Induction versus Spontaneous

photo courtesy of drewesque

I wanted to write this blog post b/c I remember in my first pregnancy - toward the end - being so afraid (and peeved) when my OB brought up the topic of the possibility of induction. I was heavily influenced at that time with the many opinions I heard about not inducing, and to instead just wait for the babe to come ("there's no time limit," "there's no eviction notice," "don't choose your baby's birthday," etc) - the opinions/advice were by birth professionals I knew, people I trusted. I even repeated the advice to people I knew - people who trusted my opinion as a doula and childbirth educator. (makes me cringe) I have since heard too many stories similar to this story (or met women) whose unfortunate outcomes did not reflect that sentiment I had ingrained in my head: "baby will come when ready and not a moment too soon." Because that isn't true in every case. Even close monitoring does not guarantee complications are not developing (or that they won't develop closer to or during labor). So it left me questioning.... Is there a time when continuing on with a pregnancy becomes riskier than delivering? That's what inspired me to write this.... I was in search of evidence for induction vs spontaneous labor at or beyond 40 weeks.

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If you are approaching 40 weeks of pregnancy, you might hear your care giver bring up the topic of induction. If you are wondering why they are hoping the baby will come sooner, rather than later, this information may be useful to you. I know the idea of induction may be very scary. Perhaps reading evidence behind the recommendation will help you understand your professional care giver’s concern and help you make a more informed decision. Because ultimately, the choice is yours.

First, in October 2013, ACOG redefined what “term pregnancy” means. A woman who was “full term” previously meant she was anywhere from 37 to 42 weeks. Now, there are new definitions and “full term” is a shorter window.

The following represent the four new definitions of ‘term’ deliveries:

Early Term:  Between 37 weeks 0 days and 38 weeks 6 days

Full Term:    Between 39 weeks 0 days and 40 weeks 6 days

Late Term:   Between 41 weeks 0 days and 41 weeks 6 days

Postterm:     Between 42 weeks 0 days and beyond

From the study: “Babies born between 39 weeks 0 days and 40 weeks 6 days gestation have the best health outcomes, compared with babies born before or after this period. ”

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Here are several studies discussing labor induction vs expectant management (waiting for spontaneous labor). 41 weeks was the common “cut off” for induction in these studies.

Please note, in the studies you will see the term "expectant management." I was confused by the term initially so I want to add the definition. Expectant management refers to "watch and wait" for spontaneous labor. It is the "hands off" approach; as opposed to induction, which would be considered active management.

#1: http://www.ncbi.nlm.nih.gov/pubmed/17054226 (October 2006)

From results: 

"If deaths due to congenital abnormality are excluded, no deaths remain in the labour induction group and seven deaths remain in the no-induction group."

Conclusion: "A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks."

#2: http://www.ncbi.nlm.nih.gov/pubmed/22696345 (June 2012 -- I believe this is the updated version of the study above)

From the results:

"There was one perinatal death in the labour induction policy group compared with 13 perinatal deaths in the expectant management group. "

and

"Fewer babies in the labour induction group had meconium aspiration syndrome (RR 0.50, 95% CI 0.34 to 0.73; eight trials, 2371 infants) compared with a policy of expectant management. "

Conclusion:

"A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction although no significant differences in the rate of NICU admission were seen.However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction)."

#3: http://journals.lww.com/greenjournal/Fulltext/2012/07000/Risk_of_Stillbirth_and_Infant_Death_Stratified_by.14.aspx (July 2012 -- Data used was from 1996-2006)

This study is about risks of delivery vs expectant management, and risk of stillbirth. It also took into consideration for those that delivered, what was the infant mortality rate - infant deaths of babies born alive that die before they turn one. 

Here is a graph from the study:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719843/figure/F1/

Keep in mind the orange line is the expectant management group - this is the non-induction group. You can see the risk of stillbirth (red line) steadily rise from 37-40 weeks. Then increases more dramatically between 40-41 weeks, then even moreso after 41 weeks.

Results: The risk of stillbirth at term increases with gestational age from 2.1 per 10,000 ongoing pregnancies at 37 weeks of gestation up to 10.8 per 10,000 ongoing pregnancies at 42 weeks of gestation. At 38 weeks of gestation, the risk of expectant management carries a similar risk of death as delivery, but at each later gestational age, the mortality risk of expectant management is higher than the risk of delivery (39 weeks of gestation: 12.9 compared with 8.8 per 10,000; 40 weeks of gestation: 14.9 compared with 9.5 per 10,000; 41 weeks of gestation: 17.6 compared with 10.8 per 10,000).

