Let me take one thing at a time. First, if you have swelling, but your blood pressure is fine, then your ob is recommending an elective induction, that is, one for no medical reason. Every medical intervention has the potential for harm as well as benefit, so by agreeing to an elective induction you would be running the risk of the harm with no counterbalancing benefit. The best way of telling when your body is ready to labor is when you go into labor on your own.

Second, the "big baby" argument is, I'm sorry to say, pretty much a standard ploy used by conventional obs to get women to agree to an induction. Studies consistently agree that induction for suspected large baby does not improve outcomes. In any case, you clearly don't have problems birthing a good-sized baby, so don't let your ob scare you about that.

Third, your ob is mistaken in thinking that reaching 39 weeks makes it safe to induce without running excess risk of the baby having breathing problems. The medical literature says 39 completed weeks, in other words, at the beginning of the 40th week to avoid respiratory problems. Again, though, the best way to tell when the baby is ready to be born is when labor starts on its own.

Frankly, are you sure your ob is "natural childbirth" friendly because he sure doesn't sound like it. Natural childbirth friendly obs don't try to talk women into induction at 39 weeks. My advice is to maintain a little skepticism and not to be lulled by his talking the talk. He isn't walking the walk.

Your ob is correct that a high Bishop score, a measurement of how ready the cervix is for labor (soft, effaced, dilated), is a good predictor of whether an induction will be successful. But a woman with a score of "9" is likely going to go into labor within a few days anyway. 

The study that concluded that there were more stillbirths with induction at 41 weeks is flawed. Read my critique and make up your own mind.

Having had a vaginal birth before, you are at less risk of an induction failing than a first-time mother, but your own last statement is telling: "Everyone I know in the Washington, D.C. area gets induced and has c-sections and then has repeat c-sections for all the rest of their kids." Follow your gut instincts. As David Stewart wrote years ago in The Five Standards of Safe Childbearing: "When nature does work, it cannot be improved. Technology does not enhance a natural process that is working. It can only mar or destroy it."

-- Henci

Henci, I just want to say I LOVED your book and it really influenced me in my birthing decisions with my first baby. 

This is my second child.  I went into labor with my first baby at 41 weeks plus 6 days and after a relatively easy 6 hours of active labor had a homebirth with no interventions at exactly 42 weeks. My first baby weighed 8 pounds and 6 ounces and was completely covered in vernix.  For this birth, we are doing the full hospital thing because I had a really bad postpartum hemorhorrage, infection, and other big issues with the midwives and we can't handle a repeat of all that...

In another 3 days I will be 39 weeks pregnant -- with my second baby this time -- and my OB keeps talking induction. This is because I am so uncomforable, have gained so much weight, and have such horrific swelling in my hands and feet and have TERRIBLE carpal tunnel in my right hand.  Plus he says my baby is going to be BIG given all the weight gain, etc.  But blood pressure has always been low-normal.

  I have already told my OB (who is natural child birth friendly but still an OB) that I am declining the pelvic exam for the 39 week appt, and he is fine with that...  He says induction of labor with pitocin is NOT more likely to cause fetal distress than but I have read that it is.   I don't want to be pregnant any more so I am sorely tempted by all this induction talk. 

Also I am worried there may an increased risk to the baby of going beyond 41 weeks?  My doulas said there was a big study that showed increase risk of stillborn after 41 weeks, and ALL the other OBs in this area always induce at 41 weeks.  Am I risking my baby by going  beyond 41 weeks? I am 41 years old and this is my last chance pregnancy to have a second child.  I needed fertility help just to get pregnant this time.

My OB says he will use the Bishop score and if my score is above a "9" there is a good chance an induction wil work.  My big question for you is How much predictive value does the Bishop score have? I have read that it is somewhat subjective, so can I really trust what score my doctor assigns me?  How risky to the baby and to me is induction?  Everyone I know in the Washington, D.C. area gets induced and has c-sections and then has repeat c-sections for all the rest of their kids.

Thanks for reading this!!!

Sounds like a plan. I suggest that "being stubborn" take the form of what we called back in the day, playing "broken record." You simply keep repeating that you prefer to let labor start on its own over and over again with slightly different words, but you don't let yourself be drawn into an argument, ex., "I hear what you are saying, but we have decided to let labor start on its own," "I'm sorry, but unless there is some clear medical reason why we should do otherwise, we're just going to let nature take its course," etc. I strongly recommend that both for this and for labor itself that you and your partner make sure that you are on the same page. It can be a real problem for the couple relationship if the partner gets co-opted by medical staff, and partners are vulnerable to this.

In labor--barring an emergency--before agreeing to a medical intervention, ask:

• What is involved? This should be explained in clear language that you can understand.
• What are the potential benefits?
• What are the potential harms?
• What other interventions might or would become necessary as a result of this one? What are the benefits and harms of those?
• What are my alternatives? This should include doing nothing.
• What are the pros and cons of the alternatives?
• How urgent is it that we make a decision?

