40 + 10 and refused induction - given quite a hard time

[Elderberries]

Hello - I just wonder if anybody could tell me if I am being very foolish as the doctor today made me feel very bad for wanting to hold out till 40 + 14 to see if I could have a natural start to child birth.

I'm 37 and have a high BMI and I had borderline pre-eclampsia in my last pregnancy which was induced at 40 + 7.

This pregnancy I've had no problems.

The doctor said that the risks of still birth go up exponentially around 42 weeks and that I was risking still birth by not having the induction. I complained that I thought she was using over the top scare tactics because my reading of the stats was that risk of still birth was about 2-3 in 30,000 at 41 weeks and 6 or 7 in 30,000 at 42 weeks so it was a small risk that went up a bit. I also said that I only wanted to delay to + 14 days which was my understanding of the outside limit of a normal pregnancy and I was prepared to come in for daily monitoring (which is what they asked me to do). Anyway after making me feel awful about the whole thing she has booked me in for induction at + 13.

I am a bit unhappy by the treatment I got but I wonder if other people think I am being overly risky?

Is the risk of stillbirth in a normal pregnancy really 1 in 200? I had no idea it was so high .

Marvellous, another thing to worry about...

You make it sound like the GP was getting something out of this for himself. It is you and your baby's safety that he is trying ensure, why do you presume to know better ? It is not a them and us situation. I think you are indeed being very very foolish. I have a relative who had a healthy pregnancy up until 40 + 9, then gave birth to a dead baby in the back of an ambulance.

I can't understand why you would question your doctor's advice. They are speaking on behalf of your unborn child because he/she can't.

Compromise in the middle - agree to very regular check-ups for placental function during the time period and baby's health and use those to decide further action. The stats from the scans should indicate the health of baby and placenta (which don't all automatically begin to fail at 40 weeks, some fail much sooner, some pregnancies in previous times went healthy to 45 weeks) and give a more objective and personal approach that you seem to be after rather than the standard.

Both ways lies risks, the risks vary wildly depending on yourself as an individual and how either is done. A medical professional should be more willing to discuss it and come to agreement with you rather than hardline you, but many Trusts are quite "A=B is done" which makes going outside of standard quite difficult for many professionals. I've experienced that lately with medicine during this pregnancy when a medicine was recommended for me (even though I no longer have the condition that I got it for in a previous pregnancy and it almost killed me last time). All he could say after trying to find someone else to ask is that's the recommendation so he'd have to put it down and I'd have to fight against it later.

Ladies - can we cool it with the suggestions that the OP must put up and shut up. It's her body and her baby and going over 40 + 10 does not make a stillbirth inevitable - or even the most likely outcome.
Of course she should question her doctor - as is all our right. The stillbirth rate in this country is apalling high imo - 17 babies a day are still born or die in the first weeks of life. However we will not lower that number by ordering pregnant women to do as they're told. I believe that it is the majority of IUDs that are unexplained by medical science not the minority. Doing as your doctor says is no guarantee of anything unforntuately.

Hi Elderberries. I think you're being perfectly reasonable and I would probably do the same- in fact I've already said so to my midwife. You've obviously done the research. Some thoughts:

People, including medical professionals, seem to forget that 40 weeks is the mean duration of a pregnancy. But if you look at the stats, it is skewed by the fact that many do give birth prematurely whilst, at the other end of the bell curve, almost no-one is allowed to go over 14 days "late".

The most common time for babies to be born (the mode) is actually 40 weeks plus 3 days and even then there will be a normal distribution around that figure.

If you lived in Italy, your due date would be given as 10 days later than it is in the UK. Putting you spot on as far as an Italian due date is concerned. They don't have a massively inflated risk of stillbirth.

The age/gestation of your baby is an ESTIMATE. They don't know exactly when it was conceived in the first place (in the majority of cases) so it may not be at all overdue even by UK classification.

If you have an induction, the chances are significantly higher that you will have a Csection which carries extra risks to you and the baby (albeit small ones but the risks of going overdue are small also).

Also, you have been checked to ensure nothing is obviously wrong. As far as anyone can tell, you don't have PE or a deteriorating placenta so in my mind there's no harm in baby staying a little longer.