Conclusion: Infant mortality rates at 39, 40, and 41 weeks of gestation are lower than the overall mortality risk of expectant management for 1 week.

#4: This was published in January 2013. It specifically addresses pregnant women that are 40 years of age and older.

http://www.rcog.org.uk/news/rcog-release-induction-labour-older-mothers-may-reduce-risk-stillbirth-say-experts

From the release: “Data from these studies show the risk of stillbirth at 39-40 weeks gestation is doubled for women aged 40 years or over, and at 39 weeks gestation these women (40+ years) have a similar stillbirth risk to women aged in their late 20s at 41 weeks gestation.”

and

“It is justifiable for experts to conclude that inducing labour at an earlier stage of gestation (39-40 weeks) in older mothers (40+ years) could prevent late stillbirth and any maternal risks of an ongoing pregnancy, without increasing the number of operative vaginal deliveries or emergency caesarean sections.”

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These are the studies I have found regarding this issue of induction vs wait for spontaneous labor. As you can see, because of the increase in stillbirth, especially after 41 weeks, it is no wonder why induction of labor is often recommended by 41 weeks. 

When deciding, it is important to compare evidence for one option versus evidence for another option. There will be anecdotes of those who went to 41, 42, 43+ weeks that ended with a healthy mom and baby, with no complications. But there will also be anecdotes of those who had elective inductions at 37 or 38 weeks that ended with a healthy mom and baby, with no complications. It does not mean either route is what the evidence supports as the safest route to go.

If you have any peer reviewed studies you’d like to add regarding this topic, please feel free to do so in the comments!

Edited 01/11/2013 to add another study:
#5: http://www.ajog.org/article/S0002-9378(08)00558-9/abstract

Results: Compared to infants born at 38, 39, or 40 weeks, those born at 41w0d to 42w6d have a greater odds of neonatal mortality (aOR: 1.34, 95% CI, 1.08-1.65). Subdividing by gestational week, infants delivered at 41w0d to 41w6d showed elevated mortality relative to earlier term births (aOR: 1.37, 95% CI, 1.08-1.73). Additional analyses support this increased neonatal mortality across all normal birthweight categories.

Conclusion: Infants born beyond 41w0d of gestation experience greater neonatal mortality relative to term infants born between 38w0d and 40w6d.

"Birth is beyond our control"

I wanted to share more with all of you the story of Acacia. Many readers had questions. I know certain questions will never be answered but in my conversations with Jenny (Acacia’s mother), I felt more of her perspective needed to be shared. 

My questions are in blue. Jenny's responses are in black. The bold areas are my emphasis.

To read the story of the birth and death of Acacia, click here

Thank you, Jenny, for being so brave to share your story.

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Can you explain what your birth “philosophy” was going into your first pregnancy? What I mean is how did you view the process?

I didn’t have a cohesive idea about birth, but I had a sense that it was “natural” and therefore straightforward.  (I thought the same thing about breastfeeding, by the way - what a hoot that was.)  I heard that “interventions” and fear during labor could cause problems for the baby, so of course I wanted to avoid all that.  Although I did worry about all sorts of things going wrong, I also felt that “natural is better.”

My childhood experiences with authority had been very negative. People with power over me had used that power to hurt me. I wasn't able to articulate this at the time, but I wanted to protect my baby.  My gut sense was that to keep the baby safe, I needed to avoid people with "power," including doctors or midwives. I had very severe anxiety, and because it was untreated, it prevented me from accessing prenatal care - I was able to see a doctor about three times in the whole pregnancy.  

How did everything end up going at the hospital for the birth of your first? How did you handle it emotionally given your anxiety? How did you feel about it at the time and afterwards?

The hospital scared me.  Sometimes I thought about not going.  Surely we’d know if something was going wrong, right?  And if nothing was going wrong, wouldn’t it be ok to just stay home?  I didn’t want something bad to happen to the baby at the hospital.  Steven wasn’t thrilled about this idea, but said it was my body and therefore my choice.  I promised him I would go if I had any doubts.

