Induce? Or wait?
May 14, 2018 6:32 PM   Subscribe

39 weeks with a seemingly large baby. Obstetrician wants to induce. Mother feels nervous. What to do?

39 weeks pregnant with a normal, uneventful pregnancy.
Mother is 39 years old, anemic, overall healthy & athletic, with a medium frame (5'6", 150 lbs with 37" hips when not pregnant, current weight is 180 lbs).

Baby's estimated weight based on ultrasound is 9 lbs 6 oz.
Blood sugar, blood pressure, and amniotic fluid levels etc all look good.
Cervix is high, closed (Bishop's score a few days ago was zero).
No mucus plug, no contractions, and baby seems high; the head doesn't "feel" engaged.

Original due date based on LMP and ovulation / intercourse tracking was May 19.
Due date was adjusted back at first ultrasound to May 12 based on fetal size.
Fetus has seemed large at most ultrasounds.

Obstetrician wants to induce this week- maybe tomorrow- based on large fetal size.

Doula's advice is that fetal size estimates tend to overestimate the weight, plus a fat baby is still a squishy baby, and that a natural labour with minimal intervention will be easier on mother and child.

Mother is concerned that induction will cause a stressful labour and be more likely to result in C-section, which she's nervous about because she had a hard recovery from orthopedic surgery involving unpleasant morphine hallucinations a few years ago.

Any advice? Thank you!
posted by anonymous to Health & Fitness (38 answers total) 2 users marked this as a favorite
 
Listen to your doctor.
I was also asked to induce. The baby was big. Fluid was an issue. I said I wanted nature to take its course.

Nature didn't take its course and I ended up inducing much later.

The baby had fluid in his lungs and was in NICU for a number of days.

Listen to your doctor.
posted by k8t at 6:39 PM on May 14, 2018 [16 favorites]


If she's able to get a second opinion with her insurance and in her area, I would do that. The doula's advice gives her a reason for a second opinion. However, I would trust the medical advice more at this stage of a pregnancy. Bias alert: survivor of a disaster pregnancy. (I found my midwife was (in her own way) just as biased as the doctors. The doctors wanted to medicalise everything, and the midwife tried to normalise everything. She was right in that most of the time, nature works as it should, but-- trust me-- you don't want to mess around in case the doctor is right and intervention is required.)
posted by frumiousb at 6:39 PM on May 14, 2018 [7 favorites]


Do what your OB tells you. He/she spent a lot of time and energy becoming an absolute expert in the delivery of healthy children.
posted by killdevil at 6:41 PM on May 14, 2018 [10 favorites]


Also whatever possible effect of the induction on the mother and process > the agony of NICU. I would not wish that upon anyone.
posted by k8t at 6:42 PM on May 14, 2018 [2 favorites]


I came here to say basically what frumiousb said: I think that most Metafilter-reading parents are aware of the over-medicalization that sometimes happens around the birth process - the tendency to be very aggressive with induction and cesareans. However, the response to this over-medicalization by non-MD providers can also be an over-reaction.

That said, ultrasounds (and particularly late-stage ultrasounds) are notoriously bad at determining fetal size.
posted by Betelgeuse at 6:52 PM on May 14, 2018 [2 favorites]


There are mixed studies indicating that inductions do or do not increase the risk of c-sections. No current research consensus. You can ask your OB about their own stats and the stats of the hospital on this topic. How many inductions ended in c-sections last year? How many did not? If your wife's concern is primarily to avoid a c-section, that's what you need to know.
posted by juniperesque at 6:53 PM on May 14, 2018 [2 favorites]


Previous pregnancies or first pregnancy?
I'd listen to the doctor... bring a book she's already read and enjoyed -- * read part of a paragraph, contraction, re-read the same paragraph* -- bring crossword puzzles, listen to good music, be ready for a long slog to healthy baby/healthy mom time.
I take it she has a birth coach and an emotional support person on her team. The times I hated during two births were when my husband was sent out of the rooms.
posted by TrishaU at 6:56 PM on May 14, 2018 [1 favorite]