All that's left to say is I hope it hurries up for you! I'm due in 9 days and getting impatient myself. Hope it all goes well when it finally happens.

"It just happens that the doctor took such a hard line with me that she got the opposite reaction to the one she intended."

With all due respect, this sounds incredibly immature and silly - you seem to perceive the situation as a power struggle and seem to feel you somehow "won" something.

As someone pointed out before, I find it hard to believe this doctor has an ulterior motive or agenda, other than protect you and act as an advocate for your unborn child.

Having said that, it's your decision and I wish you best of luck!

My husband has just been doing some reading of academic abstracts on studies on this area on the internet (not saying that is at all superior to being a medical expert BTW) and it seems there is a very slight benefit to induction over expectant management after 41 weeks but it is not that clear cut. Regular monitoring shows a slight increase in section rates as compared to induction but no increase in mortality according to a recent overview study apparently.

Northernlurker - yes some placenta fail - that is the thing that stops me thinking I will just keep going with the pregnancy beyond 14 days like some people do but I bit of me wishes I was brave enough to do this. Last time I just lay there with wires coming out of me feeling no part of anything. It was like other people were driving me. I was allergic to the epidural and ended up itchy all over. Baby got distressed half way through and they had to slow everything down - but I did push him out in the end. Anyway I hated it but I saw that it was necessary with the pre-eclampsia. This time as I seem to be healthy and the baby seems to be healthy I think 4 more days seem reasonable.

The trace they did today was described by the midwife as 'perfect' - baby was bouncing round all over the place and did everything they wanted. If I go in every day between now and Friday I just don't understand where the huge risk is - which is what the doctor seemed to be implying to me.

Many years ago I was birth partner for my oldest friend, who at just 17 refused to be induced at all, she gave birth one day shy of 44 weeks to a rather overcooked looking 11lb baby boy.

All was fine.

Just thought I would add a positive story.

If you don't want to be induced, then don't go in at 40+13.

Yes - some babies die when they are 'overdue' - some are stillborn at 38 weeks, but we don't induce everyone at 37 weeks just in case.

Induction carries it's own risks to both you and the baby, and as long as you are prepared to have monitoring then I don't see the issue. If a problem is picked up, you could consent to EMCS in order to get the baby out immediately, which is quicker than induction.

I was induced with DD1 at 40+14. Yes, she was healthy, but the problems that I incurred have made me regret my decision. I am now 11w with DC2, and have already made my wishes clear that I will NOT accept induction this time round, even if I go to 40+14 again. If baby needs to come out now as there is a medical problem, I will only agree to CS.

I don't know if you've heard of the Ten Month Mamas - they have a facebook page which might have some useful links.

I cook mine for longer too, and refused induction with the first. She was 40 + 17 and perfect. 2nd time round I asked to be induced at 40&12 out of impatience and regret it. Horrible labour - much worse than 1st time due to the prostin pains, and a high forceps delivery with a rather unhappy baby at the end of it. I think he just needed another day or two. It's a very difficult decision, and I absolutely understand why people would choose induction, but I do believe that some women just take a little bit longer to bake babies. Currently preg with no3, and will be doing the daily monitoring thing this time if it gets to that point. Good Luck.

Thanks Flissaps. I'll take a look. I think everybody has to do what they think is right with the information they have available.

PoppyAmex perhaps I do seem silly - maybe I am. I don't think the doctor had any ulterior motives but I do find that the doctors at my local hospital are not used to being challenged and asked to tell me why one approach is better than another. I read nice guidlines and I talked to midwives and thought about things a lot before I went to talk to the doctors. Anyway I do respect doctors but I don't think they are god, I think I can ask questions and challenge them. History is full of medical mistakes in the field of maternity and also changes in practice. I don't just assume they are right in everything they say....I want them to explain why they are right in a way I can understand. So that if things go right or wrong I can feel I did my best.