When I finally went into labor, I had a couple big drips of blood as I was dilating.  I knew about bloody show, but something about the bloodiness of the blood made me uneasy, so I asked Steven to drive us to the hospital.  

The blood was normal and everything was fine.  I had an excruciating 10 hour labor, and I pushed for 2-3 hours.  She’d had some meconium in her waters, and once she was born, the nurse thought she was more blue that normal, so she had to go to the warming/resus table immediately.  They brought her back to me and I got to hold her, and I was so happy.  

Everyone was absolutely kind to me and explained everything.  No one lectured me or yelled at me.  They said they were glad I came to the hospital even though I was afraid, and in the end, I was glad too.  

Going into the birth of your second, did you still feel the same about birth, about it all being a pretty safe process if it was natural?

I had therapy in between my first and second pregnancies.  I still had a lot of anxiety, but I started from the premise that we needed prenatal care.  Because we had a child already, I knew how precious the baby and I were, and how much our family needed us to be well.  The stakes were more real.

I chose a hospital based midwifery group, and Steven came with me to many appointments.  I met all twelve midwives, and I cried coming and going sometimes, because it was not easy work to talk about my boundaries or my fears.  But by the end of my pregnancy I was very comfortable with my midwives.

I did still think "natural is better" and that the more interventions I could avoid, the better. I was still afraid of ending up with a c-section.  I still believed that birth was basically safe.  As my due date approached, the midwives and I were able to talk sensibly about non-stress tests and post-dates inductions and rates of stillbirth after 42 weeks.  I scheduled my first non-stress test and prepared myself for the idea that I might have an induction afterwards.  I tried not to dwell on my biggest fear, which was that I would go for the NST and end up with a c-section.   Despite knowing there are many good reasons for a c-section, in my mind, there was nothing in between the two events besides a diffuse fear that the c-section would be “unnecessary.”  I ended up giving birth two days before my 41 week NST.  

Do you feel you took good care of yourself during your pregnancy with Acacia?

With Acacia?  Oh yes.  I ate well; I was sensitive to my body.  I did special exercises to prepare my body for birth.  I was kind to myself so my kindness would overflow onto her.  I took warm baths.  I was pleased to be getting prenatal care.  Right before she was born, I took long walks among magnolia trees, and I felt very nourished by the sight of the flowers.  I used to grab her leg through my belly and hold it.  She had a very robust feeling leg.  Compared to my first pregnancy, I was unworried.  I was comfortable with my decisions about where I was going to give birth and with who, and I felt confident in my body.  I still worried about the pain.  I still worried about “the cascade of interventions.”  I made plans to help me be comfortable in the hospital.  I was looking forward to meeting my daughter very much.

You have spoken to me at lengths greater than what has been shared here regarding your extreme anxiety with hospitals and doctors and authoritative figures... to those out there that are dealing with a similar type of anxiety, do you have any advice you could share? To those who seem the greatest fear is the "cascade of interventions," do you have any thoughts you could share here as well? Any thoughts on how to advocate for oneself?

That’s tough.  Anxiety is kind of like living in a box.  Sometimes you know there’s a bigger world out there, and sometimes you can see it through the cracks, and sometimes you have no idea you live in a box.  Being in the box feels rational because anxiety has it’s own internal logic.   My anxiety once worked to protect me, even if it was maladaptive for my adult circumstances.  Learning that my anxiety served me taught me that I could work with my fear.  If something made me feel unsafe, I learned how to find safety instead of just running away.  Counseling helped the most, but medication can also be a useful tool.  There’s nothing shameful about having anxiety, but it’s unpleasant to live with and worth addressing when it interferes with your life.

As far as the “cascade of interventions” goes, or more accurately, my fear of “unnecessary interventions,” it’s normal to be frightened of things that are unfamiliar, and which involve blood and surgery.  I think it would have helped me to understand that it wasn’t my responsibility to predict the future. Decisions that might seem less than ideal in hindsight could be the best, most ethical decisions at the time.  Successfully averting an emergency can sometimes leave little evidence of the danger that inspired the interventions.

Birth is beyond our control, but we react to it as best as we can.  Not every choice is, or can be a choice.  We can react to labor pain, or birth complications, but we don’t get to choose whether or not they occur in the first place.  Confusing autonomy with control hurts women.  It’s very easy to become crushed by disappointment, guilt, shame, and hurt if we measure our autonomy by how well we control the uncontrollable instead of by how we react when the uncontrollable occurs.  

