Tuesday, August 25, 2009

Overdue Babies and Threatened Induction

As I mentioned in my last post, this time last year I was in my 41st week of pregnancy and hoping beyond hope that my baby would arrive before I was under pressure to be induced. As anyone who has gone over 40 weeks will know, the phone calls from family and friends start on the due date and do not stop until the baby put in an appearance.

I felt, just like any first time mother does, that my baby was never coming. I just knew I was going to be pregnant for ever. The mental leap from pregnancy to motherhood was just too big for my brain to cope with. Birth was a black hole that loomed ahead of me and sucked all thoughts of the future into its depths.

I was booked to have a home birth and idea of going into hospital to be induced absolutely petrified me. I had got myself into the right mental space to cope with birth at home and I felt certain that if I ended up in hospital I would find it vastly more difficult. So I did what I always do: jumped on the internet to reseach overdue pregnancies.

The Home Birth Reference Site is an invaluable source of evidence-based information on pregnancy and birth, whether you plan to give birth in hospital or at home. It has a brilliant page on postdates pregnancies, and here are the main points that helped me to decide what to do if I went overdue by more than 10 days or so:

* The death rate for apparently "normal" babies (with no congenital abnormalities) doubles after 42 weeks from 1 in 1000 babies to 2 in 1000.

* We are often told that beyond 42 weeks, the ageing placenta cannot deliver enough oxygen and nutrients to the baby. This sometimes happens, and sometimes does not. Research is unfortunately thin on the ground. Many people have had healthy babies after 43 and 44 week pregnancies.

* Most 42 + week pregnancies have just been dated wrong; very few accurately dated pregnancies go on for this long.

* Your body may be delaying labour for a good reason. The baby might be badly positioned for birth, for example. Sometimes we just have to trust that mother nature knows what she is doing.

* You do not have to undergo induction of labour unless you want to. Like any medical procedure, it is offered and you are free to refuse. Furthermore, the date of induction is negotiable. In the UK, induction is usually offered at 10 days or 12 days overdue, despite the fact that the "normal" length of pregnancy is anything from 38 to 42 weeks. You can delay or refuse induction if you so choose.

* The UK's National Institute of Clinical Excellence says that after 42 weeks you should be offered an ultrasound examination and twice weekly checks of the baby's heart rate.

* You can still have a home birth after 42 weeks. Your midwives might be happy to support it, or they might be reluctant. If you are really stubborn, you can insist on staying at home when you finally do go into labour. Nobody can force you to go into hospital.

* You are much more likely to have meconium in your waters when your baby is overdue. This is often enough for a mimdwife to recommend a transfer from home to hospital. But if you are overdue, it is not necessarily a cause for alarm. An experienced midwife should be able to judge the colour and thickness of the liquor and decide whether or not to recommend a transfer. This is what happened to me, and my midwife kept me at home. I am eternally grateful to her.

So here is what actually happened to me. I went to the antenatal clinic for my 41 week appointment and was offered induction. I refused it, totally flummoxing the midwife, who then called for a consultant to reason with the mad pregnant woman. The consultant was straight with me and, after discussion, accepted my wishes to avoid induction and agreed to monitor me if I should go beyond 42 weeks. A senior community midwife then came to talk to me as well and told me that they would support my desire for a home birth beyond 42 weeks. Hooray! This made me feel a whole lot better about things.

My bravery in the antenatal clinic turned out to be unecessary in the end because after two "vigorous" membrane sweeps at the aforementioned 41 week appointment, I went into labour and delivered my baby 42 hours later. The membrane sweeps felt a bit odd and uncomfortable, but I think by that stage of pregnancy I was ready to experience a bit of pain, and if it was going to help me to go into labour then I was all for it (and if you are contemplating having a membrane sweep then I would say that it is absolutely nothing to worry about). I do have a feeling that I would have gone into labour without the sweeps as I had begun to feel "twinges" prior to my appointment. I also wonder if my prolonged pre-labour was caused by the intervention. But I will never know the answers to these questions and I don't really care because I was fortunate enough to have a straightforward labour and home birth and I was blessed with a healthy baby.

I think the main thing to remember if you do go overdue is that induction is not inevitable, and is not necessarily the best thing for your baby. You always have options and if you present your views with enough conviction, medical professionals will have to listen to you.


Joe said...