When you have the information, ask for time alone to discuss it. Agree ahead of time with your partner that you will not respond to scare tactics but only to factual information, and keep in mind that no intervention is harmless. Any intervention into the normal process has the potential for harm as well as good, which is why routine intervention is always a bad idea. When there is nothing wrong or the problem can be resolved by having patience or by simple measures, the woman and baby are necessarily exposed to the harms with no counterbalancing benefit.

-- Henci

Henci,

Thank you so much for taking the time to respond.  I really appreciate it.

I am so sorry that you are experiencing this distress. I must tell you that I am not aware of any evidence supporting induction prior to 41 completed wks in whether it is a first baby or a subsequent baby. The evidence supporting induction even at the beginning of week 42 is controversial, and there is a consensus that labor should never be induced electively prior to 39 completed wks because of the increased risk of the baby having difficulties breastfeeding and of having serioius respiratory problems. As for her statement that your babies would be better off outside than inside, the fact that your babies have coped with the rigors of induced labors despite not being ready to come on their own argues against that theory. Moreover, your babies may have been smaller than average, but they have not been low birth weight (less than 5 lbs). A much stronger case could be made that they should be allowed to grow to the full size they were meant to be in the womb, that you "cook" your babies longer, and, that, as has been said, "When the fruit is ripe, it falls from the tree."

The bigger problem is that your ob is not practicing evidence-based care, which means you cannot trust her judgment in other matters either.  Another red flag is the statement that your ob rarely "allows" women to go to 41 wks, which shows her misunderstanding of your fundamental right to make decisions about your care, including refusing care. Here is a link to a patient rights pamphlet put out by the Joint Commission, the organization that accredits hospitals, about your rights.

As to what you can do and what your dr can do in response, your dr should respect your right to make an informed refusal to induction--or to any other treatment, for that matter. What may happen in practice, though, may be a different matter. Not every ob respects their patients' rights, and you may, indeed, be fired by your dr, or, as you have already found out, you are extremely vulnerable to the accusation that what you want is not in your child's interest and have no way to tell whether that is the truth. The other option you are considering, that of just showing up in labor, is far from optimal too. You may still end up with an angry ob taking care of you in labor, never a good thing for you or your baby. I think your best option is to find another care provider if you possibly can. The doulas and childbirth educators often know which ones have a practice and philosophy that promotes normal birth. The nurse manager in the intrapartum unit may be willing to tell you which doctors or midwives are most comfortable with "natural" childbirth. If there is no one better or no one better willing to take you this late in pregnancy, my best thought is to schedule a conference appointment with your current doctor. Take a copy of the Joint Commission pamphlet with you.  Explain that both of you want a healthy mother and a healthy baby and that can best be achieved by, barring an emergency, her giving you accurate information on the pros and cons of any medical intervention she proposes and the pros and cons of your other options, including doing nothing. You promise to listen to any argument based on factual information but not to any attempts to persuade you based on emotional appeals and that you will make the ultimate decision. Stay calm, be polite but firm, and see where it gets you. 

Please let me know how things work out.

-- Henci 

I need advice from someone who thinks outside the box, and doesn't just look at policies.

 

I am on my fourth child.  All of my previous pregnancies were induced and I really didn't want it.  My body was not ready for labor and I ended up with long, slow pitocin labors because my body had not done any "prep" work.  My babies were all small, even my son who went almost two weeks late before they insisted induction was only 6 pounds 1 ounce.  I have long menstrual cycles, so my body is just not the standard in either realm.  There are no homebirth type midwife options in my State - they are all attached to a Dr. office and fall in line with the office's practices.  Besides, I am 32 weeks now and have too much money involved in the current situation I find myself in.  I spoke with the Dr. today and she stressed, stressed that non-first time moms are always induced at 39-40 weeks and rarely will they allow them to go to 41 weeks.  I am frustrated, extremely frustrated.  I explained that I am not normal and she didn't buy it at all.  She said that my babies might be small because they are failing to thrive inside the womb and they would be better off outside, so maybe an earlier induction would even be better.  I don't "buy" it.  I don't like it.  I was determined to stand against an induction with my 3rd and when I was 2 days past my due date they threw the "you don't care about the health of the child and you will be held liable" spill on me.  I caved.  My question is this, can I outright refuse induction?  Legally, even if something happens to the baby, could they do anything?  I would obviously not refuse an induction if I knew that it would bring harm.  Can they refuse to deliver the child if I refuse induction?  I just wonder what would happen - do you have any idea?  I am so frustrated with feeling like I have no say in this.  I really think that I could have a much more manageable labor if my body was ready for labor.  My shortest time on pitocin was 26.5 hours (with my 3rd) and it went so fast because they had a time schedule of progress that I had to meet and they just kept turning the pitocin up more and more - way too frequently.  It was the most miserable experience and I said that I would never have another child again.  I have never had an epidural, I just don't believe they are best.  I have had all sorts of crazy thoughts, from just not showing up to Dr. appointment beginning at 40 weeks, etc.  Just show up at the hospital at 44 weeks in labor, but they put so much pressure and fear there.  Any thoughts on this are appreciated.