Statistics behind the hospital induction policies

[Babysaurus]

Hi,
I am now 24 weeks and am starting to think about the birth side of things a lot more. Please don't assume I am someone who'd put either myself or my baby under unneccessary risk, but I am starting to question some of the policies I have been told about so far. Hence, I want to start reading up on things so I can get a better idea.
I have been repeatedly told that I 'have to be induced' at 38 weeks. I heard via this site this is due to the placenta starting to fail but when I mentioned this to the obs he said the main reason is due to the size of the baby in diabetics, and bigger babies have a higher risk of dying during childbirth. I am a Type 1, my last HBA1C was 5.3 (and previous to that was 6.1, 6.3 and 6.0) and the baby, so far, is measuring in the middle, to small, of the growth scales they give. Given this info, and the fact that the placenta failing didn't seem to be viewed as a likely scenario, an early induction which may result in all sorts of nasties such as forceps or c-sec seems a bit over the top.
Does anyone have any links I can have a look at to learn a bit more about the real risks of going over 38 weeks so I can get a proper picture of why they have the rules they have?
I am wondering if these polices are another 'catch all' to include Type 2's, gestational diabetics and Type 1's who have really struggled and / or had problems.
Thank you!
Bx

 

[PhoebeC]

All i know is my hospital said they always induced diabetics at 37 weeks think they said due to the size and the placenta
I didn't make it that far but had a 36 hour labour and forceps in the end
Will be interesting to know the answer x

 

[Babysaurus]

Hi Phoebe,
Mine have said similar but I asked if the size was normal, is it mainly due to the placenta and the obs didn't seem too fussed about this (I can't remember the exact way it was put) and gave the impression this wasn't an especially likely thing. Which makes me curious as to why you'd be induced, and all that entails and can entail, if the baby's size is no different to what is considered 'normal.' Seems a bit over the top really when it's viewed like that doesn't it?

I am not just being awkward for the sake of it with them, but I do think finding out why certain polices are in place can sometimes reveal that actually it is not that relevant to yourself at that particular time. I am also very wary of going through an induction for, what turns out to be, a minisucle risk but is 'recommended' for all diabetics 'just in case.'
Gawd, I am coming across as a real nit picker now aren't I?! I am not normally, honest!

 

[Babysaurus]

And as I know two people who have had massive problems since having forceps deliveries, I am not able to switch off and go into this with my eyes shut! 🙂

 

[PhoebeC]

Its understandable to worry and wonder totally natural

I was a forceps birth and so was my daughter and we are both fine (even out the odds for you)

I needed them id have never done it without them i had pre-clampsia and was swollen everywhere Saying that its okay for me to say this now she's here and fine

The more natural a birth can be the better If id got ti 36 weeks id have done everything to get her out without induction they arnt fun at all x

 

[beckyp]

I'm afraid I don't know statistics and can only share the information I found through asking people when I was pregnant last year. I had the same queries.

As I understand it, many hospitals like to induce diabetics earlier than 40 weeks due to the possibility that your baby will be larger than they'd like but more and more are trying to do this as late in pregnancy as possible now. If you are well controlled during pregnancy this should be less of an issue.

The chances of the placenta failing are low and my consultant couldn't stress this enough to me. The signs of the placenta failing in pregnancy are when you insulin requirements start to decrease instead of increase and this should be pointed out to your team if it occurs. It did with me but they still stressed that my placenta was healthy at birth.

I always felt that inducing at 38 weeks was a big risk. Unless there is something wrong with you or the baby then I don't think it should happen as the baby isn't always ready to enter the world and the chances of csection are increased. I was induced at 38 weeks (but was booked for 39 weeks) as I had high blood pressure (through the roof!) and 3+ protein and my insulin requirements had dropped by 50% (since the beginning of pregnancy). I went to the hospital on Tuesday, had a 6 hour pessary on Wednesday morning which failed, had another on Wednesday night with a stretch and sweep which failed, had my waters broken on Wednesday which failed and was then put on a drip on Wednesday night. By Thursday morning the doctor examined me and said that my contractions weren't strong enough and I needed an emergency c-section.

Inductions clearly work for some women (as proven on this website with lots of healthy babies!) but they don't work for all. From reading fellow type 1's birth stories on this website it always appeared to me that more ended in csections.

