Recently my little sister gave birth to her second baby. She was 42 weeks pregnant exactly, and had a spontaneous natural labour, that she described as peaceful. Her little girl was a healthy weight, and is absolutely beautiful.
However, the day before her labour started naturally, she was admitted for a routine induction of labour, which she refused. Despite saying repeatedly to her own midwife, the midwife on the phone and the midwife on the assessment ward that she did not want to be induced, she had to see an obstetrician to make sure she understood the risks of refusal. And that obstetrician did what all obstetricians do when women refuse induction solely for being overdue: she pulled the "YOUR BABY WILL DIE" card. Luckily, my sister refused to be scared, had a normal placental flow scan and was discharged. Her labour began properly the following evening and she had a quick, painkiller free delivery. I am VERY proud of her.
I had my second child at 42 weeks gestation as well. I was due to be admitted for an induction (which I did not want) a few hours after he was born. I had an exceptionally fast labour and when he was born, he was shown to have two knots in his umbilical cord. Not only could this have killed him at any time from around 14 weeks of pregnancy, if my membranes had been ruptured, he would have become distressed and I would have had either a caesarean or stillbirth. Instead, I had a natural birth at home, exactly as I'd wanted, and he was born healthy.
My mother's sixth child (the sister mentioned above) was 19 days late before she was finally browbeaten into an induction, however she was already in early labour. Her EIGHTH child was twelve days late, when the obstetrician on call asked her if she wanted her baby to die, to try and force her into an induction. Considering my mother's seventh child was a premature stillbirth, this was incredibly cruel. My youngest sister was born safe and happy 12 hours later.
Are there risks associated with overdue babies? Yes, of course there are, or it wouldn't be an issue. One study shows that at your due date, in a normal pregnancy, your risk of stillbirth and neonatal death sits at 0.24%. By 43 weeks, it has increased to 0.58% (Hilder, 1998). A much larger, longer case study was done in Scotland, which put the mortality rate at 43 weeks at 1.15%, as opposed to 0.22% at term. The baby, being presumed more mature, may pass meconium in labour, which may poison them. However, this is not exclusive to overdue babies.There has been a Dutch report that suggests there is increased likelihood of ADHD in postterm babies. (NHS choices, 2012). Otherwise, aside from fears of large babies, postmaturity syndrome, and placental problems, there are few
risks associated with prolonged pregnancy that do not exist in ALL
pregnancy.
However, although the NICE guidelines are that pregnancy should not progress past 42 weeks, and suggests induction of labour in these circumstances it also states that "Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour." and "if a woman chooses not to have induction of labour, her decision should
be respected. Healthcare professionals should discuss the woman's care
with her from then on." (NICE, 2012). It also advises that induction of labour should not be offered solely because of likely macrosomia (NICE, 2012), otherwise known as a big baby.
My sister had previously told her midwife that she was uninterested in an induction, and was told that the last patient who'd done that had died, along with the baby, in a teepee in the garden. She then asked my sister if she was also planning on giving birth in a teepee. When I told my midwife that I did not want to be induced, she shrugged, said she had to follow protocol (in booking it) and that it was up to the consultant. A friend (who delivered under the same midwifery team as me) tells me how her midwife was equally surprised at her induction refusal and implied it was the consultant's choice.
Another describes her delivery team as: "I was given the impression that they thought I was a silly little girl
for wanting it my way and that I'd change my mind and do what they
wanted me to do."
Another women said "It didn't feel like a choice at all, just something I was told was going
to happen. The actual process of breaking my waters was done without my
prior consent - I was led to believe they were simply examining me."
Informed, unpressured consent in the small pool of women I consulted happened in just under one third of the cases. All women described an amount of expectation, and pressure that they would conform to having an induction.Several described having to demand the information on the procedure and risks, rather than it being given as a matter of course.
What of the risk in being induced? Induced labours are markedly more painful than natural, as the body is being forced to do something it is not ready to do. Induced labours can also be much slower, which in natural labour is not much of a problem - you just carry on until you're fully dilated, unless you want to be augmented with hormones. However, once the induction process begins, you are on a timer, and if your body fails to do as it's told, more intervention is necessary to bring forth the baby.
Both of these factors can cause problems with the labour. Painful labour often means an epidural, an epidural means lying around in bed, and that slows labour down. The labour is then not progressing fast enough for doctor's, who start considering instrumental or caesarean delivery. One study quotes a threefold increase in risk for induced labours to end in caesarean, versus spontaneous delivery (Thorsell et al, 2011). There is not a lot of data available for perinatal mortality rates in induced vs natural post-term labour, however one study suggests that induction does not reduce the mortality rate (Wennerholm et al, 2009)
A due date is an estimation. Unless you have a patient who knows categorically when she concieved (for example, in an IVF pregnancy), it is difficult to know when a woman ovulated, when the sperm met the egg, when the egg implanted. Early gestational scans make the dating process much more precise, but the five days for error allowed in them means the difference between being considered 9 or 14 days overdue. Not all babies who are supposedly overdue are born with postmaturity syndome. My youngest certainly wasn't, and he could not have been less than 11 days overdue by my dates (14 days by scan), though he did have a most luxuriant mane of hair. Equally, my new niece does not display the features of postmaturity syndrome, and she was at least 14, if not 17 days late. Babies do not all 'cook' at exactly the same rate.
When the NICE guidelines advise that women are fully counselled in the risks associated with continuing the pregnancy, or inducing it, they do not also advise belittling, or ignoring the woman's preferences; or scaring her with statistics. Quite the opposite: the woman is supposed to be informed and supported in her choice between induction and natural labour.
We need to find out why this is overlooked so frequently. Do obstetricians genuinely believe that they will have a flood of stillbirths on their hands if they allow women to go more than ten, or twelve, or fourteen days overdue? Or are they trying to control an otherwise uncontrollable natural process? Are we going to end up like certain parts of the USA, where inductions are booked before the expected due date is even reached, to fully medicalise the process? Inductions are not cheap: they require drugs, monitoring, observation, and bedspace, and like any birth, can require surgical intervention at any time. However, with the increased likelihood of interventions, is it cost-effective to panic women into induction of labour before 42 weeks has even been reached?
Women deserve informed choice, especially when they are on the cusp of undergoing a physically and emotionally demanding delivery. They do not deserve to be frightened or coerced into any procedure, least of all one as life-changing as birth.
Hilder, (1998) 'Stillbirth and infant mortality births in term and post-term gestation' http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
Smith (2001), 'Perinatal death at term and post-term' in http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
NHS Choices (2012) http://www.nhs.uk/news/2012/05may/Pages/overdue-post-term-babies-adhd.aspx
National Institute for Clinical Excellence, 2012 http://publications.nice.org.uk/induction-of-labour-cg70/guidance
Thorsell, M,. Lyrenas, S. Andolf, E. and Kauser, M. (2011) 'Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women.' in Acta Obstetricia et Gynecologica Scandinavica; Oct2011, Vol. 90 Issue 10, p1094-1099
Wennerholm, U. Hagberg, H. Brorsson, B. Bergh, C. (2009) 'Induction of labour versus expectant management for post-date pregnancy. Is there sufficient evidence for a change in clinical practice?' in Atta Obstrecia et Gynecological Scandinavica; Jan2009, Vol 88 Issue 1, p.6-17
- Women's opinions and statistics gleaned by the author, from a brief online survey, comprising 13 participants between October 18th and 21st 2012.
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