Inducing labor - more common then it was?

Factual Questions
1

A co-worker’s wife is pregnant and fast approaching her due date. In talking to him, he mentioned that the doctor wants to schedule a date to induce labor, if she doesn’t go into labor on her own by then.

It seems I’ve heard that from several people over the past few years. Doctor says your due date is about September 1, and then sets up a plan for inducing not much after that.

Is this all about convenience? Is there an actual medical reason to do this? Does the date that the doctor really override the date that the body/baby want?

2

There is good evidence that babies don’t do so well if they go more than 14 days overdue. In the UK for example there is a specific Guideline (pdf) from our National Institute of Clinical Evidence for induction of labour.

The most relevant paragraph for your purposes is this one:
“Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. The exact timing should take into account the woman’s preferences and local circumstances.”

As ultrasound scanning and pregnancy testing have got more accurate we can now date pregnancies more accurately than 20, 30 or 40 years ago. When you accurately know the dates, you no longer have the luxury of sitting on you hands and waiting for a few more days “just in case she’s really not due for another week”.

As we can more easily pinpoint the due date, so too we can more accurately pinpoint the latest date by which labour should be induced. As this guideline states, that date is somewhere between 7 days late and 14 days late (or 41 and 42 weeks of gestation), allowing for the maximum chance of a natural onset of labour and delivery and the minimum chance of health problems for baby caused by post maturity.

3

If you had a choice of performing a particular job at 1:00 pm a week from Thursday, or performing it at an unknown time of the day or night on an unknown date, which would you choose?

In no way am I saying that it’s right that doctors are doing this more and more often when it’s not strictly necessary, but when you look at it that way it’s no shocker that they do it.

4

There are medical reasons to induce labor as it approaches the due date. Babies who are left in too long are at higher risk of getting stuck due to large size, as well as putting their mothers at risk for later-pregnancy complications like preeclampsia.

That’s not to say induction is always done for those reasons. It can also be done to make schedules easier and to put more women delivering during daytime hours, when medical staff is cheaper.

Yes, it’s done more often now than it was in the past. The induction rate in the US doubled from 1990 to 1998, and about 25% of those were found to have “no apparent medical indication”.

Any further discussion of whether or not this is a good thing is going to get this moved to Great Debates, I’m sure. :wink:

5

I forgot to mention what the risks of post maturity are! :smack:

As the pregnancy progresses past term there is less amniotic fluid in the womb, the placenta may also struggle to keep up with baby’s needs and baby may start to use up its stores of glucose.

Mum also has to deliver a bigger baby and stay pregnant for longer.

So risks for baby include increased risk of:
foetal distress, intrauterine hypoxia, birth asphyxiation, traumatic delivery, shoulder dystocia, intrauterine death, oligohydraminos (lack of amniotic fluid), meconium aspiration and intra-uterine growth restriction due to placental insufficiency.

Risks for mum include increased rates of:
difficult labour and operative delivery ( remember some babies are late because they just weren’t going to come out that way!), pelvic trauma, bleeding and blood clots.

More stuff here and here.

Hal, I do have to say that it is a bit of a fallacy to state that an induction gives complete control and predictability to the doctor. It doesn’t.

It can take 12 hours for labour to start from the induction process beginning, and another 12 hours before you know whether things are going the right way…
You could still end up doing a forceps delivery or a crash c-section at 4 am after 14 hours of induced labour, or a crash section because baby no likee the induction drugs, or everything goes swimmingly and mum has a lovely natural birth at 5am, only to bleed heavily from a retained placenta…

An elective c-section will give you some control and predictability, an induction of labour, really not so much.

I’d really rather have someone walk through the door 6cm dilated and have their baby naturally with a midwife present and me in my bed than spend 12 hours titrating up their oxytocin, breaking their waters, monitoring their baby for distress and eventually having to deliver it with forceps at 1am!

6

I was induced with both pregnancies. For the first, my water broke, but I wasn’t showing any signs of labor after 6 hours. For the second, the doctor let me go a week beyond the due date and then induced because she felt the baby was getting too big. (He was 9.5 pounds and so long that he had to have PT for torticollis from being wedged in there–and I’m not a small person.)

7

About three months ago my wife was induced on the morning of her due date. (Our “appointment” was at 5:00 on Saturday morning; our kid popped out at 12:48 Sunday afternoon.)

Reasons given by her OB were that (1) the baby was on the big side; and (2) the amniotic fluid volume was dropping. Both of these (possibly combined with my wife’s “elderly” state - she’s 36) had multiple doctors agreeing with the decision not to let the baby hang around in there longer than necessary.

8

I would amend this to say that there are medical reasons to induce labor once the due date has passed. (Well, actually there are medical reasons to induce labor prior to the due date, but not for a normal, uncomplicated pregnancy.)

9

There are doctors who consider a large estimated size medical reason to induce *before *the due date. (And I’m really, really working hard not to get debatey here!)

