I am a childbirth educator (HypnoBirthing and Lamaze) and doula.  It seems like the OBs (and some midwives, frankly) around here will make up any reason to induce, although I am aware that the safest approach is only to induce for medical reasons.  Problem is, doctors make every reason seem medical.  The term is ambiguous to me.  Can someone clarify what exactly ARE medical reasons for induction?  For example, I would suspect that preeclampsia is one.

I'll give one example--a first-time IVF mom in her early/mid 40's, with LOTS of fluid, baby measuring about 8-10 weeks ahead of dates (fundal height and u/s), with a history of 2-3 unexplained bleeding episodes (according to u/s, no problems w/ placenta) and high blood pressure throughout pregnancy (no other pre-e s/s), is being induced by OB at 39 weeks, because doctor is afraid she will go into labor on her own and membranes will rupture, causing a prolapsed cord, etc.  Her cervix is tight and thick.  On the surface, this seems like it could be interpreted as a medical reason to induce.  However, I'm very skeptical.  Mom wants a natural birth, but trusts her doctor because she doesn't want to risk causing harm to her baby; she is also very adamant about avoiding a c-section.  She might just be heading down that path, though.

There's not much that can be done about the above situation, because the induction will happen in 24 hours unless mom goes into labor (and that's unlikely), but I'd like a reference for what medical reasons are for inductions.  References to studies would be great, too!

Thanks!

Cindy

While I agree that many obs fall in the category of "you can always find a reason to do something you want to do," your client clearly has some medical problems with her pregnancy. The best that can be done here is to "teach her to fish," that is, for her to know what questions to ask that will help her make informed choices about her care. She needs to know:

• What intervention is planned? She should be told what is involved in language she understands. 
• What other tests or interventions might or will be necessary as a result of having this one?
• What are the potential benefits?
• What are the potential harms? How likely are they to occur?
• What are the alternatives, including doing nothing?
• What are the potential benefits and harms of the alternatives, and how likely are they to occur?

A few notes if she agrees to be induced:

• In the studies, waiting until "39 weeks" to minimize respiratory morbidity with elective term delivery means "39 completed weeks," in other words, at the beginning of the 40th week.
• If cervical ripening is required, prostaglandin E2 (Cervidil, Prepidil) works just as well as misoprostol (Cytotec), although a bit slower, and results in identical c/sec rates. Cytotec has caused severe problems even with a low dose.
• If the concern is membrane rupture leading to prolapsed cord or other problems, then rupturing membranes artificially should NOT be part of the induction process.
• Inductions are much more likely to succeed if the cervix is ripe (softened and effaced). Artificial ripening does not make a difference. 

-- Henci 

Thanks for the reply, I really appreciate it.  It seems to me that there is quite a gray area when it comes to what is medically necessary and what is not.  Quite certainly, this is complicated by the fact that only medical doctors are really allowed to make this distinction (i.e., medical advice cannot just be given by a childbirth advocate).  That said, I appreciate that you cannot comment on that specific situation, nor would I expect you to.  I'm wondering, though, how is it that one knows, in these 'gray' situations, when the baby is really, truly better off being born than continuing to gestate? 

I'm thinking about the fact that, although there are studies concluding that induction/c-section before 39 weeks is not recommended, many also recommend waiting until at least 42 weeks of gestation for induction (due to the median length of gestation being 41 weeks, 1 day).  It gives a mixed message that medical intervention between 39-42 weeks is really a personal judgement call, in the absence of an emergency.  In reality, this seems to vary widely based on the provider.

I hope I'm not talking in circles.  I guess I feel like I'm walking in circles around this issue.  Is there just no definitive information, in many circumstances, about whether the baby is truly better off being born (unless it stares you in the face, with symptoms of preeclampsia, fetal distress, etc.) even if the mother's bishop's score is 0 and it is a failed induction with 0 progress, followed by c-section at 39 weeks (as was the case with the above example)? 

Or perhaps it's an informed consent issue.  If mothers can really get the real risk/benefit conversation, rather than just the risk-of-staying-pregnant conversation (which is frequently catastrophied), maybe we will then really have a lower induction and cesarean rate.  After all, women told Listening to Mothers that they weren't really asking for the inductions and cesareans, right?

Thanks for the dialogue,

Cindy

I hear your frustration and share it. In the end, as you say, it is a judgment call based on expert knowledge and experience, which means that the key is for women to have enough understanding of the issues to find a care provider whose judgment they can trust. Practitioners worthy of that trust will also understand that decision making is a collaborative process and that their job is to provide the women they care for with accurate, unbiased, complete information so that they can arrive together at the best option given each woman's individual circumstances. (If I may get in a plug for Lamaze, educating pregnant women so that they can make informed decisions is a principal goal of Lamaze childbirth education.) 

-- Henci