It’s hard to give a really nuanced answer to the question about self-advocacy because every person’s situation is different.  For a person who was taught that having boundaries is dangerous, communication is not an easy thing to do.  Systemic factors such as racism and classism also impact the way that many women in the U.S. will experience and access maternity care. Any answer is going to be limited by these and other factors.

It can be helpful to ask as many question as you need to, before the birth, during, and after.   It’s also helpful to go into birth with a set of ordered priorities, so that if a complication arises, you know which goals you hold paramount and which you can set aside.  You do have rights; knowing them, and knowing who to complain to can help as well.   As much as it is possible to have a respectful dialog with care providers, that will help too.  

After the birth and death of Acacia you started to share your story with others... I have seen firsthand some of the appalling responses... Knowing the complication, I know that it is not something that can be remedied at home... no matter who may have been there with you during delivery, you would have been transferred.... and yet some seem very desperate to believe that it could have been prevented with the right person with you, as if a midwife or the right paramedic could remedy *any* potential complication. Why do you think that is?

I'm a grieving mother. Acacia’s first coos, first words, and first steps will never exist. To share her with the world, I talk about her birth and her death.  For some people, the idea of a baby dying is incomprehensible and it’s very natural to try to push those possibilities off and say, “That couldn’t happen to me.  I would make better choices.”  It’s too scary to think about otherwise.  There may be an element of hubris, too, in thinking it’s possible to be superhuman in an emergency, or thinking that reading something on the internet makes one an expert.  But I think it’s mostly fear.

People don't have to worry about the unthinkable happening to their babies if they can make up a narrative in which it wouldn't. After we learned what it was, I read everything I could find about my daughter's complication.  I questioned her doctors and my midwives endlessly. I made up a hundred different stories about how she could have lived, but in the end they are just stories. If we could have done anything different, we would have. To this day I wish I would have skipped the bath and just gone to the hospital.  This is wishful thinking too, because there was no indication that I needed to be in the hospital that early in my labor.  

How do you feel about birth now, after Acacia?

I don’t count on the process of birth.  My body is strong and wonderful, but it’s falliable.   I count on my care providers to be sensitive and cautious, and I count on my own resilience.  My third child is due in the spring, and I am doing what I can: prenatal care, screenings, ultrasounds, taking my vitamins, exercise, and a practice of gentleness.  Perhaps I will get to walk among the magnolias again.  I plan on going to the hospital at the first sign of labor.  Fear comes to me occasionally, but it’s an old friend, now.

My main concerns are brain damage and death.  My midwives know that if the baby doesn’t seem to be tolerating labor well, I prefer a non-emergency c-section to waiting and increasing the chances of an emergency developing.  This is no guarantee that the baby and I will make it through with minimal injuries, but it’s enough for me.

I'm struggling with how to ask this question as I don't want it be a question used to get an answer to scare pregnant women, so I'll just ask it and see where it goes... if you could say anything to someone who believes that birth is "as safe as safe gets" or who believes that "trusting birth" is all it takes to have a good outcome (and perhaps with a midwife present), what would it be?

Each of us makes our decisions based on what levels of risk we are comfortable with.  I can’t tell others what to do, because it’s such a personal decision, but I can share about what it feels like to be on the other side of a birth accident that occurred outside of the hospital.  

I have made my peace with my daughter’s death, and have found pockets of incredible beauty and holiness in our time with her.  This is a mystery to me, because that peace includes acknowledging that there's nothing beautiful about an innocent baby suffering. There was nothing wonderful about deciding to withdraw life support interventions from our dying, brain damaged baby so she could have a peaceful death.  

Even if absolute risk may be low, the impact of birth complications can be catastrophically high.  I can’t control whether or not these complications will occur, or even that I will be in the right place at the right time, and yet, I still will try because I think there is value in trying to avert things that are terrible, even if we can't guarantee we will be successful.  There’s value in trying to avert death or terrible injuries, even though all life ends in death and we cannot avoid all injuries.  Uncertainty is part of being human. This might sound bleak, but it's a very peaceful place to be.

"Magnolia" photo courtesy of fionaandneil