Don’t let them induce you

Midwives are always yammering on about “evidence-based practice”.  This little catch-phrase seems to over-ride common sense and clinical experience.  If the evidence sounds fishy and doesn’t support patience and kindness towards pregnant women and unborn babies, be very sceptical about whose evidence it really is.

This is an expose of the poor “science” that started the induction epidemic back in the 1990s. Women continue to be induced to this day despite the publication of this article.  Gloria

Routine induction of labour at 41 weeks gestation: nonsensus consensus

BJOG: An International Journal of Obstetrics and Gynaecology Vol: 109 Issue: 5pp: 485-491 PII: S1470032802010042. Copyright © 2002 RCOG All rights reserved..
Savas M. Menticoglou, Philip F. HallDepartment of Obstetrics, Gynaecology and Reproductive Sciences, University of Manitoba, Winnipeg , Canada. Accepted 16 2002

Article Outline:

1. Introduction
2. What are the true fetal and neonatal risks of reaching 41 weeks of gestation?
3. What are the maternal risks of reaching 41 weeks of gestation?
4. Resource consequences of a policy of routine induction at 41 weeks of gestation
5. Inevitable, unintended and undesirable consequences of routine induction at 41 weeks
6. Conclusion
References
* * * * *
“Falsehood flies and the truth comes limping after; so that when men come to be undeceived it is too late: the jest is over and the tale has had its effect.” Jonathan Swift, The Examiner, No. 15, November 9, 1710

1. Introduction

Traditionally pregnancy has been considered ‘post-term’ at 42 completed weeks of gestation. At this gestation, if the cervix is unfavourable, debate over best practice has been between routine induction of labour and expectant management with some form of serial fetal monitoring.
Popular wisdom seems to be that meta-analysis of the available randomised controlled trials has settled the question in favour of routine induction[ 1 ]. The largest included trial, containing over half the cases ( n = 3407), was carried out in Canada and published in 1992[ 2 ]. The results of the meta-analysis led the Society of Obstetricians and Gynaecologists of Canada (SOGC) to issue Clinical Practice Guidelines in 1997[ 3 ]. The guidelines recommended that:


1.     after 41 completed weeks of gestation, if the dates are certain, women should be offered elective delivery;
2.     if the cervix is unfavourable, ripening should be undertaken; and
3.     if expectant management is chosen, assessment of fetal health should be initiated.
              
It is presumed that randomised controlled trials or, even better, meta-analyses of randomised trials, provide the best evidence to determine appropriate care. However, once information has been declared ‘the best available evidence’, particularly if that assertion is used to justify clinical practice guidelines or ‘consensus’, further inquiry may be inhibited[ 4 ].
Since it is implied that ‘the answers are all in’, mutation from clinical practice guideline to standard of care is prompt and uncomplicated, particularly if the labels ‘consensus’ or ‘policy statement’ are used between the two as conceptual mutagens. The standard of care in Canada now is assumed to be routine induction at 41 weeks. This commentary is intended to give pause to those who have accepted and adopted this standard.
              

              