I think it's sad that we are just expected to accept the doctors word as law, it your body and your baby, whatever happened to informed consent. Some placentas do start to fail around 40 weeks, others fail much much earlier. If this was a knee-jerk reaction then I'd counsel you to do your research and see if you still feel the same but having already done so then you are more than entitled to go ahead as you wish without anyone saying you are stupid. There are risks associated with everything, only you can weigh up which ones are acceptable to you.

Just for clarity, 1/200 babies are stillborn in the UK - that includes all babies who are born without sign of life at a gestation of greater than 24 weeks. It is NOT saying that if you have an otherwise healthy pregnancy at 40+ weeks you have a 1/200 chance that your baby will die.

I completely agree that decisions such as this should not be a "them vs us" scenario. However, from personal experience the attitude of the nicest HCP's can change dramatically if you have audacity to question their dictate recommendation. Its hard to have a meaningful conversation re. risks and options to try and agree a plan of care when your HCP's treat you like a naughty 5 year old who can't possibly understand the issues or have an opinion, and make sure you can't demonstrate to the contrary by talking over you for 10 minutes solid . Unless you are prepared to roll over and do what you're told, it can be very hard to not wind up in an adversarial situation - however much you might appreciate the knowledge and input of an experienced consultant if provided as part of a mutually respectful discussion.

(Sorry - just getting a bit carried away with my own personal experience there, but it seems to have quite a lot in common with Elderberries).

As for "the Drs are only acting in the best interests of you and your baby", I disagree. IMO obstetrics in the UK has become a lot more litigious over the last decade or two, making most obstetricians practice a lot more defensively. Its much easier to defend action than inaction in a post-dates scenario - that doesn't mean it action is lower risk or in the best interest of any individual mother/baby combination. Doctors will also be influenced by their own personal experience, and by the experience of the colleagues - they are still human, after all. However, personal experience doesn't equate to evidence based practice.

Many women seem happy to take the advice they are given and not question it - and that's fine. For me, as a woman that wants to be able to ask questions and understand, coming up against a HCP that would rather hold an argument by intimidation than by engaging in a rational discussion tends to alienate me - especially when I know damn well that they're lying to my face and relying on bluster and scaremongering to try and make me agree to their preferred course of action...

Elderberries - if all your instincts are telling you that things are fine and you're having regular monitoring then what you are suggesting doesn't sound at all unreasonable to me. No, its not without risk - but you know that any course of action has risks. If you feel the risk/benefit profile of expectant management is better for you and your family at this time then why would you not do it?

However, if you do wind up being induced it doesn't have to turn into a nightmare scenario - DD1 arrived spontaneously at 41+3, with DD2 I had to be induced at 36 wks following an IUD (due to my ill health rather than any placental problems). I was dreading the induction as I felt that at 36 weeks it had the potential to be a massive ordeal involving every possible chemical and intervention. As it turned out, I needed 2 doses of prostin gel and that was enough to kick off a naturally progressive labour - I didn't need a drip, I didn't need an epidural (or other chemical pain relief), I didn't need forceps and once labour started properly it took

Thanks Tangle. Great post. You have just said everything that I have been feeling but would not have expressed nearly as well. All this has roiled me up so much I'm not sure I am going to get to sleep any time soon.

No induction doesn't have to be a nightmare but at my hospital they seem to proceed to a drip fairly quickly after the gel (in my experience). Different places seem to do things very differently. I'm not clear why.

I do hope I go into natural labour over the next couple of days but I can't see any sign of it happening.

Lots of shagging needed!

I would take the experts' advice personally and trust that after their training and experience, they know more about childbirth than you.

Notlettingthefearshow - The op knows her body and she, not the medical professional, says what will happen to it.

So why come on am Internet forum then and ask the advice of complete strangers? Stop trying to police the thread. She asked for people's opinions, whatever they may be.

Notlettingthefearshow, if the op was at the hospital in which I work the very same consultants would be telling her that waiting until t+14 was not only safe but best practice. It's important to realise consultants as much as any other staff are constrained by guidelines and it is up to them how they interpret them.

notlettingthefearshow - its also possible that right here, right now, Elderberries and her DH have a more detailed knowledge of the research around the risks of continuing the pregnancy than the consultant that she spoke to, if only because they seem to have been doing a lot of digging and reading and have immediate cause to have assimilated and retained that information until such time as their baby arrives.