Basically, without any more waffle from me (and unproven theories!), I guess what I'm trying to say is that the better controlled you are (you obviously are judging by your HBA1C's), there is less risk that your baby will be too big. My hospital had a guide on how big is 'too big'. If your baby is 'too big' a csection would be advised. All hospitals do things differently though. My advice (for what it's worth!) is BAKE THAT BUN FOR AS LONG AS POSSIBLE! They will be monitoring you weekly at the end of your pregnancy (from about 34-35 weeks) so will be able to judge how things are going.

I hope the rest of your pregnancy goes well.

 

[Babysaurus]

Becky thank you ever so much for your answer.
I am in full agreement that 'cooking' that baby for as long as possible is a good thing, and it is good to hear that your consultant also seemed to think the placenta failing is not a major issue for induction. The one I spoke to didn't seem to think it was too high a risk either, and also, although he didn't elaborate too much, seemed to think it would be gradual rather than sudden thing. He was far more concerned with the whopper baby scenario, despite not evidence to imply that was on the cards.
I am obviously going to have to enquire more and more, but as things so far with this pregnancy seem fine (I realise that may change, although not if I can help it!) now I also think all the talk I have heard so far of how I 'have' to be induced at 38 weeks at the latest seems a bit over the top.
As this is my first baby (and possibly my last!) I very much doubt that he or she will be ready to come out on the dot of 38 weeks, and have a horrid suspicion that it may end in either instruments or c-sec due to this. While this would be part and parcel of the whole having a baby thing if I was carrying a 10lb or over baby, or had another health problem which would make early delivery important, I am not sure it makes sense if there actually aren't any other issues but it simply fits with hospital policy for 'all diabetics.'
As I have said before, I would not want to put either of us at any risk but I also feel as if fitting it with a one size fits all policy won't do us any favours either.
I may change my mind closer to the time, and I realise things could change as things progress, but I am still going to be questioning things to the maximum first (for my peace of mind if nothing else!)
Thanks again!

 

[Medusa]

Hi, I have had two babies, the first the induction took a long time but i had a perfectly normal delivery no forceps or anything like that, he was 8lb7, the second one i was taken in to be induced but luckily i was already dialated, my control was better second time around but the baby was just shy of ten pounds! I think they like to play it safe but the chances are they wont induce you bang on 38 anyway due to volume of births that take place, i think maybe it would be worth you getting a second proffesional opinion which you are entitled to as although i can share my experience i am not knowledgeable in every aspect of the inductions stats etc

 

[AlisonF]

I have no experience of this, but I would be asking exactly the same questions as you Babysaurus if I was in your place.

In the back of my mind, I was sure I'd read that induction at 38 weeks was starting to be considered less necessary, if size, placenta etc were all fine and close monitoring continued. But a quick scoot round the internet didn't come up with that, so I'm starting to think I heard it at a conference or dreamt it.

The NICE guidelines for diabetes and pregnancy http://www.nice.org.uk/nicemedia/pdf/CG063Guidance.pdf say:

1.4.1
Timing and mode of birth
1.4.1.1
Pregnant women with diabetes who have a normally grown fetus should be offered elective birth through induction of labour, or by elective caesarean section if indicated, after 38 completed weeks.

I think the key words there are "should be offered", ie you don't have to accept. But we're still lacking any real evidence for you to make an informed decision with I'm afraid. If it were me, I'd be spending a few hours on the internet, trying to find the latest research, and possibly asking for a second opinion. I'd be interested if you do manage to find the latest evidence being used to make the induction recommendation/anything that contradicts it.

 

[RuthieG]

Induction?

Hi Babysaurus

I am a few weeks behind you (nearly 18) so haven't had a big conversation yet about the birth with my consultant but from what we have discussed thsi si what thy have said at my hospital (St Mary's Manchester):

- Usually they will induce at 37-38 weeks and i got the impression this was due to the size of the baby, although I would need to ask for the full reasons and policy
- My last HBA1Cs are nearly identical to yours and during my last chat with the consultants Obs he said something like 'the way you are going you will be begging us to induce you at 40 wks'. I said that I was under the impression that they always induced at 38 weeks but the consultant said no, not if it isn't necessary - this pleased me no end
- The consultant was really keen to stress that they like to do it as absolutrely naturally as possible and as much like non-diabetics do as possible.

I am there tonight so might ask if I get chance and if not I will ask in two weeks at the 20 wk scan appointment. then at least we can have a view of what different teams/hospitals say. I defintely think you are right to ask questions and to understand the reasons behind every decision being made - then you can put your two-penneth in!

