1. Exactly what physiological danger is there in waiting until labor starts naturally? By this, I mean after 41, 42 weeks (primips especially)....?
The main problem is that about 1 in 1000 babies die in utero in the 41st week. Presumably, inducing labor will prevent those deaths. We don't know that, actually, because we don't know if that baby had something wrong that wasn't obvious at the time of delivery, and it wouldn't, say, died of SIDS two months later. And then, of course, inducing labor isn't risk free. In particular, studies consistently show that it doubles the risk of c/sec in 1st-time moms. C/sec introduces its own risks to the baby, and especially to the babies of future pregnancies.
It is also true that longer gestations are associated with more difficult births and complications, but this is at least partly due to 1st-time mothers averaging longer gestations. They are much more likely to have problems than women with prior vaginal births. As the days roll by, a greater and greater proportion of women who have not gone into labor will be first-timers. By the way, the median gestational age for 1st-time mothers is 41 wks 1 day
not 40 wks. The median length in women with prior births is 40 wks 3 days.
For the problems with the research on this issue go to
When research is flawed: Management of postterm pregnancies.
The normal process should be the default unless and until a specific problem crops up, and all normal physiologic processes have a wide variation around average. As David Stewart wrote in
The Five Standards of Safe Childbearing, "Technology does not enhance a natural process that is working. It can only mar or destroy it."
2. What danger exsists when amniotic fluid levels are low (again, around 41-42 weeks)? A recent student/mom had this issue, even though she was drinking water constantly. Is this a proven reason to induce?
Disclaimer: I'm not a doctor or midwife, so this should not be taken as advice. However, let's think this through logically. Low amniotic fluid increases the risk of abnormal fetal heart rate during labor from umbilical cord compression. Part of the usual induction procedure is to rupture membranes. Now the baby has no amniotic fluid. Low amniotic fluid may also signal fetal compromise. Inducing labor usually causes contractions that are longer, stronger, and closer together than normal labor usually is. Consider as well that measurements of amniotic fluid volume aren't very accurate. You are trying to measure a complicated three dimensional volume using a modality that is two dimensional. The best they can do is tell you that you have way too much fluid or almost none. Problem is, once you have a test that tells you the baby may be in trouble, no one is going to sit on their hands. This is one reason to be wary of agreeing to routine testing. I also don't know of any studies showing improved outcomes with inducing labor for low amniotic fluid, but I also haven't looked that hard. It may be valuable to politely ask the ob who is pushing for induction on these grounds to show you or direct you to the research supporting that practice.
3. What tests are there that accurately assess the baby's well-being during the last weeks in-utero?
None. All tests of fetal wellbeing have high false-positive rates, that is, the test says there is a problem, but there really isn't. In a low-risk pregnancy, the test is much more likely to be wrong when it says there is a problem than it is to be right. Studies evaluating the worth of routine tests of fetal wellbeing have failed to show better newborn outcomes.
4. I know EFMs are famously questionable. What advice do you have for parents who are told that the baby's HR is decelerating (either before labor or during contractions)?
My advice is to consider the pros and cons of fetal heart rate evaluation before labor (nonstress testing) and of continuous electronic fetal monitoring, more properly called cardiotocography, during labor. In most cases, the best advice is: "Just say 'no.'" In the case of continuous EFM in labor, the only time it has been shown to have even short-term benefits is with high-dose oxytocin protocols A.K.A. "active management of labor" where it reduces the risk of newborn seizure. Even so, no long-term benefits have been found. Meanwhile it increases risk of c/sec. It would seem to make more sense just to use more physiologic oxytocin regimens when oxytocin is needed.
5. Do you know the actual percentage of babies with cords wrapped around their necks (I sense that it is high), and the risk factors associated with it? I'm constantly told, "Oh, they had to get the baby out quickly because the cord was wrapped around his/her neck," and I have a hard time believing that this is a cause for alarm.
I don't know the percentage, but it isn't uncommon, and it isn't usually a problem. In most cases, the cord just needs to be unlooped after the baby's head is born. When blood is flowing through the cord vessels, it is like a fire hose. It is fairly difficult to kink it. If it is a problem, it will become clear during pushing, but even in this case, the baby can often safely be born vaginally. When it is a problem, while a c/sec might be needed, it probably won't be an emergency. Mostly, staff just have the woman stop pushing and perhaps give her a drug to stop contractions while they set up for the c/section. I think it is one of those phrases obs like to use to convince women that they needed the c/section. Telling her she has a "paper thin" uterine scar during repeat c/section is another one. Canvas can be "paper thin."
-- Henci
By: Henci Goer