2. What are the true fetal and neonatal risks of reaching 41 weeks of gestation?

The SOGC Clinical Practice Guidelines assert that “women who reach 41 weeks should be counselled appropriately regarding the higher risk…to their babies if they should pursue a policy of expectant management”[ 3 ]. How large is this purported higher risk, and what is the strength of evidence used to support this assertion?
The following information comes from studies conducted before 1992 when ’41 weeks undelivered’ had not been categorised as vigorously as a time of higher risk. In that era, intervention by induction for gestation only was not routine practice, and fetal surveillance because the pregnancy was undelivered at 41 weeks of gestation was not used.
Such evidence does not describe the natural history of all pregnancies that would have reached 41 weeks without intervention. Women with identified maternal or fetal complications such as pregnancy-induced hypertension, other medical problems, or suspected fetal growth restriction likely would have been delivered sooner, and women with favourable cervices might have been induced, but the situation of the remainder would have been similar to that of women eligible for the Canadian study.
Based on data from New York City (1987-1989)[ 5 ], Japan (1989-1992)[ 6 ], Sweden (1982-1991)[ 7 ], and London (1989-1991)[ 8 ], the risk of stillbirth in the subsequent week to women undelivered at the beginning of their 41st week (41 weeks zero days) is about 0.1% (1.04-1.27 per 1000) – (Table: [ 1]. Similar estimates were presented in reports from New Zealand (1983-1986)[ 9 ] and England (1978-1985)[ 10 ]. The stillbirth rate in the expectant arm of the Canadian study was similar at two fetal deaths in 1700 women (1.18 per 1000)[ 2 ].
Table 1: Stillbirth risk in following week per 1000 undelivered women at beginning of week. (6.49 KB) [unavailable]
These estimates are contemporary with the Canadian trial and are consistent, as they are with the situation contemporary to the Canadian study at one Winnipeg tertiary obstetric hospital – (Table: [ 2]. In the latter setting, from 1982-1991, induction for gestation only was not routine and fetal surveillance for post-term pregnancy was not begun until 42 weeks. Of 7725 pregnancies that reached 41 weeks undelivered, eight stillbirths occurred in the next week, and there were three neonatal deaths- two from disseminated herpes, one from birth asphyxia- in babies born between 41 weeks zero days and 41 weeks six days.
Table 2: Women’s Hospital, Winnipeg 1982-1991. Exclusions:
1) Transferred from other institution with fetus already dead in utero;
2) No prenatal care before gravida arriving with dead fetus;
3) Fetus known to have died before 36 weeks;
4) Principal cause of death related to congenital anomaly. (8.85 KB)
The authors of the Canadian study suggested that, were it not for their fetal monitoring, perinatal mortality would have been higher than two babies in 1700 (1.18 per 1000).
However, evidence from six countries (one being Canada) suggests that, as of a decade ago, when such monitoring was not done for gestation alone, the stillbirth rate in the subsequent week was about one in 1000 and approximately 1000 inductions would have been necessary at 41 weeks to prevent one stillbirth in the ensuing week, presuming cause and effect relationship between that death and gestational age.
Since serial fetal assessment is now common in our setting, in part in defence against implications of the SOGC Clinical Practice Guidelines, most significant perinatal complications have been identified and dealt with by delivery before 41 weeks, and the odds of stillbirth in the following week likely have been further reduced.
What of the meta-analysis[ 1 ] which claims to demonstrate that “routine induction of labour after 41 weeks reduces perinatal death”? Meta-analysis attempts to describe what happened, but not why. As retrospective assessment, inevitably such efforts are subject not only to what happened in the past, but also to the accuracy and completeness with which those events have been described and analysed.
According to the aggregate data, seven nonanomalous perinatal deaths occurred in 3002 women randomised to expectant management, compared with 1 from 3071 women who were induced. Of the seven perinatal deaths in the expectant arms, two deaths occurred in the 1960s[ 11 ], before the availability of modern fetal testing.
Of those, one was a stillbirth in a mother with an abnormal glucose tolerance test; such a situation would not likely be allowed to reach 41 weeks now, and was a specific exclusion from the Canadian study.
The other was a neonatal death, from meconium aspiration, following refusal of induction by the mother after positive amnioscopy.
One perinatal death[ 12 ], in China, was caused by pneumonia in the newborn period, a cause unrelated to the duration of pregnancy.
One perinatal death[ 13 ] was caused by meconium aspiration in a baby born at 43+3 weeks, which is irrelevant to whether induction should be carried out at 41 weeks.
Of the two deaths in the Canadian trial[ 2 ], one was a stillbirth at 41+5 weeks, but the mother had not received any fetal testing.
The second was an intrapartum death of a 2600 gm infant at 42 weeks, ascribed to fetal distress, which presumably could have occurred and resulted in similar management difficulties during earlier induction. This death was plausibly preventable by induction at 41 weeks, as was a stillbirth in another study[ 14 ] from massive abruption at 41+5 weeks. However, 2600 grammes is an abnormal birthweight in Canada for 42 weeks of gestation, so the hypothesis that death occurred as a result of gestation alone is dubious.
Thus of seven perinatal deaths in 3002 women randomised to expectant management, only two occurred in women who received contemporary fetal testing, before 43 weeks, from a cause possibly related to pregnancy duration. This is against one death in the induction group. The higher risk that routine induction at 41 weeks aims to reduce is dubious, if it exists at all.