There's actually a fair amount of evidence that an induction at 39 weeks may be a good choice for all babies, primarily due to the risk of still birth. The evidence shows that inductions, if they are done following the most up-to-date methods, have basically no negative issues in terms of length of delivery, c-section risk, etc. I would recommend asking about how your hospital does inductions, and pay particular attention to the time they allow for cervical ripening, methods like Foley balloons, slowly ramping up pitocin, and the like. At my hospital (UCSF) they were happy to talk about how they let the process unfold and the steps that would be followed in my induction.

The anesthesiologist should be informed about the morphine reaction., and can absolutely take it into account in how they treat the mother.

I am always skeptical about claims of letting nature just take its course in pregnancy & delivery - it's very natural to have lots of babies & women dying in childbirth.
posted by Jaclyn at 6:57 PM on May 14, 2018 [30 favorites]


Doulas aren't supposed to give medical advice, so not sure why that's on the table. You could run her opinion that the baby is just "squishy" by the OB and see what they say. Also sounds like she is already at 40 weeks?
posted by yarly at 7:08 PM on May 14, 2018 [4 favorites]




Anecdotally, I went to 42 weeks and 4 days with my kid before they finally induced me, and delivered a totally healthy 9 lb 4 oz kid. I'm a crunchy hippie though, and had a midwife, not an OB.
posted by woodvine at 7:16 PM on May 14, 2018 [1 favorite]


If the due date is May 12, then... Isn’t she past her due date?
posted by amro at 7:16 PM on May 14, 2018 [1 favorite]


All the fears and concerns are understandable and you are making thoughtful decisions.

As someone who lost a baby to a labour gone wrong, a child who would be entering tennagerhood this year, had I been able to have a c-section in time, I hope you will please keep in mind that a c-section is neither a great thing nor the worst thing. Mom’s health and comfort is also important, absolutely...just don’t let the need to avoid a c-section eclipse the actual health goals.
posted by warriorqueen at 7:16 PM on May 14, 2018 [20 favorites]


Do what your OB tells you. He/she spent a lot of time and energy becoming an absolute expert in the delivery of healthy children.

This is overstatement that's as dangerous as telling you to ignore your OB's advice completely. Lots of OBs are excellent. Some OBs suck. Many are great and most are completely well-intentioned.

Check the mortality rates in the US compared to elsewhere in the developed world if you don't believe me.

You have a right to make this decision without having the notion that your doctor is 100% right because doctors are 100% right front and center.
posted by TryTheTilapia at 7:29 PM on May 14, 2018 [21 favorites]


I would follow the doctor’s advice and induce. A large baby delivered later might also result in a c-section. You really don’t have any way to determine the odds on this. As time goes on the placenta will start to age and get weaker, and you will have lots of NSTs and fetal movement to be worried about.
posted by permiechickie at 7:37 PM on May 14, 2018


FWIW my daughter was estimated at 8 pounds by ultrasound on Friday. On Sunday we had a 9 pound 4 oz baby. We also felt that the hospital where we were avoided doing a c section as much as possible; I know this because they discussed it obliquely around us.
posted by Comrade_robot at 8:01 PM on May 14, 2018


It's a tad more on the common side for babies to read bigger on the u/s at the end of the pregnancy, but u/s are by no means 100% accurate. I would suggest another ultrasound with a different technician if you want some further advice before making a decision.

I was induced for my second. My doctor let me go past 40 weeks but as we started to get to week 41 she insisted that we were getting into territory where there could be meconium in the water. I had the kind of induction where they put medication next to the cervix, and later I had an epidural. Start to finish it took about 12 hours, and sure enough there was meconium in the water, but just barely (ie, it had occurred just prior or possibly during the birth process, but it wasn't that it had been present for days, and baby did not go to NICU). Those 30seconds when they took him across the room to suction him, before he started crying - I still tear up thinking about it.