10

Unfortunately for the OBG, inductiones don’t go like clockwork. My wife was induced starting at 6:00 AM then delivered at !:00 AM the next day. They came in and broke her water at 2:00PM. It is not horribly uncommon for inductions to go for several days if there is no progress. I assume though in those circumstances, the water wasn’t broken.

11

Stupid question here, but what did they do in the ‘old days’ when a baby was too big and wasn’t being born? Did mother and baby both just die in that case?

12

There are some herbal remedies that midwives and doctors used which can cause uterine contractions and bring on labor. “Squaw-” vine, weed or plant may refer to a dozen different plants native to the US, but often was the local solution to a stalled or not starting labor. Blue Cohosh (Caulophylum thalictroides) is a good one; I usually combine it with Black Cohosh (Cimicifuga racemosa) in low doses for the last two weeks of pregnancy as a mild uterine tonic, and then when the due date hits and Mom is begging to deliver, up her dose until labor is well established. Acupuncture can also be useful, and has been around a few thousand years. But yeah, some babies and mothers died, as they still do today. But in general there was more of a “wait and see” approach, since due dates were considered both more flexible and harder to calculate before ultrasounds.

Remember also that we’re talking about women who were, on average, in better physical condition due to harder daily work and more exercise than women get today. Obesity and sedentary lifestyles are not good for maternal health or easy labors. Few babies are actually too big for the pelvic outlet, but sometimes modern mothers are just too exhausted (and modern doctors too worried) to keep going after a prolonged labor. Back when a c-section meant likely maternal death (either from bleeding or from infection), it wasn’t turned to nearly so quickly. Now that it’s relatively safe, it’s used much more often.

13

Obstructed labour is still relatively common in some populations where a sedentray lifestyle and maternal obesity aren’t major issues. Ethiopia being a case in point- there, child marriage and malnutition lead to a small pelvis and obstructed labour.

Modern doctors, unfortunately are often more worried because they have more information- an acidotic foetal scalp pH or a worrying CTG (heart tracing). If you know you’re facing 50% odds of foetal hypoxic brain damage because of a poor trace or you have an already hypoxic and acidotic foetus, you don’t hang about.

Modern babies are really big.
The average weight in the UK is now about 8lbs for a term baby. That’s 2lbs heavier than 100 years ago, or a 30% size increase. Pelvises, in contrast aren’t 30% bigger, on average, than they were 100 years ago.

samm- back in the day there were 3 options for obstructed labor.

  1. Do nothing- everybody dies
  2. C-section to save baby (mum probably dies)
  3. Do what veterinarians do- dismember the foetus with a cutting wire and deliver it in pieces (mum might live)

That was the type of situation where someone asked husbands to “make a choice”.

14

Hah, it never occurred to me that early inducing might have been indicated in my case. Certainly I would have been one of the cases where we just died from exhaustion in the old days. My first was over 10 lbs., which would have been OK if that was the only factor (I’ve got solid peasant hips), but she was also facing the wrong way. I think she was so squished that she couldn’t flip over. Anyway, she just bounced off my pelvic bone for 24 hours and never descended at all. Her face seemed to have done most of the bouncing. By the time they got her out with a c-section, we were both in some trouble from exhaustion.

My second baby was born by planned c-section 10 days early, and she was over 9 pounds. One of the biggest placentas they’d ever seen, the staff all exclaimed. I’m so proud.

Now I’m wondering if an induction before my due date would have allowed me to give birth in the usual way. Oh well, doesn’t matter much now.

15

In my case, the birthwaters were black, which the matron told Mom meant they were rotting; I had hypoxia, needed an adrenaline shot at one point because my heart had stopped beating, the delivery took just shy of 24h, and in general it’s amazing I didn’t come out yelling even louder. Fun! The underlined part just can’t be stressed enough :frowning:

I think another factor is that we have better means, not just to know whether Mom can or can’t count (mine could, it was the Ob who couldn’t), but also to induce the birth. This is just a WAG, as I have no idea what methods were available 40 years ago (when that Ob realized he’d been miscounting all along, tried to induce and failed) and nowadays, but even if it’s the same compounds, there’s probably better delivery methods.

16

I feel it would be inappropriate not to point out, maternal death in delivery is only a tiny fraction of what it was 50-100 years ago. Between improvements in drugs, surgical techniques, fluid replacement, and major improvements in neonatal respiratory care moms and or non malformed babies dying in deliveries is a huge deal.

17

Depends on your definition of ‘old days’. I had my daughter 32 years ago. It was much harder to be sure of the due date or what was going on inside the womb. The policy then was to let the first child go to term - whatever that was - but second on was induced if gone beyond 2 weeks over the estimated date. I probably wouldn’t have been left go to term these days - my daughter had not moved much at all and went head down ten weeks before delivery. No kicks at all, and bleeding during the pregnancy so I was confined to bed for months.

Out came a really healthy baby, nearly 8 lbs, long finger nails, smooth skin and slept through from the start. And she stayed that easy!