3. What are the maternal risks of reaching 41 weeks of gestation?

The SOGC Clinical Practice Guidelines asserts that “women who reach 41 weeks of gestation should be counselled appropriately regarding the higher risks to themselves…if they should pursue a policy of expectant management”[ 3 ].
Bias arising from improperly executed randomised designs threatens, and potentially invalidates, the conclusions of such efforts. Avoiding such errors requires not only eliminating bias from entry allocation, but also differing treatment. The Canadian study found that “the rate of cesarean section was significantly higher among women in the monitoring group (24.5%) than among those in the induction group (21.2%)”[ 2 ]. Its authors admit a bias that might have accounted for part of the induction cohort’s lower rate of caesarean section, that prostaglandin gel was used for cervical ripening only in that arm of the trial.
Although the authors acknowledged later that “use of prostaglandin gels appears to be the best method for inducing labour, particularly when the cervix is unfavourable”[ 15 ], prostaglandin was proscribed in the expectant cohort “because we thought that most of the women in that group who would require induction of labour would have evidence of fetal compromise”[ 2 ].
In fact, a third (34%) of the women in the monitoring group were induced, but only half of them (17% overall) for ‘fetal compromise’, with the nature and validity of that generalisation undefined. The above-mentioned rationalisation for withholding prostaglandin from the monitoring group implies that the method was believed to be too dangerous given possible fetal compromise. It is more logical that suspected fetal compromise would make reduction in the number of contractions needed to accomplish vaginal delivery desirable.
Thus, prostaglandin cervical ripening would be indicated, not contraindicated, and rationalisation in the Canadian trial’s is a non sequitur.
A second bias that could have contributed to the higher rate of caesarean section in the expectant cohort is that the trial was not blinded. Both accoucheurs and patients knew that what was being assessed was whether it was safe to let pregnancy continue past 41 weeks. It is likely that as the duration of pregnancy extended, both groups would have felt increasing pressure to intervene, possibly with caesarean section, in this so-called and so-conceived high risk situation. This assertion is not hypothetical, rather probable, given the revelations of Tversky and Kahneman about how humans make decisions in the presence of uncertainty[ 16 ].
There is a third important bias which could lead to greater use of caesarean section in the monitoring cohort.
Within that group, 17% of women were believed to have sufficient evidence of fetal compromise that “the fetus was to be delivered immediately”[ 2 ]. Envision a woman randomised to the expectant, possibly conceptually high risk group. The clinician is told that monitoring indicates that the fetus is ‘compromised’ or in distress and should “be delivered immediately”. In such enhanced alarm, tolerance of typically benign intrapartum fetal heart rate changes or the passage of meconium would be reduced, and caesarean section for such imprecise signals would be more likely[ 17 ].
There is considerable evidence for such behavioural bias in obstetric settings, and that obstetric thinking confirms in vivo what Tversky and Kahneman described as the availability error[ 16 ]. The Toronto Tri-hospital trial revealed that labelling a woman gestational diabetic conferred a doubled rate of caesarean section, regardless of the fetal or maternal condition, and with no relationship to birthweight[ 18 ].
Elsewhere, false positive prediction by ultrasound of macrosomia provoked a 50% increase in caesarean delivery of same weight babies[ 19 ]. In a German study, the label growth retardation biased interpretation of, and action taken for, fetal cardiotocography and led to twice as many caesarean sections as occurred in undetected cases of growth restriction[ 20 ].
In a Swedish study, older nulliparae had dramatically increased odds of caesarean delivery, regardless of maternal or fetal condition[ 21 ]. A study from Iceland and Scotland of 522 twin pregnancies in 1990-1993 revealed no difference in management or outcomes of natural ( n = 453) versus assisted ( n = 69) conceptions, except that elective caesarean delivery was twice as likely in the assisted conception group[ 22 ].
A Canadian study of the definition and management of dystocia found that among the strongest determinants of a decision for casesarean section were acquisition of a dystocia perception and label, or its equivalent in the mind of the attending physician and the hospital in which the decision was made, although a significant proportion of such decisions were made before active labour[ 23 ].
The higher rate of caesarean sections in the Canadian study’s expectant group was almost completely accounted for by more operations for fetal distress [8.3 versus 5.7%][ 2 ]. The authors suggested this occurred because fetuses become progressively compromised and more prone to intrapartum fetal distress as pregnancy becomes more post-term.
