How many times have you been talking with your friends about their birth stories and it started like this:
“Well, my doctor said my baby was measuring large so they induced me at 39 weeks…”
“I had to be induced because my water broke and I didn’t go into labor…”
“My doctor told me my placenta was old and calcified and they induced me on my due date…”
“The hospital has a policy that doesn’t allow women to go past 41 weeks, so I got induced…”
As a birth doula, I hear these stories countless times. When it happens to my clients, I try to educate and inform them to understand the ins and outs of medical inductions and why they’re so frequently recommended. I also let them know why they may want to be wary of this happening to them at the end of their pregnancy.
Typical pregnancy is considered full term anywhere between 37-42 weeks. Almost everyone—including doctors, midwives, and online due date calculators—uses Naegele’s rule to figure out an estimated due date (EDD).
Naegele’s rule assumes that you had a 28-day menstrual cycle, and that you ovulated exactly on the 14th day of your cycle.
FUN FACT: Not everyone has a typical 28 day menstrual cycle–or ovulates at Day 14!
To calculate your EDD according to Naegele’s rule, you add 7 days to the first day of your last period, and then count forward 9 months (or count backwards 3 months). This is equal to counting forward 280 days from the date of your last period.
In cases where the date of conception is known precisely, such as with in vitro fertilization or fertility tracking where people know their ovulation day, the EDD is calculated by adding 266 days to the date of conception (or subtracting 7 days and adding 9 months). This increases the accuracy of the EDD because it no longer assumes a Day 14 ovulation based on the first day of the last menstrual period.
Rebecca Dekker, phD, RN, in her Evidence Based Birth Program, has some evidence information on EDD (estimated due date) here
When you’re calculating your EDD think of a few things. When do you ovulate? Do you know best about conception time? Do you think your understanding of your EDD is more accurate than the date given to you via an ultrasound growth scan?
Frequently, obstetricians use these common reasons to induce women before their bodies (and their babies) choose to labor physiologically. Let’s talk about a few of them in more detail.
- Advanced maternal age (also referred to ‘geriatric pregnancy’)
- Size of baby.
- Amount of amniotic fluid.
- Placental insufficiency/Calcification.
AMA (Advanced Maternal Age)
How many pregnant people with uteruses are given the label “geriatric Pregnancy” or Advanced Maternal Age— person who becomes pregnant and delivers after the age of 35. Okay already, you’re old (?!) and you’re pregnant.
I live and practice as a birth doula and pelvic PT in Boulder County– a large percentage of my clients fall into this category. I had my last child at 43 and had to advocate against induction—at every visit—at the end of my pregnancy.
Studies have shown there are relative risks with AMA that show increased numbers of miscarriage, stillbirth, and difficulty with childbirth. Midwifery care has been shown to decrease the rate of interventions with no increased risk to the baby. Comparative studies have shown regarding induction resulting in c-section in people categorized ‘geriatric’. These found that induction at week 39 vs. waiting to 41-42 weeks to induce showed similar c-section rates.
For evidenced based information on AMA, click here .
In a healthy person, who experiences a normal pregnancy, their age alone is not a valid reason to induce prior to 42 weeks.
Size of Baby
Baby’s size? You’ve been told your baby is “2 weeks ahead of their growth curve” or “around the 90th percentile” (Is my baby going to be a Ten Pounder??!!) How accurate are ultrasounds in determining baby’s size? Unfortunately, Ultrasounds are correct about half the time and wrong about half the time when they predict a big baby. Although 1 out of 3 women in the US are told their baby is “too big” at the end of their pregnancy (as an indication of induction), only 1 in 10 is actually born “big”. Ultrasound results are usually anywhere between 15% above or 15% below your baby’s actual weight. This measurement is so subjective, that a person can have two measurements in the same day and get entirely different numbers. Or two different sonographers could measure concurrently and have significantly different results. To learn more about the evidence surrounding “Big Baby” click here.
Low Amniotic Fluid (oligohydramnios)
Oligohydramnios is a frequent reason being given to my clients to suggest they should be induced. There are multiple factors–Both from mother and baby-that can contribute to low amniotic fluid at term. What does this mean?
Is my baby going to dry up?
- water breaking
- position of body during measurement
- Time of year of measurement (summertime =more dehydration)
- placental insufficiency
- kidney or Urinary tract problems
- gestational age (14 days prior to spontaneous labor, urinary output starts to decrease), as well as baby swallowing more amniotic fluid. With post term babies, they begin to swallow significantly more fluids.