I enjoy reading your posts as you are a few weeks ahead and your bloods etc are almost identical to mine!

 

[Babysaurus]

Thank you everybody for your replies. I was thinking about this a lot last night when I was trying to go to sleep and its getting me quite wound up (not badly so, but I am now desperate to have a proper discussion about it with someone at the hospital.)

To me, at the moment at least, it looks as if the induction at 38 weeks business is a blanket policy to cover everyone, including those who have ignored any medical advice, have developed gestational diabetes but not treated it properly and so on. When I asked, briefly as it was when I was only about 14 weeks at the time, why they induce it was a brief answer basically along the lines of it being the safest option. I suppose now I need to ask them why it is supposedly more safe.

I am starting to see it like this: inductions are mainly done due to the size of the baby. They are gruelling to say the least and almost always require an epidural so the one being induced can cope with the pain. (I have to say, something that makes an injection and tubing inserted into the spinal cord look like the preferable option isn't a nice thought!) Due to how epidurals work, they can more often than not then lead into a cascade of other interventions such as the hideous forceps / ventouse or c-sec (c-secs seem to happen a lot in diabetics, do you reckon this is due to inducing early?) Obviously these methods can lead to problems of their own in terms of recovery, for both the mother and the baby.

The baby is meant to be in there for 40 weeks (interestingly, in France the gestational period is considered 42 weeks, not 40) for a reason surely? I have also read that the suck reflex is better in babies born 40+ weeks (not looked into this yet, will keep you posted) which makes breastfeeding in particular, but I imagine bottle feeding too, easier would it not?

Another thought I have had re the 'big baby' scenario is how big is 'big' meant to be? I ask as many women have babies of 9lb or more and they are not pumped full of drugs to get them out early are they? If my baby was looking big-ish, as was the woman next to me, why does it make sense for me to have my baby asap but not for her to? Also, the estimated sizes given are notoriously inaccurate (I realise this can work both ways!) so its not like it's set in stone anyway!

Ruthie the obs I have spoken to, admittedly not in huge detail as yet, seemed a lot less flexible that the one(s) you have dealt with so far. Please keep me posted as to how you got on today.

Right, I shall get Googling and see what I can come up with! Thanks again for your replies x

 

[allana]

Hi,

I have a 19 month old little girl and I'm 17 weeks pregnant. When I had Amelia I was induced again they told me it was due to the size of the baby. When she was born she was only 5llb 10 oz. I agree with other people on here, if you have good control your baby shouldn't be huge. I have my next appoint at 21 weeks so I am also going to ask more questions, as it would be much nicer to go in to labour naturally.

Please do let me know what answers you get ladies

Allana xx

 

[Babysaurus]

Allana, your story is exactly the kind of story that bothers me about this whole induction policy business! This all sounds very much like a case of 'one size fits all' doesn't it?
I am compiling my list of questions and getting my research sorted all ready for the apt tomorrow (not sure if it's jsut with the endocrinologist or the obs as well but hopefully it is the obs.)

I can't believe this doesn't all get questioned more often!

 

[allana]

Tbh I'm angry that I didn't question more 1st time round! But as you know managing pregnancy and diabetes is a full time job lol. I think they want to minimise risks so treat everyone the same. Please do let me know what answers you get as it wil also help me get answers. I hope you do get to see the obs tmrw Hun.

Good luck!

Allana

 

[Medusa]

i do remember though being thankful of induction at 38 weeks the last few weeks are very long.... ask anyone who goes to 42 lol

 

[Twitchy]