An alternative, better substantiated explanation is that monitoring created and reinforced bias toward inference of fetal distress and made it more likely that caesarean delivery would be the response to that inference. Imprecision of the term fetal distress in obstetric care, despite its liberal use, promotes the availability error in decision making, given uncertainty[ 16 ].
As the true risk, in contrast to the perceived risk, of a fetus dying between 41 and 42 weeks, in the absence of monitoring, is only 0.1%, it is extremely unlikely that the 17% of fetuses in the expectant group believed to be compromised were actually in trouble. Over 99% of the supposedly compromised fetuses detected by monitoring most likely were not, but were rescued from normalcy by operative delivery for enhanced provider and patient anxiety.
The assertion that induction at 41 weeks results in fewer caesarean sections than expectant management is doubtful at best. It is particularly difficult to reconcile with considerable and consistent evidence that induction, especially in nulliparae with unfavourable cervices, markedly increases the rate of caesarean sections[ 24, 25, 26, 27, 28, 29, 30, 31, 32 ]. In a four-year period in southern Alberta, the caesarean rate for women induced in their 41st week was 23%, compared with 14% in those who laboured spontaneously in the 41st week[ 32 ]. The SOGC cautioned against induction before 41 weeks, in that “particularly in nulligravida…the likelihood of cesarean section may be twice as great when labour is induced as compared with spontaneous”[ 3 ].
Why this should not be the case for induction at 41 weeks is unexplained, and unlikely. Given the odds of stillbirth of 0.1% in the 41st week without induction for dates alone or special fetal surveillance, the influence of fetal risk is more likely that of perception than reality.
One of the most influential biases in the acquisition of evidence is choice of the question, and the best evidence in answer to the wrong question is useless. The rate of caesarean section were reported in the Canadian study by intention-to-treat, but they should be analysed also as actually treated. In the intended-to-induce group, 31% of women were not induced, and in the intended-not-to-induce cohort, 34% of women were induced.
In essence, one-third of each cohort were treated by the opposite method to that intended. In that true fetal compromise is rare at 41 weeks, the Canadian study was comparing elective induction compared with expectant management at 41 weeks. Comparing the rates of caesarean section in all women induced versus all women who laboured spontaneously at 41 weeks would be a more valid test of whether induction at 41 weeks alters the caesarean rate, or conveys any other advantage or disadvantage.
One can estimate the results presented as ‘treatment actually received’ using the Canadian study’s reported percentage of women in each group treated by the method intended (Fig. 1a and b). Assuming a rate of caesarean section of 16% in women starting spontaneous labour, regardless of intention-to-treat allocation, one would obtain a caesarean rate of 16% in women who laboured spontaneously compared with 29% in those who were induced. If one recalculates using the 14% caesarean rate for spontaneous labour at 41 weeks in Alberta in the early 1990s[ 32 ], this difference becomes even more striking.
(11.4 KB)Fig. 1: (A) The numbers of women and caesareans at the bottom of the vertical columns from Hannah[ 15 ]. The numbers in each cell are estimates derived from ref. [ 2 ]; (B) the results if one assumes a 16% caesarean rate in women who start labour spontaneously. The numerators are numbers of caesareans, the denominators are numbers of women, and in parentheses is the percentage of caesarean sections.
The appropriate counselling “regarding the higher risks to themselves”, that the SOGC Clinical Practice Guidelines assert must be provided to women who reach 41 weeks of gestation, should be that the higher risk is of caesarean delivery for dubious reasons, and that to avoid it they should labour and deliver where induction for dates alone is not the ritual at 41 weeks of gestation.
Despite excluding women with medical or fetal problems, an urgent need for delivery or contraindications to vaginal delivery, 31% of nulliparous women in the Canadian study were delivered by caesarean section[ 15 ]. Rather than establishing the case for routine induction at 41 weeks, the results of the Canadian trial reflect the high intervention rates of obstetric practice in Canada, which has the second highest rate of caesarean section in the developed world[ 33 ].
Given this specific intervention epidemic, it may be appropriate to note as well that since previous caesarean section was an exclusion criterion, the conclusions of the Canadian study even if valid, would be inapplicable to women in such circumstances.

