When babies aren’t ready to come

Induction – the word feared by many a pregnant woman! Sure, some babies need to be induced for medical reasons, but when does “not coming out on the date they said” become a medical reason?

I remember in my antenatal class being told about induction, and the increased risks that go with it. I did not want to be induced! In my head induction meant possibly a faster, more intense labour, could put the baby at risk, resulted in more interventions and more C-sections. Where did that information come from? My antenatal class, friends, social media, mainly. In the end, both Girlbug and Boybug came naturally (eventually), so I avoided the issue.

So I was a little surprised to see this doing the rounds this week:

Stillbirths could be halved in the UK if NHS induced expectant women two weeks earlier.”

I won’t lie, my first thought was what quack has the Sun managed to interview this time? But in reading the piece, there were some knowledgeable people behind this, arguing that women should have a choice of early (39 week) induction. The main doctor interviewed is a consultant gynaecologist, practising in the NHS as well as in a Harley Street clinic. And Sands, the Stillbirth and neonatal death charity also argues women should have more choice regarding induction. And finally, the president of the Royal College of Obstetricians and Gynaecologists say that induction at 39 weeks may play a role in reducing stillbirths. Though he did say that there were other priorities, like gestational diabetes and improved foetal monitoring.

So what are they basing this information on? What does the science say?

What the NHS do at the moment

Currently women in the UK with uncomplicated pregnancies are offered an induction some time between 41 and 42 weeks. This is the point that the National Institute for Health and Care Excellence (NICE) have decided the risk of placental degradation becomes greater than the risks of induction. Induction should at this point be a choice, though I know many women feel pressurised into having one. If a woman refuses induction, they are advised to have regular scans to check placental function. It’s a hard balance to strike. Some women just have late babies, and their placentas will be fine, others the dates are a bit out and they aren’t really as far as they’ve been dated, and others still the placenta begins to fail very early. While there may be some mother’s intuition, none of us can really know the course a pregnancy will take. The clinical guidelines are there to try to protect the largest percentage of women and babies.

Interestingly, NICE plan to review their evidence later this year, so there may be a change coming! I’ll keep my eyes out for that one!

And the science?

As pregnancy goes past 39 weeks, the risk of still birth increases (see here, here and here). Particularly if it’s your first baby. The risks are still tiny, but they are there. That’s why some advocate induction at 39 weeks. There are also increases in other complications – asphyxia, shoulder dystocia, umbilical cord complications, post partum bleeding.

For a long time, the counter-argument was an increase in Caesarean section rates for the mother, along with other potential complications for mother and/or baby. However, recent studies have shown no increase in C-section rates in those that were induced and those that went into labour naturally. These studies are limited at the moment, one looks only at those women over 35, another at those with gestational diabetes, and those with “non-urgent” complications.

But there are other complications. A recent study of over 200,000 women in Canada suggested for those with gestational diabetes, induction at 38 or 39 weeks may reduce the likelihood of C-section, but increase the risk of neonatal intensive care admission. In those with “non-urgent” complications, there were increased risks of neonatal outcomes, and longer hospital stays in those induced at 39 weeks. That, and synthetic oxytocin has been associated with poorer mental health and lower breast feeding rates. These are obviously a concern. But, if there’s a chance it will also cut down stillbirths, it definitely warrants more research. One of the problems with this, is that still births are (thankfully) so rare, you need a very large group to study them.

Should we be offering to induce women at 39 weeks?

If induction at 39 weeks doesn’t increase the chance of C-section, and might reduce the rate of still births, then I can see why it is being advocated by some. But, while C-section and still birth rates are probably the most serious complications for the mother and baby respectively, there are other issues to take into consideration. The mental health of the mother, breastfeeding rates, prolonged hospital stays. It’s not yet clear what effect induction at 39 weeks would have on the rate of these.

I am all for choice, but in this instance I can’t imagine how I’d decide whether I should be induced at 39 weeks, 40 weeks, 41, 42 or not at all. I am still wary of inductions (possibly as I have never had one), and would still prefer to go natural…but I am, by nature, pretty risk-averse. The thought of reducing the risk of still birth is tempting, even if the initial risks are tiny. On the other hand, I kind of enjoyed the “will it be today?” aspect of both my pregnancies. Does that sounds a bit frivolous when put next to the potential of reducing the chances of still birth? Maybe.

The recent science is interesting, but not conclusive, and the balance of risks is going to be so individual that without individual risk profiles the decision is going to be hard to call. Every pregnancy is so unique, so unpredictable, I’m not sure that giving the mother the choice of early induction (where there’s no obvious clinical need) is necessarily the right move. Not without being able to provide some insight into her individual risks, anyway.

And I wonder how many people would take up the offer? Would hoards of people call for induction, impatient to meet their new bundles? Or would they, like me, do anything to avoid it?

What would you do, given the choice? Would you want that decision in your hands?

Tough one – I’m glad I’m not planning any more babies!!

 

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