It's better to get on the induction calendar now (protip - both of my kids have birthdays in the next couple of weeks - you really don't want to be sweating whether or not your OB will be in town over a holiday weekend); hopefully nature will intervene before the doctor has to.
posted by vignettist at 8:05 PM on May 14, 2018 [1 favorite]




I’ve had four babies, four inductions. I’m 5’1”, my husband is 6’5”, all our kids have been large at birth.

Baby #1, I believed in the most natural childbirth possible, stuck it out to 42 weeks before being induced. Ended up with a C/S due to almost 10 lb baby not descending.

Baby #2, induced at 41 weeks, also large, several hour on and off pushing stage. A VBAC, but just barely!

Baby #3, 41 week induction, hours of pushing, 9 pound kid.

Baby #4, I insisted on being induced at 40 weeks. 20 minutes of pushing, comparatively svelte 8 pound baby. I kept remarking on how tiny he was, while the nurses said umm...that’s a normal size for a baby.

In sum, if you have a family history on either side of tall people or large babies, induction may be the way to go.
posted by Wavelet at 9:17 PM on May 14, 2018 [1 favorite]


My son showed as being large in ultrasounds and was around the projected size at birth. If your insurance will tolerate it, do another sizing ultrasound to verify the first result. Otherwise I'd follow their advice.
posted by toomanycurls at 10:18 PM on May 14, 2018


Midwife here (TINMA, IANYM, etc.) Agree with others above that a doula is not qualified to give medical advice and your OB is in the best position (of any of us) to make the call for induction. That said, it doesn't sound like mom and baby are in a great place for a successful induction given baby not engaged and bishop score is zero. However, if baby has been measuring consistently large, may be more reliable indicator of fetal size than just one term sono. It sounds like this is first baby, so pelvis hasn't been "proven," so no idea what internal pelvis is like (external hip measurements are irrelevant), which would give a better idea of how big a baby can pass through mom.

As mentioned above, I'd encourage you to ask questions of your OB and others in the office (are there midwives? What are the hospital's policies on induction? Will they send you home if foley bulb fails or will they want to section, etc.?) Do you have a birth plan, is your care team supportive, and what are your goals? Finally, (and I apologise if this sounds cavalier, as I am a doula supporter) but the doula's advice that big babies are "squishy" is a bit dangerous. One of te risks of delivering a large baby vaginally is a shoulder dystopia (when the shoulder can't pass under the pubic bone and baby is stuck). It happens with babies if all sizes but larger babies are at higher risk. So waiting to deliver a "squishy" baby is not necessarily harmless.

Bottom line: it sounds like you are not ready to consent to an induction today. Take this time to ask questions, get second opinions, etc. If you don't feel ofmfortable with your OB, ask another one because you do want to feel safe with the person who is delivering your baby. But please do make sure to take on well-educated advice that is evidence-based and will give mom and baby healthy outcomes. Hope this hasn't come out harshly, been awake for a long time! Sending good thoughts to the family.
posted by stillmoving at 11:10 PM on May 14, 2018 [20 favorites]


Anecdata here, but I had two inductions that progressed very easily to labor and two uncomplicated vaginal deliveries. In both cases they induced at 37.5 weeks due to babies measuring too small, and in both cases like your wife nowhere near natural labor.

So it’s not necessarily a bad thing, not necessarily a c-section. I apparently make tiny babies, and both were perfectly healthy.
posted by ohio at 1:11 AM on May 15, 2018


For my first baby, I was induced on the due date, after the water had broken, and with good reasons. It couldn't have been otherwise. But, after I tried an all natural birth with number two, I now know that the level of pain is completely different, regardless of the size of the child. Number two was a whole kilo bigger than number one, but the pain during labor wasn't even a fraction of the first time. So my advice would be to get a second opinion and only go through this if it is necessary.
Obviously, people on the internet don't know a thing about the actual situation.
posted by mumimor at 1:47 AM on May 15, 2018


Seconding amro and adding that if the due date was May 12, she would be in week 41 (40+3), not 39. Look up the stats for the right week and take into account the mother's age.
posted by meijusa at 2:19 AM on May 15, 2018 [1 favorite]


" a fat baby is still a squishy baby" is absolute nonsense. Fat babies can and do get stuck. they're not extruded through the birth canal like play-doh.