Great post. This high induction rate goes hand-in-hand with the high c-section rate - both are often unnecessary and overused. I guess in the doctor's point-of-view, in the case of overdue induction anyway, they don't want to be liable if anything goes wrong and they haven't offered it. But that should be it - offered. I have a cousin who recently (well, last June) had her baby, and 2 weeks BEFORE her due date, she was already talking about the "deadline" date "that the doctor said" she would be induced. I knew it wouldn't go well if I opened my mouth (some people you just KNOW it's better to say nada), so I said nada. Sure enough, she had a c-section.

I am thinking about the possibility of a home birth next time around, so thanks for the link!

willow81 said...

I was in a similar situation to you before Monkey was born, planning a homebirth, TERRIFIED of induction/intervention. I had absolutely convinced myself that I was going to be in an overdue/induction scenario. My midwife visited at 40+4, said the baby wasn't engaged, posterior, she would *definitely* be seeing me in a few days time... 6 hours later I began contracting and babe was born the next morning. We did end up having to transfer after an hour of pushing, but it was absolutely the best thing as I had to have surgery afterwards and the babe had pneumonia. The AIMS booklet about induction is very good.

carol b said...

This is such a great post full of really great information.
I was 43 when my daughter was born and under immense pressure from my midwife from about half way through the pregnancy with regards to induction...she was quite convinced I'd have no choice given my age to go even a day overdue.
Luckily I was strong enough to hold my ground, - absolute conviction that nothing was going to go wrong coming from a strong spiritual bond with my as yet unborn baby - and a second midwife supported my choice. My girl was born at 40 + 4 which according to my dates was bang on time.

cartside said...

Thanks for the post. It definitely will make me post too, I went to 14 days over when labour started and Cubling was born 15 days over. I was offered induction before due date because I was unwell. I declined. It was very hard to do so because you feel so vulnerable and you're inclined to think the obs must know better. HOwever, the obs made clear that he offered to do me a favour, not for any medical reason. Once I declined, I was monitored twice to three times weekly from 41 weeks and left alone. I then chose to be induced at 15 days over (because of the increased risk of stillbirth after 42 weeks) but labour kicked in before. My hospital was great, they really respected my choice to wait.

Interestingly, I had an early scan in Germany and my due date from that scan was 4 days later, so maybe I was only 11 days over. It just shows that dating isn't an exact science.

Having seen my sil induced and end up with a c-section when labour stalled after 3 hours, all I can say that it looked like baby wasn't ready and that the only thing that could have avoided a c-section would have been waiting for labour to start naturally. Of course, that's a what if and I may be wrong.

Jessica said...

Awesome info. I'm going to send this link to my sister who's due in November.

I was pregnant for 42 weeks (I knew within a few days of when I got pregnant) and had a midwife who wasn't worried about it one bit.

Since I'm Caucasian, her theory was that my ancestors are from the Nordic region of the globe (which, at least reviewing the last few generations that I know of is absolutely true) and women from this region typically have longer gestation periods so as to plump the baby up. An extra two weeks inutero, she explained, could mean the difference between life or death if born mid-winter, for example. An evolutionary advantage, so to speak.

I've never researched this, but I trust her due diligence.

I did have high levels of meconium that worried her and so we did move to the hospital. Everything ended up being great even in the hospital. Having her there made all the difference, I think, too.

allgrownup said...

My cousin gave birth to her second baby last week at 41+5. She didn't tell any family or friends her actual due date, as last time she went over and felt so harrassed. (She just said baby due September time). She ended up hiring a private midwife (luckily they can afford it) as her NHS midwife was not supportive. She gave birth to a very healthy 10 lb 13 boy after 90mins of labour, at home, planned that way. My brother in law lives in Japan, where women are told gestation is 42 weeks, so very few go overdue, and it's no big deal. Why can't we have that??

Cave Mother said...

Such great comments. They would have made me feel a lot better a year ago when I was worrying about being overdue! Sorry I haven't got time to reply to them all. But so true about induction/intervention/c-section rates being linked - I think this is what terrified me most about it. And Jessica, I'm honoured that you passed it on to your sister :)

Lisa - edenwild said...

I wish I had had the 40-week "deadline"! I was high-risk and my deadline WAS 38 weeks, but since I was doing well they pushed it back to 39 weeks. I was heavily pressured into an induction and it was a nightmare.

But if anyone is interested in "encouraging" labor to start, there is hypnosis, chiropractic, massage, acupressure/acupuncture that all work with the body to help align everything so that one's body is "ready to go." So to speak (you still won't go into labor until the time is right). Even stress can hold the baby in--anger, anxiety, etc.

docwitch said...

