Tuesday, December 07, 2010

Elective induction, patient choice, and physician preference

The CNM I am seeing recently wrote about how both patient choice and physician preference play into elective inductions. While she was doing her CNM clinicals a few years ago, she worked at a small community hospital that had two obstetricians (now there are four). At the time, it was common practice to do elective inductions at 37 or 38 weeks.
While working at Witham Hospital, I became well aware of how good physicians can obtain bad reputations from the natural birth community simply based on their induction rate. At the time, Dr. Winkler and Dr. McCarty were the two obstetrical providers in the practice and both held stern ground in not inducing labor without a genuine medical indication prior to 39 weeks. However, once reaching 39 weeks, most all moms were lining up for their induction, leading to a fairly high induction rate by World Health Organization standards.

It is quite common in obstetrical units for nurses to triage phone calls of clients sharing concerns that are nothing more than normal discomforts of pregnancy, yet they aren't seeking reassurance that their pregnancy is healthy and normal, but instead the perfect complaint that will justify an early end to their miserable pregnancy.

I distinctly remember being told by a pregnant mother that if the on-call physician did not induce her labor (at 37 weeks), then she would be happy to take her business elsewhere. The truth was she could go to any other local hospital and her wish would be granted. These two doctors declined her request and risked losing her as a client. They refused to put her baby and herself at risk, for the sake of her own convenience.

Not one of these physician's peers would fault them for inducing women earlier. They all did it in their own practice. Women want early inductions, and we're all about women's rights. However, they would have failed to withhold the oath, "do no harm." These physicians stood firm in the face of persecution and I was quite impressed.

Around the same time, one of the physicians discontinued his routine practice of artificially rupturing the amniotic sac in elective inductions. This would otherwise commit the client to birth, or more specifically, cesarean section because too often mom or baby simply wasn't ready. If the attempt to induce failed, this physician was comfortable telling mom after a day or two's effort to induce, "Sorry, we need to discharge you home as your induction was not successful. We can reschedule you in a few days." The nurses gave this physician a round of applause and many of us began to choose him as our own provider.


  1. "Inductions" come in all shapes and sizes - some not so obvious. My midwife did a stretch and sweep at 38.5 weeks and 2cm, "Just to prepare things," she said, "it NEVER leads right into labour." Of course, I was in labour later that day and had a wonderful homebirth the next evening - despite our daughter's insistence to come out sunny-side up!

    My husband still won't let it go though - he met our midwife in the grocery store a bit more than a year later, and had to make a comment: we had been looking forward to a few more weeks to just sit back and relax before the birth. We all have a good laugh about it now, but I guess I'm just naive, and can't understand the whole elective induction thing.

    Now five months pregnant with #2, I know I'll take a pass on the S&S this time. Live and learn.

  2. I have never heard of a doc sending someone home after a failed attempt at induction. granted they usually break the water at some point making it impossible to send them home. this ob is awesome!

  3. I've never understood the whole elective induction thing either...I sure as hell was uncomfortable at 41 weeks, but why would I want to put myself and my baby at risk just because I was "uncomfortable". It seem so immature to me!

  4. Amazing! You can only hope and pray more doctors will choose to be like this but it is highly doubtful when it can be so convenient for a doc to schedule everything around his schedule!

  5. I'm not surprised at this in the least. (I've had a lot more people react with "They made you go that long?" than react with "They let you go that long?" when I say how far past my due date my kids arrived.)

    What I find frustrating is that patient choice and autonomy, even in the face of best practices, seem to only run one-way. How many stories have we heard of women wanting VBACs who cannot find a doctor to take them at 36/37/38 weeks, or doctors who support VBAC for their own patients but won't take a late third trimester transfer from another doc because they don't want to look like they are undermining the other docs in their area? But a woman who wants an induction at 38 weeks or even earlier has no problem obtaining it.

    Why does fear that informed consent won't protect you from a lawsuit in the case of a bad outcome not apply to elective induction at 37 weeks, when it's all we hear about when it comes to VBAC?

  6. I have a friend who is expecting her first child in March, and she's mad that her doctor won't induce her before 39 weeks.

    Yeah, I really don't understand "wanting" to be induced. I just don't. Then again, I don't have kids yet.

  7. I can totally understand wanting to be induced, or rather, wanting to go into labor. I think it is most likely a very old survival mechanism. Before there was the option of c-section or induction, it was probably quite adaptive for women in late pregnancy to want that baby out! I had spent about 6 months learning about how to have the best chance at avoiding a c-section, and at 39 weeks a part of me felt "I don't care anymore just get it out!". Women need information. They need to know about iatrogenic prematurity. They need to know that their feelings are totally normal but may not be pointing them in the safest direction. Some people may never listen, but I have to think that most women whose doctor explains to them the benefits of waiting would choose to wait.

  8. @ Emily - I completely agree with you. That desperate wish for the pregnancy end must be "natural" because it's so common. It's not just some modern aversion to discomfort. It prepares you mentally and physically for labor - and helps you be less afraid, right, because you're like JUST MAKE IT END. My boys were born at 41 w exactly (S&S - I didn't know it counted as a form of induction) and 40 w 5 days. With #2, I elected for another S&S hoping it would bring on labor, but in my situation my husband lived a 5 hour drive away and was only home on the weekends. It was very stressful to have the pg go on and on in such a state of anxiety about where he would be. My midwife decided I was favorable for the procedure, and then I had some acupuncture to help get things moving, but it was a very gentle treatment. I would not have ask for (or received) a medical-induction.

    Anyway, my point is, I agree w/ Emily that the feeling is natural. The problem is we now have a medical-treatment-on-demand system where many doctors don't inform patients of the risk and they will perform unnecessary (and medically risky) inductions to make their "customers" happy - this is what happens when health care is a business. I'm a very strong believer in patient autonomy, but I think there's a difference between a patient's right to REFUSE an intervention and a patient's right to DEMAND an intervention that is deemed medically risky/ unnecesssary, especially one like induction where the potential benefit of an on-demand induction is usually very minimal, medically speaking.


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