cm dilated when they gave me the spinal anaesthetic). He was the smallest of my babies and showed no signs whatsoever of being late.

Throughout the entire process I was treated like a silly little girl who just wouldn't do what was told, rather than a 39 year old who had actually researched and thought about it. For some reason all the working with people and seeing them as bringing expertise to the table to goes out of the window in maternity care once they start talking about induction.

"Offered" or bullied/emotionally blackmailed into consenting to? So many women are told they have to have an induction or their baby might die, rather than having the risks of both courses of action explained to them in a factual and unemotional way. I also believe very strongly that the choice should be offered between induction or C-section. So many inductions end in sections anyway, but 2 or three days down the line when the mother is exhausted and often in severe pain. I would choose a section over an induction every time, having experienced both.

Fishy so much of your post resonates with my experience. I also knew my dates were at least 1 week out but no-one was prepared to take my word for it, despite me being able to show on the calendar the only time we'd had sex in 4 weeks.

I would never be induced again.

I had it at 40 weeks and after 3 days of intervention that caused me pain and distress as well as to my baby it didn't work. I was still 1cm dilated at the end of it and so decided to book in a c section at 41 weeks and hope he'd come beforehand.

He didn't come and I had the c section, my doctor said he would have never have come naturally as he was so high up (they had to use forceps even in my c section) and the midwives who done the induction should have known that when undertaking sweeps.

They wanted to put a balloon in after 3 days of nothing and I point blank refused.

He came by c section and good job it was at 41 weeks as he had pooed the meconium was still in me when they got him out luckily he hadn't swallowed any but he would have done if he was in there until 42 weeks.

I'm happy for the recommendation to be made on the basis that it is more likely to result in lower risks for the baby however it would be nice if additional funding and resources were put into supporting the mother for pain relief and potential problems caused by inductions.

I was induced by a drip and couldn't get into a good position to give birth due to being connected to the monitors. A longer cable would have been a start!

Fortunately I had a good experience and the staff and care I received were great however I have heard of others that have not had such a good experience due to busy wards and a lack of resources. I hope NICE have considered this.