4. Resource consequences of a policy of routine induction at 41 weeks of gestation

Left alone, a significant proportion of pregnancies are undelivered by 41 weeks of gestation. In one study using ultrasound dating, 19% of women were undelivered at 41 weeks, whereas only 3.5% were undelivered at 42 weeks[ 34 ]. In the aforementioned Swedish study, 30% of nulligravidae reached 287 days undelivered whereas 10% reached 294 days[ 7 ]. In our setting, 23% of women undelivered by 36 weeks remained as such at 41 weeks versus 7.5% at 42 weeks – (Table: [ 2].
Although proportions of pregnancies undelivered by 41 versus 42 weeks vary between populations, depending in part on the use of ultrasound dating[ 35 ], about 15%-20% more women will be induced given routine induction at 41 as opposed to 42 weeks. Using an annual delivery volume of 4000 births per year, about 1000 inductions would be done solely because gestation had reached 41 weeks, versus 140-400 per year (3.5%-10%) if induction for gestation only was deferred to 42 weeks.
Presuming that hospitals would reserve such induction for otherwise untroubled mothers and fetuses to five weekdays in each of 52 weeks, a hospital with 4000 births per year would have to provide for three added inductions per day, given a policy of such interference at 41 weeks. These would be in addition to those indicated for legitimate and significant maternal or fetal threat. This is a staggering imposition, given that at least 500 and more likely over 1000 inductions must be done to prevent one perinatal death from unspecified relationships to gestation.
We anticipate at least two objections to this analysis. One is that the SOGC Clinical Practice Guidelines do not state explicitly that induction must occur at 41 weeks zero days. The document is written vaguely enough to be interpreted that induction any time between 41 weeks zero days and 41 weeks six days is acceptable.
However, in response to the Clinical Practice Guidelines, Canadian obstetricians, at least the ones in the authors’ hospitals, now book induction by, if not before, one week past the supposed due date, ignoring the modifier ‘estimated’, as well as biologic norms and realities. They fear medico-legal implications should the fetus die at seven or more days past the due date, with no regard for the true odds and likely causation of such outcomes.
The adverse consequences of Clinical Practice Guidelines have been described in various situations[ 36, 37, 38 ]. Lest we be perceived as criticising the best intentions of our competent and caring colleagues, the nonsensus consensus about management of uncomplicated undelivered pregnancy at 41 weeks is simply a Clinical Practice Guidelines-reinforced example of the availability error.
Thereby, adversity odds are significantly overestimated, normally odds are even more significantly underestimated, and both logic and behaviour are warped as a result[ 16 ].
A second anticipated objection is “Those to be induced at 41 weeks must labour and deliver sooner or later, so what is the difference?” The difference is between arriving in labour and delivering 5-10 hours later compared with induction with an unfavourable cervix, requiring ripening with its variable success, then labour for 10 hours or more. The workload increment for nursing, midwifery and medical staff is significant given the need to induce 15%-20% more of the pregnant population, and in that improved outcomes are dubious, indefensible.

5. Inevitable, unintended and undesirable consequences of routine induction at 41 weeks

Greatly increased obstetric workload may be argued to be an acceptable imposition because, otherwise, one baby in 1000 reaching 41 weeks might die. We concede that, rarely, one such fetus might be saved. No test of fetal wellbeing is or likely ever will be perfect.
But it is uncertain that routine induction at 41 weeks will reduce the number of fetuses who die, and it is arguable that such practice could increase perinatal mortality and morbidity. Attention is a limited resource[ 39 ]. The extra attention needed for such added induction and its consequences will draw attention away from women labouring spontaneously or who are being induced for more compelling reasons. A mother, or a fetus of less than 41 weeks who needed help, harmed because people were busy with somebody else who did not need help, will not be counted in morbidity and mortality analysis of intervention by induction of labour at 41 weeks of gestation.
In one of the authors’ hospitals, a pregnant woman admitted because of hypertension complained of headaches while her blood pressure rose to 170/110 mmHg. Intravenous antihypertensive drugs were allowed to be given only on the labour floor. Transfer to the labour floor was delayed because there were no beds available, several being filled with 41-week inductions. The woman died from intracranial haemorrhage before transfer. Anecdotes are not the singular source of evidence.
But we wonder, whenever near-misses, near-catastrophes or true disasters occur on labour wards, whether they could have been anticipated and prevented had the staff not been so busy. As was stated in another context “preoccupation with the potential benefit to the numerator may make doctors less sensitive to the adverse effects on the population”[ 40 ].
The Canadian trial[ 2 ] resulted in a grave which we discovered during research into cervical cord injury[ 41 ]. A mother randomised to induction was induced, with prostaglandin. Precipitate labour ensued, with rapid progress to full dilation, severe decelerations, forceps rotation and extraction. The baby sustained high cervical cord injury and quadriplegia. This complication was not identified in the publication[ 2 ], a subsequent reinterpretation[ 15 ], nor in the SOGC Clinical Practice Guidelines[ 3 ] and there was no such incident in the study’s expectant cohort.