I do not have an opinion on the obstetric situation (IANYD) but neither should your doula!
posted by chiquitita at 2:55 AM on May 15, 2018 [4 favorites]


It sounds like part of the problem right now is the mother doesn't believe that the doc has the right due date, so she doesn't believe that the baby is late yet. Which it is, if you go by the doctor's due date of May 12th.

And, I think, no matter what she thinks, the doctors are going to make decisions based on a May 12th due date and there probably isn't any way to convince them otherwise. Which means that the latest they will want to let her go is 10 days past her May 12th due date. And they will probably want to start trying to induce labor around 7 days past her due date (if it hasn't started already), since inductions can sometimes take a while.

All of which means that the time-table for an induction in the next couple of days sounds like fairly standard procedure, big baby or no big baby.

I mention all of this because it sounds like she is hoping that she could convince the doctors to wait maybe another 2 weeks or so to let the baby come in its own time, and I think that is probably impossible, given how doctors calculate risks and what we know about how the risk of a stillbirth rises when a pregnancy goes post-term.

So even if it is annoying and frustrating, I think it might be better for her to just accept the May 12th due date and talk to her doctor from that point of reference.
posted by colfax at 4:51 AM on May 15, 2018


Anecdotal: pregnancy 1, I had a placental abruption at 41 weeks, waiting for labor to start spontaneously. Emergency c-section, recovery was terrible—I was knocked out on drugs and barely remember the first month of my kid’s life.

Pregnancy 2: induced at 40+3, successful VBAC, mostly unmedicated. Way better experience.

In retrospect I would have induced my first kid when my doc brought it up at 39 weeks.
posted by emkelley at 5:11 AM on May 15, 2018


If you do go ahead with the induction, just be aware that what's tough about it (in my experience as a birth supporter, n=1) is that it is a marathon! You can spend like two days in the hospital before the faintest contractions start. So whereas other people are waddling around, making soup to freeze, and sleeping in their own bed for those two days before contractions start, people being induced are hanging out in a hospital waiting for the cervix to soften, trying to get a little shut-eye in between the nurse check-ins. Then, the 8-60+ hour labor process starts. My point is, pace yourself emotionally and physically. Watch movies, get as much sleep as you can, have friends visit to keep you distracted, let them give you something that helps you fall asleep if they suggest it, that sort of thing. But, in my friend's case at least, the induction went smoothly to a vaginal birth. Good luck, you can do this!
posted by slidell at 5:49 AM on May 15, 2018


If you don't trust what your doctor is telling you, you should see another doctor. I know that is easier said than done for many reasons at this point in your pregnancy, but maybe there is another doc at their practice that could consult?

My wife was induced at 42 weeks by our very patient, very non-medicalizing OB. After 12+ hours of pretty low key labor they were about to wheel her into surgery, but one last check showed it was time to push. It took a while, but our daughter was delivered vaginally with no complications.
posted by Rock Steady at 6:05 AM on May 15, 2018 [2 favorites]


Just another note of anecdata to say that I was induced at 39 weeks on my OB’s recommendation, and had a very successful labor. I had just a single high blood pressure reading at my check up, and induction was my OB’s way of playing it safe. I’m very glad that I followed her advice.

Best wishes! Feel free to me-mail me if you would like to hear more details about my induction experience.
posted by ewok_academy at 6:29 AM on May 15, 2018


The reason for not waiting is in part to reduce the risk of stillbirth. Even the "39 week" rule may be overly restrictive.

Also, it's not clear that a "bad" Bishop score means the induction won't be successful. A meta-analysis showed that Bishop score was a poor predictor of successful induction.

