Tuesday, January 25, 2011

Risks of going postdates vs. risks of induction

Here is a question (slightly rephrased and summarized) I received by email recently:

“I am currently 29 weeks pregnant, and my doctor told me he would like to induce me if I don’t go into labor by 40 weeks. I was slightly surprised to hear that, because I thought the cut-off point was generally 42 weeks. I was told that after 40 weeks, the rate of sudden fetal death goes sharply upward, and my doctor said I don’t want my baby to “overcook”, since he personally knows of three cases when babies died because their mothers went postdates. I know you refused to be induced and gave birth to your last baby at past 43 weeks, and would like to ask what you think.”

I’m not the person, of course, to be giving out medical advice, but I believe that when it comes to our health, we should make an informed choice. Thankfully, we live in a period of time when information is easily accessible, and by comparing various sources, we can do our own research and make our own considerations. You don’t have to discard your judgment just because you are not a doctor – you are still allowed to think and ask questions.

40 weeks is the time when an average pregnancy usually ends, which means at least half of all pregnancies will naturally end beyond 40 weeks (most, but not all women will naturally go into labor by 42 weeks). That’s the normal course of things. By saying he doesn’t want you to go past 40 weeks, your doctor basically says there is at least 50% possibility you will be induced – and that is not normal. Interfering with normal pregnancy should be a last resort, not a routine procedure.

It’s true that there is a slight increase in the rate of sudden, unexpected fetal death past 40 weeks of pregnancy, however, this increase is not as dramatic as doctors would like us to think while they frighten us into unneeded inductions (many of which are performed for legal, not medical reasons). I currently don’t have internet access so I can’t provide a link, but you can find the actual numbers online.

Even with the help of ultrasounds (and many doctors discard even that and just go by the arbitrary and very imprecise line of LMP), it isn’t always possible to know exactly when a woman became pregnant, and therefore, when she approaches the “cut-off” point of 42 weeks. The woman’s own instinct often provides a far more accurate estimate of when she is due. During my second pregnancy, I just knew I could not be as far along as the doctors said, and the fact that all along, I was told the baby is “small for gestational age” was additional proof. She was eventually born at 43 weeks and 3 days, at a very respectable weight of nearly 3,5 kilos, and with no signs of being “postdates”.

Some women are naturally inclined to have longer pregnancies. It is helpful to know medical history of the family, as well as the woman’s personal history (though if she was repeatedly induced shortly after 40 weeks, there’s no way of really knowing).  

Had I fallen into the hands of a doctor who would convince me to be induced at 40 or even 41 weeks, my baby may well had been born with prematurity issues and at a low weight. That’s one risk of inductions doctors gloss over. There is also the fact that use of pitocin and the unnaturally strong contractions it causes increase the rate of fetal distress and emergency C-sections (and of course, if you are induced most likely you will need an epidural, which carries its own risks). Such a scenario only recently happened to someone I know, a young woman only 25 years old. She was talked into an induction at 41 weeks, the induction didn’t work but caused fetal distress, and she was rushed to a C-section where the life of her baby was “heroically” saved. Now, every subsequent pregnancy will be considered high-risk for her, and the chances of a repeat C-section are far higher, carrying with it the risk of more complications.

Taking all this into account, I believe that for a healthy woman, with a healthy pregnancy, going past 40 weeks (and with observation, even past 42 weeks) is less risky than consenting to an induction when there is no obvious medical reason for it (apart from going “postdates”). However, most importantly, I hope you make your own, truly informed choice, without giving in to pressure and scare tactics.

I was blessed to experience two uncomplicated natural births, and it saddens me to think many women would like to have a natural birth as well but are robbed of the experience for no good reason. Good medical care does not mean “medicalizing” a normal physiological process. During pregnancy, labor and birth, I believe medical care should be used as back-up, ready to step into action should anything go wrong, but otherwise not interfering.


Alissa said...

I think it is very interesting that if a woman's due date is calculated from early ultrasound dating rather than LMP, the incidence of going past 42 weeks almost disappears.

Basically, LMP is not the most accurate way to determine due date, so most women who go "past due" probably just had the "wrong" due date.

I don't think lots of ultrasounds are the answer, but it was comforting to me to know that there was nothing wrong with going postdates, and that my due date could just be off a little.

Gothelittle Rose said...

Pregnancy due date is usually determined by starting on the first day of your last period. However, the amount of time between the start of your menstrual cycle and ovulation differs for every woman.

If you've been tracking your ovulation and can point to the date when your luteal surge occurred, you are much more likely to give birth "on time".

My daughter was born 4/2 and her due date was 4/3. I had a slow labor that got sped up (long story), so it's possible that without medical intervention, she may have been born exactly on her due date.

Rightthinker-Andrea said...

Well, I think rarely induction is necessary..RARELY.

In my last pregnancy, our 6th child, if I would have been with a doctor, I likely would have been induced for "size" weeks before.

I was extremely healthy, gained only 38 lbs on a great diet and activity, and had a midwife. I went to just shy of 42 weeks (by a day or so) and delivered in my home.

The interesting part? I'm a VBA2C (our 3rd was an un-turnable transverse, and 4th was a forced unecessary repeat..5th was a VBA2C and 6th) and had a great 5th and 6th left alone birth. This last one that went "post date" and "too big", was 10 lbs 9 oz, 23" long with a 15 3/4" head. I had a 4 hr labor, 45 minute hard labor phase, and pushed him out in under 15 minutes with no problems for him or me.