6. Conclusion

The median and mode for uncomplicated singleton pregnancy are 40 weeks two days and 40 weeks three days, respectively[ 42, 43 ], not ’40 weeks’, and two standard deviations beyond that is approximately 13 days.
Approximately one-quarter of pregnant women have not laboured by 41 weeks. Their stillbirth rate in the subsequent week without fetal surveillance is approximately 1 in 1000. Routine induction at 41 weeks is ritual induction at term, unsupported by rational evidence of benefit. It is unacceptable, illogical and unsupportable interference with a normal physiologic situation.
Two decades ago it was argued “that any infant born at term should survive, provided the infant has no lethal malformation”[ 44 ]. If only a fragment of such hyperbole is used to rationalise ritual induction at 41 weeks, to be logically consistent, we should induce everybody at 40, or perhaps 39, or 38, or even 37 weeks. Although the stillbirth rate at those earlier gestations is less than at 41 weeks, the absolute number of fetuses who die is greater.
Since more babies die at those gestations than die in week 41 – (Tables: [ 2, 3], more lives could- we have not written would-be saved.
Table 3: Number of stillbirths at each week of gestation. (5.43 KB)
Almost a quarter of a century ago, the prescient authors of an article entitled Intervention and Causal Inferences in Obstetric Practice cautioned that “as … interventions are applied to an increasingly large proportion of the obstetric and fetal population, a threshold will inevitably be reached beyond which the marginal risks of the procedure will outweigh the marginal benefits”[ 45 ].
The ‘evidence’ on which current practice and popularity of routine or as we prefer to think of it, ritual induction at 41 weeks, is based is seriously flawed and an abuse of biological norms. Such interference has the potential to do more harm than good, and its resource implications are staggering. It is time for this nonsensus consensus to be withdrawn.

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43. Baskett TF, Nagele F, “Naegele’s rule: a reappraisal”, Br J Obstet Gynaecol, Volume: 107, (2000), pp. 1433-1435
44. Stubblefield PG, Berek JS, “Perinatal mortality in term and post-term births”, Obstet Gynecol, Volume: 56, (1980), pp. 676-682
45. Chalmers I, Richards M, “Intervention and causal inferences in obstetric practice”, Chard T, (Ed.) Benefits and hazards of the new obstetrics, Clin Devel Med, Volume: 64, (1977), pp. 34-61
Copyright © 2002 RCOG All rights reserved. To order it online, go here.

20 thoughts on “Don’t let them induce you

  1. Dear Gloria,
    How are these people avoiding lawsuits? I’d think that at least the insurance companies would be interested in the fact that they are being billed for fradulent and unnecessary procedures which cause more long term problems for a higher number of mothers and babies than expectant management. And the charges that the government has picked up which were also unnecessary? I’m having a lot of trouble understanding the fact that the research was there over 20 years ago to minimize obstetric interventions, and yet they’ve ballooned. No other industry, when proven that they are endangering the public, has been allowed to increase their level of damage, so why has this happened in birth? Where are the recalls for birth technologies, which kill and injure more people than asbestos, Firestone tires, and tainted pain relief? There are human rights laws in place to prevent this type of abuse, so what does it take to get them enforced?

  2. Good question, MargeC. Dr. Hall actually came and presented this info at our local tertiary care hospital (B.C. Women’s). He spoke passionately and eloquently about the error in thinking that was causing so much suffering to mothers/babies. At the end of his talk the head of obstetrics at the hospital stood up and said to the crowd “If anyone in this audience thinks they can apply this information, they’ll be sticking their head in a noose.” Doctors are more afraid of NOT being aggressive than being aggressive. It’s difficult for lawyers to pin brain damage precisely on the induction drug (maybe the child would have been brain damaged anyway?) so, they use the drugs with impunity. It’s dreadful, I agree.

    • I am 41 weeks today and feel as though I am not being supported in my team of care givers.
      I was under the impression that having my baby at BC Women’s was the best choice I could make for baby and myself. After reading this article and your comment it really makes me reconsider who helps baby come into the world and where this happens as well.
      I just want a natural birth with no interventions but the more I state this it seems the harder they push for it. What gives?

  3. I used to be a big proponent of “evidence-based” practice, until I realized that it resulted in some very uncomfortable “protocols” with little or no positive results for moms and babies. Thanks for addressing this Gloria. I love your first sentence in this post, it’s a great thing to quote!!