I suspect instead of a 'one size fits all' policy this has historically been more of a 'this is safest for most' approach...The diab specislist Obst who delivered my babies in '07 & '10 had decades of experience & a wary 'lets get a live baby out of this pregnancy' approach - from the first time we met him he told me i had a 70% probability of it being a c section. Unfortunately i'd already been suckered into the whole 'must do this natural nct earth-mother style or i'm a total failure' psyche so i wasn't best impressed! I can only speak from my experiences but baby 1 was born by 'semi elective emergency c section' at 34w 5d due to severe Pre eclampsia, which is associated with t1. He weighed 5lb 12oz which was bang on the 50% percentile. I'd been achieving HbA1cs of around 5.6 - 6.5% by obsessive control, but the docs still thought baby was surprisingly well sized given thx degree of PET, they think the PET cancelled out thd big diabetic baby factor. Baby 2 was born at 35w4 d, again semi elective emergency c section, this time due to failing placenta (sudden, severe inexplicable hypos). Having been warned to watch out for these hypos i self presented at hospital. The 'normal' docs were talking about leaving me til my planned date, or maybe inducing if the hypos continued...they were happy because bizarrely i was only crashing at lunch times (but then mega hypo!!). I knew my doc was back in thd next day, & when the ward doc looked at my notes & started talking about maybe bringing things forward to the end of the week i asked for the specialist...he took one look & declared baby was to be born today!! And she was, hugly macrosomic (sumo style!), by emergency c section & needing forceps to 'unwedge' her! She was 7lb 13oz, which is apparently normal for full term babies, but this was only 35w4d. My control had been described as 'excellent' through this pregnancy too. She was beetroot red - the placenta failing had meant she'd been generating lots of extra red blood cells apparently, & her initial apgar score was thru the roof because she was now getting more oxygen! The comment was 'tomorrow would have been pushing it.'

I don't know why i only seemed able to do 'half baked babies'. Maybe it's being a very 'old' diabetic, after many years on the pants 2 jabs a day routine...dunno. I'm not telling my experience to scare anyone, just to put across why docs can be cautious. At the end of the day, if i'd demanded to try for a vbac, i honestly don't believe baby would have survived, & for me the important thing was baby surviving. First time round i was too ill to care about how baby arrived, 2nd time round i trusted that one experienced, cynical, caring doc. (thank God!!!

Re feeding, baby 1 struggled, kinda got there in the end with top ups but a combo of my diabetic control, his jaundice (assocd with br feeding) & collective exhaustion meant it was far from easy. Baby 2 was a hungry little monkey, latched on within hrs of being born & fed far better. There is an association between gestational 'age' at birth & feeding success, but again my personal take is 'pushing it' might not be worth it if there is evidence (hypos etc) that it's necessaryto get baby out.

Hope that makes sense & doesnt sound like im trying to worry anyone, just sharing what happened to me, like i said i might have just been unlucky, it might be how long id already been diabetic, but if i were to have another baby with this dodgy body of mine id rather have a live, slightly early c section birth baby who maybe needed formula than gamble it all & lose, as it were. Right, am off to hide now before the hit teams of the nct & la leche league hunt me down & beat me with (organic) sticks lol... 😛

 

[RuthieG]

Appt today

Hi Babysaurus

I only saw the diabetes doc today so no news but I am seeing Obs next time (two weeks today) at 20 weeks. I will keep you posted and also see what he answer are to your questions (hopefully tomorrow)

Ruthie

 

[Babysaurus]

Twitchy, thank you ever so much for your post.

It is helpful and thought provoking to hear another side to things as I was, well still am to an extent, of the train of thought that it's all precautionary and for every single diabetic regardless of their individual circumstances. Your post has given me another viewpoint to the induction side of things to mull over (it has especially sunk in that you too are / were very well controlled.)

I think I am getting enough questions, and sometimes knowing the answer regardless (always helpful so you can work out how straight they are being!), together to start enquiring more. The way I see it, if I went in and asked for an elective c-sec they'd more than likely refuse on the grounds that it was an unneccessary medical procedure. I feel a similar way about an induction if there are not solid grounds for it, that too would be an unneccessary procedure. Hence, I need to get asking more and more about what's behind the policies and also weigh up the real risks.

It seems as if it is not just me who is questioning all this so I will, of course, keep you all posted!

 

[Babysaurus]

Ruthie, I was wondering how you'd got on! I see my diabetic doc tomorrow and sometimes these apts also include the obs so, if I get chance, I will do some enquiries and keep you posted. I also have a midwife apt at 9am so will see what her views are on things too, although I will not expect too much as, good as they are with some things, the midwives are not specialists with diabetics and all that can entail.

 

[Smit]

I hate to say but good control does not always lead to a smaller baby. See my post from last week. 5 weeks ago I was measuring too small and the consultant said he was happy to leave me until 40 weeks as I have really good control. Then last week at my scan I was measuring 2 and a half weeks ahead and now they are saying if things continue I will be induced at 38 weeks if not earlier.

I agree with you babysaurous, research everything and ask lots of questions. Thats what I have being doing since I found out I was pregnants but remember things can all change as you are well awhere with my situation. Good luck and keep us posted on what you find out/consultants say. I'm dreading my next appointment. Bloods all back in range but sure baby is growing rapidly. Doesn't help my hubby is 6ft 6!