Guess it was best to leave our bodies alone!

Cherish said...

Excellent post! I'm not yet pregnant, but one of my questions in choosing a midwife will be how they handle going past 40 weeks.

Bethany said...

Great post. I personally have wondered why I hear a lot of older friends of mine (I'm 17) are being induced, probably 90%. I personally wouldn't want to be induced and see no need for it unless the well being of the mother or child is in danger. I think inducing labor has become way to common these days, it's like the doctor wants to decide when you can have your baby which would be convenient for them, but not for the mother or child's best interest.

Kate said...

Here's another risk of pitocin-inductions: unnaturally forcing the cervix to open can cause cervical incompetence. Also, it can cause the uterus to not expel all afterbirth, blood, clots and tissue as effectively. Hemmoraging and/or infection can occur.

thecurryseven said...

I went postdates on four of my six pregnancies (the other baby came on her due date and the last was twins who very nearly went postdates as well.) I think what Anna has written here is right on target. Also, I have made a very unscientic personal survey that it seems that women who have longer monthly cycles (ie 30-33 days rather than 28) also seem to have longer pregnancies. My thinking is that for those women (myself included), they are not really postdates, but what is normal for them.

Stealth Jew said...

This is a deeply unfortunate post and I am sorry you made it.

Here are references. The risk of going postdates are actually _greater_ than we had previously thought.

The relevant portion begins:
"Recent studies have shown that the risks to the fetus (citations) and to the mother (citation) of continuing the pregnancy beyond the estimated date of delivery is greater than originally appreciated."

LMP can indeed be inaccurate, which is why it should be augmented with ultrasound.

IYH this post will not be responsible for a mother "informing" herself through the wide variety of misinformation on the web, and CVS she should have a bad outcome, as so many others have had and did have before routine induction at 42 weeks.

Kate said...

AMEN. I love how you think! :)

Corner Mystery said...

hello friends ^_^, nice to know u

Kelly said...

Agreed. I normally don't post comments, but in this case I wanted to because of my own experiences. I have had one child, and my pregnancy lasted longer than "average". To the writer of the original email: OBGYN's (esp. male) can only offer you textbook theories, an outside observer's beliefs, and their personal philosophies. They also have a terrible habit of generalizing. What was right for the last woman- or the last 100 women - they saw, might not be right for you. What is normal for the average woman may, or may not be, normal for you. You know best what is going on inside your body, you are the most connected to your baby. So listen to your body and pay attention to what it is telling you. As far as your baby "overcooking" - ha! This is a little person, not a casserole. Some need a little bit more time than others do. **DON'T LET ANYBODY PRESSURE YOU INTO NEEDLESS MEDICAL PROCEDURES. REMEMBER TO STAND UP FOR YOURSELF AND BE ASSERTIVE WITH THE DOCTOR AND THE MEDICAL STAFF.** By the way, congratulations and I hope all goes well for you and your new little one!

Rightthinker-Andrea said...

To the PP who mentioned that the risks of going past due are "actually higher" and cited a source, I'm sorry I have to disagree with the actual information pool in that post.

The information gathered is for women with doctor/hospital births. Many of these women perhaps are higher risk anyway.

I would like to see a study (aside from something like The Farm's: http://www.naturalbirthandbabycare.com/farm-statistics.html) that includes healthy women in a non-medical setting such as a homebirth or birth center going past 40 weeks.

In Europe, the length of a normal pregnancy is 42 weeks from LMP, and you are not considered post dates until 43. With careful monitoring of kicks, fluid, maternal BP, and heart rate assessment, most mothers and babies do well on their own time tables.

The only fetal issues I've ever had in my 6 births, are the ones where the doctor is the "expert" and therefore removes my baby from their growing space before he/she was ready! Not the last 2 births where I went post dates by 2 weeks!

Kimberly said...

In one of of my many birth books there is a wonderful graph that shows the risks to the baby about post dates.

Basically the risk is high up to 38 weeks and then it drops very low, the lowest point being at 40 with a slight rise until 42 and then a BIG rise at 43 weeks that is comparable to being born at 37 weeks.

What that breaks down to is a month worth of time in which it is ideal to give birth/be born. What has happened in modern maternity care though is due dates-very precise to the very date, all based on a conjecture of when conception occurred, and this has led to all kinds of obstetrical mischief.

Marytoo said...

Stuff like this just burns me up. Often the reason for inducing is simply the doctor's convenience. He does not want to be disturbed at night or on the weekend.

Something else that makes me crazy is how they now "know" how many weeks and days the pregnancy is. I'm rather thinking that unless you had sex only one time, it is impossible to know with that much precision.

Anyway, who says what a proper gestational weight is? Is every 5yo child the same height or weight as every other 5yo? What about a 21yo adult? Or a 50yo? So who says a newborn, or preborn baby must weigh exactly the same?

I know of so many doctors who threaten pregnant women with, "If you don't have this baby by x date, we're going to induce." And is often even before their due date. What is up with that???? I find it interesting, not in a good way, how freaked out they get if it goes one day over, but when it comes out early you never hear them say, "This baby is too early, let's put it back!"

Unknown Mami said...

I'm 37 weeks right now and considered "high risk". I've had to be a bit firm about not wanting to be induced unless there is a compelling reason.

Very well written post.