  4. So, considering the fact that the dr.s are disinclined to change their guidelines and their standard of practice, it looks like it really is up to women to challenge these actions. This seems to be true even though practitioners are required to gain valid consent, which would sound like, “I want to induce you at X time because of Y, even though studies have proven that it causes Z risks and complications. I do not offer evidence based care, and you are at risk just having me involved in your birth because I am more concerned with deviation from non-evidence based practice because the Bolam Test protects me if I happen to get sued. Midwifery care is protective of the fetus and woman even in riskier births, but I do not recommend midwives because I and the hospital need to pay bills.” The problem I see is that women rely on their docs. to be truthful, and these people are actually using their degrees in a slight of hand manner, to distract women from participating in their own care.

  5. I was having that conversation with a midwife the other day. Both of us had experiences where a doctor lied to us in our pregnancy and the trust was broken permanently. We realized that we had to take charge of our own families, there was no wise doctor out there who just had our well being in mind. We were commenting that so few other women realize that informed consent is a lie. Here’s one of my favourite quotes in obstetrics:
    > “Dr. Dermot W. McDonald of the National Maternity Hospital in Dublin
    > Ireland
    > suggested that the medicolegal pressure to perform a cesarean may abate
    > only
    > when mothers begin suing physicians for assault, alleging that they were
    > not
    > given fully informed consent…
    >
    > “‘If one went to the extreme of giving the patient the full details of
    > mortality and morbidity related to cesarean section, most of them would
    > get up and go out and have their baby under a tree,’ [Dr. McDonald] said.”
    > [Neel J. Medicolegal pressure, MDs' lack of patience cited in cesarean
    > 'epidemic.' Ob.Gyn. News Vol 22 No 10]
    >
    > Irish physician McDonald’s remarks accord with the 1990 findings of
    > British
    > research statistician Marjorie Tew who concluded that the British
    > maternity
    > system is run by obstetricians who “withhold and pervert knowledge in order
    > to maintain public ignorance and delusion.” [Tew M. Safer childbirth? A
    > critical history of maternity care. London: Chapman and Hall, 1990.] end of Quote.

    • Thank you for this quote Gloria, it sums up how I felt about my birth experience in a British hospital in 1998, I was another one of the unneccesary inductions that lead to an unneccesary cesar. I felt truly like I had been viciously violated and have undergone extensive therapy to heal this state of mind. I am now pregnant with my second baby 13 years later and I’ll be delivering this baby under that tree;) At best this obsession with not being sued results in horrific vandalism of a woman’s body, women need to be educated to stop this nonsense, I just didn’t know any better at 21 to ask enough questions, I trusted the medical staff.

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  8. Bit of a long post, this, but please bear with me as i want to share an unfortunate time i’m having with my chosen hospital due to refusing induction (my plan is to get baby monitored every day to every other day and wait for her to come!) and say if anyone else is going through this, try to remain calm ans strong. I’m ’42 weeks overdue’ tomorrow and am facing a battle at my hospital every time i go in to have my baby heart monitored. I was offered when 10 days ‘late’ but refused and i still refuse. Not only do i keep getting asked in aggressive tones WHY I’m not going for induction but when i try to explain why and to engage with someone on the stats and the risks of both choices, and when i’ve asked about placenta degradation (ie how long soes it take not to function? How quickly does this happen etc) I’m more or less ignored and the same old mantra comes out from the docs: that my baby is now at risk and the spectre of the grim reaper looms. Upsetting. I sort of gave in last Friday and had a membrane sweep which appears to have led to a ‘show’ and some mild contractions over this weekend, but when i went in to get baby’s heart monitored today, it was the same old story with one midwife saying that i havent actually reached proper labour and that this stage is basically not important-just pre-labour. This really upset me as I was so happy and positive about being in the beginning stages of labour yesterday and now the contractions actually appear to have slowed down. They have said at the hospital they just want me to make sure I’m making an ‘informed’ choice yet the only info repeatedly given is the risk I’m taking by going ‘so far’ over my due date and not being induced! One woman (who runs the maternal assesment unit) asked me last Friday: “Well what’s your plan? Are you just going to go to 43 weeks then 44 and wait for your placenta to shut down?” I couldnt believe how aggressive she was! (Of course i stood my ground) They just dont really appear to be interested in what i have to say. I’m sticking to my guns, by refusing induction and asking to be regularly montitored (which is tough as a hate going to the hospital but I want to at least do that) but it’s so hard at times. This should be a happy, exciting time and the hospital experience for me really puts a dent in the magic and sacredness of this amazing event that’s hapening in my life. If anyone is going through similar, let me know and we can support each other! KWag

