A justification for induction? High pulsality index (PI) in umbilical artery (UA)

[Bob2017]

Hi there, Looking for thoughts/experience of my situation.

I am 41 yo, 37 weeks, first baby. All has been fine through this pregnancy. However, at last scan (37 weeks) the pulsality index (PI) in the umbilical artery (UA) was found to be sitting right on the 95th percentile which is apparently right on the borderline of being outside of "normal" range.

For this reason they are going to scan again next week and already tell me I should anticipate being induced early.

While I am not keen on being induced, I will take their advice if I can see enough justification for it (i.e. I'm not totally against being induced in due course). But from all I have read they are suggesting induction for a singular small "sign" of possible placental insufficiency. Apart from this borderline UA PI, my blood pressure is fine, no protein in urine, the baby is and has been growing fine (has continuously been on the small side of the normal range), the baby's heart sounds good, the baby moves around lots, etc.

Induction would occur at 38/39 weeks if we went ahead. I just find it hard - and have been reading quite a bit - to see enough reason for this induction (also knowing the tendency towards more inductions generally).

I am inclined to ask them for increased monitoring.

Anyone have experience of this? Thanks in advance!

I've twice been induced due to high umbilical PI, both times at 38 weeks.

As you say, it's one small indicator that something could be amiss, but an indicator it is. DD1 was completely unaffected by it - had a scan at 4pm, was immediately admitted and induced the next day. DD2, however, was affected and her growth stalled.

Thanks for responding. So for you as well that was the only indicator leading to advised induction? Sorry to hear DD2 was affected - do you mean in the womb or after?

Thanks for responding. So for you as well that was the only indicator leading to advised induction? Sorry to hear DD2 was affected - do you mean in the womb or after?

I suffered in both pregnancies with high blood pressure, although it was well controlled, so not 'active' as such.

DD2 was affected in the womb. Her growth had pretty much stopped and she was only 5lb when born. They anticipated she may be small, but not quite that small. They were ready for her to need extra support when she was born, however she was perfectly healthy - just small.

Entirely up to you of course but at 37 weeks, your baby is already full term, and at age 41 with a first baby, you are in a high-risk category. Any additional concern about the placenta or cord would scare the socks off me. Technology for monitoring foetal wellbeing in the womb is not perfect and can only tell you what is happening right now on the scan, not what might happen tomorrow. Of course your baby may well be fine waiting for spontaneous labour but what are the benefits to outweigh the risks of waiting?

Having had both my babies born with very non-eventful safe and healthy inductions for separate medical reasons, I wouldn't hesitate to agree to induction if I were you. I very strongly dislike the pressure in our culture to put 'natural birth' on a pedestal above all else and I think there is lots of scaremongering about inductions and other interventions in the name of natural.

If you are unsure and still have concerns, can you request an additional appointment to speak with a consultant and go through your options again? You say your preference is for additional monitoring instead - you should ask a lot of detail about what the monitoring involves and what its limits are, and how quickly a problem with the placenta could effect the foetus. But really, they are experts who are highly trained and experienced and are recommending what they believe is the best course of action for your baby. I am not trying to say we should all blindly agree "doctor knows best" in every circumstances but in a case like this, where you are privileged to have access to the best medical technology for scans at 37 weeks, why would you not use that information and the expert opinion on it to take the action recommended?

I have twins and since 20 weeks they were concerned about this with one of the babies and he was also growing more slowly as a result. I had scans monthly and then eventually ended up with them twice a week from around 30 weeks. The results fluctuated, one scan would be fine, the next would be high, so they booked me in for induction at 36 weeks. I didn't make it that far though as was induced and gave birth via Caesarean eventually due to preeclampsia. The baby was born gripping his umbilical cord which had caused the blood flow to change. During my pregnancy I asked many times what the significance of the readings were and I never really did get a straight answer: one of the sonographers said it was basically a test they're obliged to do, that they have a set range of criteria and she didn't really understand why they do it!

I should add that the baby was born at 4lbs7 oz whilst his brother was born at 5lbs12oz so a significant difference as a result. If they're concerned I would say you should agree to the induction. Mine wasn't so bad, the Caesarean was required for unrelated reasons.

I was coming to say exactly what sycamore said. You are full term already. Any issues with cord or placenta, I will not hesitate to even have a section there and then. In fact at 37 weeks due to cord issues I did have a section there and then. The alternative is unimaginable. I have seen the alternative with friends and it's not something I will wish for anyone.

Placental failure is a major cause of stillbirth, and the rates are higher when the mother is over 40.

They're planning to re-scan in a week, by which time you will be indubitably at term.

It will be your choice if you do not consent to early delivery. But do think (and I mean really, really imagine it) about why they recommend it when the early signs of placental failure are detected. Not everyone is lucky enough to get a warning sign in time to do something about it.

Much appreciate all of your inputs and has given me valuable food for thought.

I am 29, both my pregnancies resulted in induced labour for different medical reasons. I had plenty of medical reasoning to be induced and my Dr's still left it as long as they felt they could safely to induce. I don't think that they splash induction around willingly, they would much rather everyone went naturally. If they are actually outright offering you induction they must feel they have medical justification to and that in itself would make me think "Ok, it's probably smart to play it safe and listen to the Dr". I hope whatever happens you and baby are ok and baby makes it here safe and sound

I would ask them to explain the statistical risks that are increased by the finding (i.e. not just that a risk is 'doubled' but what the risk actually is), explain any risks the induction also has, and really just chat all your concerns through with a supervisor of midwives or similar, possibly with the consultant present. When they are able to give evidence for their recommendation it often feels easier to make judgements about what you would like to happen. BTW I have had a fabulous induction (midwife broke waters, I went for a walk and baby born 90 minutes later!) so it really can be okay and your wishes can be respected in lots of ways in the context of an induction - mine were, by and large.

The thing is, signs of the placenta not working as well as it should are small, and incomplete.

The definite, absolute signs occur when the placenta has failed.

I'd take the minor signs, when you're at or near term, and thank whatever God you believe in , that there was some symptom, before the placenta failed.

I went past 42 weeks so ended up with the farce that is expectant monitoring. It was honestly the most stressful 5 days of my life, and I had no risk factors at all other than dates.

I had no confidence in the expectant monitoring given various issues with appointments and lack of urgency, and I also had constant badgering regarding induction and dead babies (literally this was the conversation with my consultant).

Don't do it, would be my advice. Placental insufficiency is extremely poorly understood and hard to predict.

Semaphorically, sorry you mean your advice is not to go expectant management?

Yes, if I did it again I would avoid expectant management. I didn't feel safe at all. They told me that I wasn't doing what policy said I should do and that from "a medico-legal point of view" the consequences would be mine to bear.