And, as others have pointed out, it's not true that induction at 39 weeks increases the risk of C-section. Mounting evidence indicates it actually reduces the risk of c-section, especially for older mothers.

I would not rely on lay sources like Evidence-Based Childbirth or doulas, because they tend to be agenda driven and they fail to take into account the most recent research ... not to mention being unable to actually take your particular clinical situation into account.
posted by yarly at 6:37 AM on May 15, 2018 [3 favorites]


Anecdata: I was 40 (healthy, in good shape) when my daughter was born, and went past 40 weeks. My OB recommended induction not just because she was measuring large, but because the statistical likelihood of stillbirth for a first-time mother over 39 and over 39 weeks is almost twice that of a younger mother. The odds are still good in an absolute sense that the baby would be fine, but on balance induction seemed like the wiser (or at least less-anxiety-ridden) course to me.

I went in with a Bishop score of zero, baby not engaged, spent about a day on misoprostol, then about another half-day on Cervidil. My water broke, labor started and proceeded naturally. It was a long labor, but I think that was partly because my epidural was too strong (if I were doing it over, I’d know to ask them to dial it down so that I could feel the contractions a bit) and because it was a compound birth (baby had her arm over her head). There was meconium present, but the baby didn’t breathe it in. She was totally fine and healthy (and 8lb 12oz, so biggish, but not the over-9lb baby predicted).

It was a positive and happy experience for me – it was kind of nice to schedule a time to head to the hospital and stop for a nice lunch on the way. I found the 2 day induction pretty pleasant and relaxing. I’m happy that we went that route.
posted by Kriesa at 6:48 AM on May 15, 2018 [2 favorites]


Going against the grain here to say: you should probably refuse to be induced! What's the worst that can happen - baby gets stuck and you need a last minute C-section? Well that's FINE. It's no big deal at all. Millions of people have last minute C-sections. As long as you are laboring and giving birth at a hospital, the chances of anything going seriously wrong are almost nil (from just this variable of you refusing induction - other complications could occur but those would happen either way). Induction is SHIT and in your case it doesn't actually solve any problems worth solving.

Doctors have ONE mandate: to keep you and the baby alive. That's it. They usually don't give a shit about anything else. They don't care if you have a complicated recovery and lingering side effects from complications. They can justify that away as medically unavoidable even if it wasn't.

It sucks, because being alive is kind of important! And you CAN trust doctors to keep you and baby alive. But pregnancy is actually reasonably safe and not generally a life threatening condition. You have to assess your own self, and body, and risk tolerance... And you get to consider your own comfort and your needs and the best overall health outcomes you desire. IMO giving birth at a hospital but keeping doctors out except if there is an emergency is an excellent way to do this. Your body is yours, and don't let anyone fear-monger their way into commandeering it. Pregnancy presents a particularly high risk ofthat happening to you. It can be traumatic, needlessly so.
posted by MiraK at 6:53 AM on May 15, 2018


What's the worst that can happen - baby gets stuck and you need a last minute C-section? Well that's FINE.

Well, no, the worst that can happen is stillbirth, which is statistically more likely in late babies born to older women.

Listen, I am as anti-intervention as they come (I fired my OBGYN at 37 weeks and did a non-hospital birth to avoid intervention) but the stats say that stillbirth is a possibility.

I was ADAMANT about no interventions when I was pregnant -- but I am here to tell you, from the other side, that the ONLY important thing is a healthy baby and mama. I think I got too caught up in chasing a "perfect birth" and I think that's common. If I was pregnant again today and past 39 weeks, being over 40, I would seriously consider inducing. Birth doesn't last long, but the outcome (good or bad) is forever.
posted by rabbitrabbit at 7:40 AM on May 15, 2018 [10 favorites]


Going against the grain here to say: you should probably refuse to be induced! What's the worst that can happen

Uh, the worst that could happen is that the baby dies, since the risk of stillbirth increases after 39 weeks for women who are nearing 40.