    • Please, find any way you can to relax and go through motions they ask you without getting “mentally hang up” on their negativity. Surround yourself with positive people as that is the atmosphere where baby wants to come. :)

  9. Oh Kwag! I am soo sorry to hear your experience!! and amazed no one has commented further!
    I can only assume that you held your ground and your baby came in its own time and is happy and healthy … and if this is true .. then full credit to you sister! you did it !! and with no support at all from the people in the “Care” industry!!
    I just had my second child on 15th June .. a home birth that was half planned as a home birth with midwife attendent.. except I was so keen to “do the labour right this time” that I didn’t call the midwife until I was feeling the urge to push .. which meant that she didn’t make it in time!!
    So we did it ourselves.. and did a great job and have a perfectly happy healthy boy and all feel soo proud of ourselves!
    All this was really made possible due to my wonderful midwife who listened to all my anxieties and concerns .. and all the silly things I was doing to “protect my energy” in the lead up to the birth .. I knew that I was so supported in this journey and I had the power to turn around my first birth story (my daughter ended up being forced out in a hospital .. in that most incredibly painful and impractical position – on my back- and as a result of her birth story has cerebral palsy), that it really helped keep me focused and confident during this labour …
    I know that if I was checking into a “care” centre without this support I certainly couldn’t have had the confidence to do what we did so well.

    At the same time as I was due my midwife had another lady due.. with her first .. and in the end she went to 17days past her due date .. and had a happy healthy delivery ! My midwife was amazed at how relaxed this lady way .. all they did was check placenta and heartbeat .. a few scans to make sure all was good .. and while she was happy to wait .. my midwife was happy to support her.
    I also personally know 2 women who home birthed their second children at 16 days late .. and although these two weren’t as relaxed as the first time mama .. they also had happy healthy deliveries ..
    I understand there are valid reasons to be concerned .. but wish that the support we are meant to have is so tied up in fear and protocol. a bit like hep B shots at birth and genital wart vaccinations for babies! That scares me!!
    Anyway.. hope you are all well and hope to hear your happy stories!?

  10. Reading this makes me very glad that I waited it out until my baby decided to come at 43 weeks. Lucky that I had taken Gloria’s advice and told the doctor the date of my last period was one week later than it actually was so they thought I was 42 weeks! The baby was big (10lb), but vigorous and healthy and no tearing occurred. It drove me crazy waiting though!

  11. AMEN Gloria.
    Thank you for the research. Lots to digest but printable information for my clients to use with their care providers.

  12. inductions! bah!! I feel like I spend so much energy trying to calmly explain to my friends why they actually dont have to get induced. lots of women have a sense that it’s a bad idea, if only because they’ve heard from others that induction makes the labour more painful. very very few women are willing to stand up to their doctors even when they know from their reading that the doctor is endangering their baby and their own health.

    it starts when you hire a care provider as soon as you’ve found out you’re pregnant. you immediately give a lot of your power away by implicitly saying “I need your expert assistance in order to make me safe during this time when anything could suddenly go wrong and you are the only person who can save me.”

    by the time women get to 41 weeks the design of the medical system means that they have no power left at all, and they go like lambs to the slaughter. sick. sick. sick.

  13. Pingback: Induction: No Thanks. « Johnson and Johnson make another Johnson

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  15. i had my second baby at 40 weeks 13 days. i had declined to schedule an induction at 4o weeks 10 days (the standard practice here in Australia) after a ‘harmless’ stretch and sweep with my first started the cascade of interventions which ended up in a vacuum extraction of my perfectly healthy 8lb 9oz baby. baby number two arrived in the same great shape after a spontaneous, active labour without any interventions, 8lb 13oz and this time, no tearing. what got me was that they all spoke darkly to me of the risks of declining induction, as though having gone past my due date i never would go into labour on my own – but nobody once raised the subject of the risks of inducing, i had to do so myself when explaining why i was declining the induction. having read this article i felt very comfortable following my intuition and waiting. it also helped to assuage my partner’s concerns on the subject. thank you for providing this valuable information.

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