Towards the end of my A-levels my maths teacher commented that what struck him most when he graduated was how the degree course had opened his mind to what a small percentage of the information regarding his field he'd actually learnt (and how many other fields there were still under the banner of "maths" of which he knew nothing). I have great respect for consultants, but I think its a lesson that some of them could with being reminded of occasionally!

Elderberries - I had my first run in with a registrar 4 1/2 yrs ago when DD1 was breech and, having been told we would booked for an ECV and if that failed a CS, we then asked what the alternatives were if we declined. To be fair she was prepared to talk about it, although she was more or less quoting guidelines at us. Since then I've met a few more, and its quite sad that the more senior they've become the less inclined they've been to discuss things. All in all, its a subject I've given far too much thought to!

Re. induction, your hospital may tend to proceed to a drip quite quickly but you don't have to accept it if you don't want to. I'm guessing you've got the NICE guidelines on induction already - if you've got the energy and inclination it might be worth seeing if you can turn up any hospital specific guidelines with a quick google and see how things vary. Then take them to the Head of Midwifery/Consultant MW and ask them to explain why they take a more aggressive approach. A significant percentage of women seem to find that the senior MWs are much more open about things than their consultant colleagues - you may well be able to agree an induction plan with the midwifery team that you feel is more pragmatic (and having the signature of the HoM on the bottom should give it a fair amount of clout if its needed). Sorry - I'm speculating now... I know for some women going through the steps to get that in place would be more stress and hassle than it was worth, but for others it might be a process that gives away out from pressure. Feel free to ignore at will

Elderberries, I'm sorry you feel unhappy about your care. You say you work in statistics and your husband has been searching scientific abstracts and from that I think you would like clear information about risks etc?

I found this article which is from 2008, is quite detailed and appears fair:
Induction of Labour and Perinatal Outcome in Post-term Pregnancy

It doesn't go into maternal risk factors other than the gestational age i.e does not discuss any effect of maternal age etc. (Latter comment made with me being currently age 42 and in late pregnancy, so not a comment on you!)

Hope all goes well for you.

Also, Cochrane Review dated 2006 on Induction of labour for improving birth outcomes for women at or beyond term

Suspect this may be one of the papers your DH found, but in case not... Again this is for all-comers with no sub-grouping of potentially riskier patient groups.

Abstract below (my bolding)

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 to awaiting spontaneous labour or later induction of labour.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2006). We updated this search on 14 July 2009 and added the results to the awaiting classification section.

Selection criteria
Randomized controlled trials conducted in women at or beyond term. The eligible trials were those comparing a policy of labour induction to a policy of awaiting spontaneous onset of labour. Trials comparing cervical ripening methods, membrane stripping/sweeping or nipple stimulation without any commitment to delivery within a certain time were excluded.

Data collection and analysis
Two review authors independently evaluated potentially eligible trials and extracted data. Outcomes are analysed in two main categories: gestational age and cervix status.

Main results
We included 19 trials reporting on 7984 women. A policy of labour induction at 41 completed weeks or beyond was associated with fewer (all-cause) perinatal deaths (1/2986 versus 9/2953; relative risk (RR) 0.30; 95% confidence interval (CI) 0.09 to 0.99). The risk difference is 0.00 (95% CI 0.01 to 0.00). If deaths due to congenital abnormality are excluded, no deaths remain in the labour induction group and seven deaths remain in the no-induction group. There was no evidence of a statistically significant difference in the risk of caesarean section (RR 0.92; 95% CI 0.76 to 1.12; RR 0.97; 95% CI 0.72 to 1.31) for women induced at 41 and 42 completed weeks respectively. Women induced at 37 to 40 completed weeks were less likely to have a caesarean section than those in the expectant management group (RR 0.58; 95% CI 0.34 to 0.99). There were fewer babies with meconium aspiration syndrome (41+: RR 0.29; 95% CI 0.12 to 0.68, four trials, 1325 women; 42+: RR 0.66; 95% CI 0.24 to 1.81, two trials, 388 women).

Authors' conclusions
A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.

[Note: The 10 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]