Keeping the baby alive is a goal that most people would consider towards the top of their list. Can you articulate exactly what the benefits are of waiting, when counterbalanced against the increased risk to the baby?

And given that induction actually *reduces* the risk of c-section, I'm not sure why it would reduce complication to avoid induction anyway?
posted by yarly at 7:43 AM on May 15, 2018 [2 favorites]


I was ADAMANT about no interventions when I was pregnant -- but I am here to tell you, from the other side, that the ONLY important thing is a healthy baby and mama.

Agree (as another one who went too far in the "natural birth" direction, in retrospect.) Hopefully this isn't too much of a derail, but I think maybe my experience can be part of a useful answer to the question.

Basically, the key thing here is to understand your own ladder of preferences and values when it comes to medical interventions. Your choice for childbirth should really fit into this, instead of birth being somehow set apart as a different medical event. Because it's a medical event, first and foremost.

For myself and for my child, it turns out I have *no* hesitations to use the very tippy top in modern medical science, when called for. This doesn't mean I don't research the heck out of the condition and treatments. I do, and I have absolutely rejected some medicines and procedures that were recommended. But I always do this from the perspective that modern medicine is good and helpful; not that there is some kind of "natural" solution that I should seek out. Also, the illnesses and conditions that require medical intervention are not some kind of referendum on my bodily autonomy or value as a woman/mother. They're conditions that require treatment, period. I know it's a bit hackneyed, but I would (now) no more think that it was reasonable to believe I would forgo available pain relief in labor, than I would turn down Novocaine for a filling.

TL; DR. Don't treat this like a fraught moral decision; treat it like a medical decision.
posted by yarly at 7:51 AM on May 15, 2018 [5 favorites]


My second didn't come until 41.5 weeks. At 40 weeks my midwife started making preparations for me to go to the hospital. Since I had a (very traumatizing) c-section with my first, induction was off the table, which meant pretty much a c-section was guaranteed.

It was a very heartbreaking week, and I really thought she would have come by then. I did a lot of crying and a lot of walking and two days before she was born I was barely dialated and with next to no effacement.

But on a Sunday night after a day of the piddliest contractions ever, my water broke full force around midnight she was born Monday morning at home with midwives.

Cautiously waiting as I did is an option. Agreeing to every other day stress tests is an option. Less invasive inductions than skipping straight to pitocin is also an option. I won't necessarily advocate for those, but you have time to ask questions and assess still. Really do what's best for you and for baby, and sometimes......sometimes those can be contraindicated. I was absolutely selfish with my second pregnancy because my PTSD from my first was off the charts during it and the only way I'd be able to take care of a baby was by taking care of myself and not exposing myself any more than I had to the very conditions that put me in that terrible and unfortunate position in the first place.

Whatever decision is made will be the right one. No one can fully predict consequences or outcomes and both the worst and best continue to happen for reasons and no reason at all.
posted by zizzle at 9:23 AM on May 15, 2018


you should probably refuse to be induced! What's the worst that can happen - baby gets stuck and you need a last minute C-section? Well that's FINE. It's no big deal at all. Millions of people have last minute C-sections.

Actually there are a lot of other complications. Shoulder dystoxia is a pretty bad one, which can result in permanent damage to both baby and mother.

Stillbirth is tragic. I still regret that I had a coworker who was pregnant a few years after I lost my daughter who had gone pretty far down the "natural" birth community road and was waiting at 41.5 weeks...and I didn't say anything to her because you don't upset the pregnant lady. Well, she did have an induction in the end - to deliver her stillborn son, because you don't do a C-section to preserve a life that's already ended.

And infant loss due to oxygen deprivation, which is what I went through because even in a hospital, my daughter and I were not able to get an emergency (red light emergency) c-section in time, is darn awful.

What I learned from that: about 2% of babies in Ontario do not go home. 2% seems very small, until you are missing a wanted family member for the rest of your life.
posted by warriorqueen at 9:41 AM on May 15, 2018 [7 favorites]


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