Great post. And oh yes - this is very familiar to me. I went to 42 weeks with no signs of imminent labour, and despite an ultrasound showing a very healthy, oxegenated placenta, I was heavily pressured, even bullied into having an induction, (which makes for a hellish labour as many are aware). I was told that if I didn't my baby would "probably die".

When my daughter finally arrived, the midwives noted that she was very healthy, but only just full term. And she still had a fair bit of lunago hair on her. I then later find out that virtually every baby in my family decides to come along at about 43 weeks of their own volition.

If I hadn't felt so vulnerable I would have resisted, and challenged a lot of things along the way, but there you go.

Amanda said...

Fantastic post with great info! It always amazes me that when due dates are such a guessing game anyway, how "the institution" can get so wigged out about "overdue" babies.

Mamma Po said...

This day four years ago, I was in labour with my daughter - at 24 days overdue!!! I was a true 10 Month Mama!

As my first baby, I suspected she'd be late but when 2 weeks past my due date came and went I did start to get a bit nervous. I had to fight tooth and nail with the medical staff to hold my ground - they told me I was wildly irresponsible to refuse induction - and think I became a bit of a local talking point! Obviously I did all the usual - pineapples, curry, bumpy drives, long walks (and, yes, even THAT) but nothing. 3.5 weeks late, I finally started contracting...and contracting and contracting. Sadly, my planned home birth didn't pan out. After 3 days of labour and only 3 cm dilation, Daughter was born by emergency C-section.

It was glorious, of course, to finally meet my darling baby but even now I find the memory of that awful surgery deeply traumatic and wonder why the A-listers choose to have their babies like that.

2 years later, my son was born in a blueprint fashion but only 10 days late. Guess some people are just slow-cookers. I didn't have the births I wanted (clearly some design fault inside me) but automatic inductions is not the way to better births.

Cave Mother said...

Mamma Po - Wow, a 10 month mama. You must be a rare breed. I can only imagine how big you must have been. I'm sorry you didn't get the births you wanted, but I'm glad that you did what you thought was right regarding refusing induction. I bet your baby needed that extra month inside!

Anonymous said...

Midwife speaking here.......! Our policy is for 12 - 14 days before medical induction, with 'stretch and sweep' x 2 offered at 41 weeks (48 hours between sweeps). As you say the research is not massive on this but research will often be stopped if it can be seen that there are adverse events and this may be the reason why. A problem with the fact that some babies will be fine going 42 weeks plus whilst others an only cope with term is that it is difficult to know for sure which will and which won't, and if they don't ten the consequences an be tragic. My manager, when verbally slapping my wrists, always says 'it was normal in retrospect'. I hate it when she says that...but unfortunately there are times when she is right.
Meconium, difficult one as post-dates babes do pass it naturally due to maturity BUT whether due to age or distress it is still meconium and if they aspirate it will still cause problems.
Can't remember if you mentioned the effect increased maturity will have on the ability of the skull bones to mould and overlap, basically it reduces the ability so larger diameters passing through the pelvis.
Now the advocate of waiting.....scans are over-rated in terms of estimating size and gestation. Induction is an intervention, it changes 'normality' to medicalised and so increases the likelihood of further intervenion, epidural, assisted birth, c-section.

Cave Mother said...

Thanks for taking the time to write that comment, midwifemuse. It is good to hear what a midwife thinks about this. And I didn't know about the skull bones hardening - probably a fact that critics of induction keep to themselves!

Laras Mama said...

Very true, I went to 41 weeks. I had been threatened with an induction at 41+3 and I was NOT going to let that mean doctor anywhere near me - especially after he steam rolled me into an induction form. Luckily castor oil worked and I went into labour and gave birth with a great midwife in just four hours.

Anonymous said...

Really struggling with this concept: Pregnant for the second time and had a rather difficult delivery with the first - marred by the whole "how long is too long to wait" debate. Went 15 days over and after 3 attempts at induction; 45 hours and lots of stress, my cervix looked "like someone who was not pregnant" i.e. longated, posterior, 0% effaced and 0 cm dilated. So off to C-Section. Although I have high hopes for a VBAC the OBGYN I saw today (who specialises in VBACS) said in her 15 year experience she has only had 2 situations like mine where they could not get the body to respond. So lingering questions again--- perhaps I need 42 weeks? But am I ready to endure 15 days over; 45 hours of labour and then a C-Section with resulting complications (allergic to morphine I found out!). A lot of mentions here to being offered a sweep, but as I understand, they can only do a sweep if your cervix is in the right position and softened - so this was never even an option for me. Such stress and all for a normal part of life that I don;t want to medicalize...

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