There is no evidence that isolated oligohydramnios at term is a risk factor for poor outcomes. Contrarily, induction for isolated oligohydramnios leads to higher Cesarean rates. It can also lead to complications from low birth weights in babies induced before their time. Therefore in a healthy, uncomplicated pregnancy at term (37-42 weeks)
- Ultrasound measurement is a poor predictor of actual amniotic fluid volume
- Poor outcomes seen with low amniotic fluid are usually due to underlying complications such as pre-eclampsia, birth defects, or fetal growth restriction
- The main risk of low amniotic fluid at term in a healthy pregnancy is induction (and Cesarean delivery as a result of the induction) and potentially the risk of lower birth weight
Current evidence does not support induction for isolated oligohydramnios at term. For more information on oligohydramnios, and what to do about it, read on here.
I’ve also heard many clients claim the reason for their induction was due to their OB or MFM seeing calcifications on the placenta on a scan. (Wait, are there bones in my placenta!?)
Placenta (the organ grown from the beginning which takes 50% from sperm and 50% from the egg) is an organ that like your baby, also ages. Both baby and placenta reach a certain level of maturity in order to be born healthy. The placenta doesn’t suddenly expire when a pregnancy reaches an arbitrary number of weeks.
Due to the wonders (and sometimes the pesky details) of ultrasound, we’re now looking at things that were once hidden. Now we’re giving the placenta a grade, regarding it’s development;
Grade 0-less than 18 weeks gestation
Grade I 18-29 weeks gestation
Grade II 30-38 weeks gestation
Grade III 39 weeks-birth
One of the features of a grade III placenta is that it often shows circular indentations that have calcium deposits (calcifications). This is a natural part of the aging process , just like our skin when we age. And just like wrinkles in skin don’t indicate a person is at risk of imminent death, neither does the appearance of calcification in a normal placenta at term.
Exceptions can be taken into consideration if calcifications are seen in a Grade I or II placenta. With these results, there can be increases in adverse outcomes (low birth weight, premature delivery, low APGAR scores or neonatal death) and these risks went UP with other perinatal risk factors (diabetes, hypertension, or smoking)-(Chen, & Lee 2012)
Medical Induction is complicated. We’re forcibly evicting our babies with artificial prostaglandins (Cytotec), cervical dilators (Foley Bulb or Cook Catheter) artificial rupture of membranes (AROM), and artificial oxytocin (Pitocin). We think when we’re induced that we’ll meet our babies the next day. Unfortunately more often than not, that is misleading. On the contrary, sometimes the prostaglandin approach to induction takes 24 hours alone! That is before our cervix is even ripe enough to insert a foley or cook catheter, start to labor and watch to see if the body kicks into labor without more medicine. More often than not, a typical labor induction can take 2-4 days. This comes as a surprise to many of my clients. And by the time they realize it, they’re on continuous EFM (external fetal monitoring), and the labor preferences that were once so important to them (moving around independent of the monitors, laboring at home, and a low intervention birth) is now not an option.
You can see for yourself that there are countless indications for medical induction prior to a baby’s spontaneous arrival. It is important to educate yourself on the relative risks of each of those indications as they’re presented to you.
One of the hardest things for me, as a doula, to advocate for is a full term, spontaneous delivery when a client’s OB has presented them with an induction that is in the ‘best interest’ of mom and baby. The phrase “healthy mom, healthy baby” is used in almost every induction to validate induction being the ‘right choice’. Obviously we all want a healthy mom and healthy baby. We also want a mom who is empowered, educated, intuitive, and calm. We want a baby with a healthy birth weight, has played a role in their birth-day, and arrives without stressful interventions and a forceful eviction.
Talk this over with your doctor, your partner, and other birth professionals in the community before it is mentioned or suggested in your care plan at the end of your pregnancy. Find out how your provider thinks about and manages the risk factors leading to medical induction and always find a provider whose overall philosophy–as well as descriptions and interpretation of these test results and measurements–feels most congruous with your intuition and preferences.
It’s simple to fall into the seduction of induction. As we get into those last few weeks, we’re uncomfortable, sleeping poorly, we have heartburn and swollen ankles. Our SI joints are loose, pubic bones are painful, sometimes we’re peeing ourselves, and our bellies are harder and harder to comfortably carry. As your doula, and the mother of 4, I hear you. I see you. I care about you and your baby. And I encourage you to wait. Just a little longer. Your labor will be easier, your baby will come when they’re ready, and you’ll be happier knowing you trusted your body’s magical, intuitive birth cues.
Without a doubt we live in a time where our obstetric providers are less trained, comfortable or tuned into physiological, normal birth. We live in a risk avoidant society, and that has carried over into childbirth and birth outcomes.
There are times when a medical induction is the best answer. My hope is that my clients both feel and believe based on the evidence, that induction is the right answer for them when it’s offered. And when it’s not, that they can advocate against the seduction of induction.