The con of being "overdue"

date on calendar

Everywhere in the West, when women reach their “due date” (I hate that term), everybody around them starts to behave like something is terribly wrong with them. And I mean EVERYONE: their medical caregivers, their family and friends, even random strangers in the street.

“Your baby is late” “Have you had the baby yet?” “Are you STILL pregnant?” “we are booking you in for an induction” and so on.

I know pregnant women who stop answering their phones and stay off social media because of this.

HOW ON EARTH is that supposed to help?

Do people think that that kind of pressure helps the woman (who is already fed up) cope with the wait? Do they think that somehow, it’s going to speed things up?

Recently I was starkly reminded of this, when at an antenatal class reunion, a woman told me she was completely convinced that the pressure she was under, the stress her caregiver put upon her by treating her like a ticking time bomb, prevented her from going into labour. She had read the research, she was well informed, she knew the risks where small and she wanted to wait for nature to take its course and for labour to start on its own. In the end it all became too much and rather than consenting to an induction, she had an elective caesarean. But she was really angry about the way she had been treated.

I just don’t get it.

For labour to start, the pregnant woman needs to feel safe and as relaxed as possible (which is kind of already difficult when you’re fed up of waiting and uncomfortable), so this added pressure and stress is sure to delay things up even further.

In my area, when you reach 42 weeks at midnight you suddenly enter the “high risk” category-which means that the birth centre is no longer available as an option-something many parents have lamented about-again after 40 weeks have passed and you are trying to stay hopeful and patient, you do not need the added pressure of knowing that your birth options will decrease unless you birth before a certain deadline.

Babies come when they are ready to be born, and even today in our highly medicalised world, with all our cutting edge science, we can’t predict that.

Imagine if our culture treated women who are waiting for their labour to start with the reverence and kindness they deserve? Imagine if everyone, instead of pressurising women, gave them words of encouragement, told them stories about how their own babies were “late” too, and just generally behaved like everything was normal and we just needed to wait until baby was ready? I love this article on the topic.

The “due date” is like a curse. In the days before pregnancy tests and scans, when we had to rely on the woman’s intuition that she was pregnant and things like missing periods. People used to say something like “the baby will be born in the Spring” and nobody worried about the “date”.

I find it very odd indeed, because EVEN FUCKING SCIENCE show us that this is still true today. The medical definition of pregnancy term is 37 to 42 weeks. That’s right, 5 WEEKS. So WHY ON EARTH aren’t women given a “due month” or a “due period” or whatever the hell they want to call it, instead of this blooming “due date” thing? The whole due date thing is based on a con anyway, on a study of just 100 women done by a Dutch doctor nearly 300 years ago, that was wrongly interpreted by American doctors. Yep you read that right, and you can read the whole story on the evidence based birth blog. And by the way, to show how ridiculous the whole “due date” thing is, just over the channel, in France, the due date is set at 41 not 40, weeks. Stats also shows us that, on average, first time mothers are much more likely to give birth at around 41 weeks than 40.

You can tell I’m pretty pissed off right?

Too right I am.

First, I experienced this first hand with my first child, who arrived 16 days after this “due date”. I was lucky enough to have a very supportive midwife (at the time when case loading midwifery was still the norm in my area-so I had the same midwife throughout) who completely respected my decision to decline induction. And my family was pretty supportive too. Yet I was still given the society’s pressure. I still heard that “you’re STILL pregnant?” sentence more times than I care to count. I also recall the freaked out “get out of my shop” expression that appeared on shopkeeper’s faces when they asked when the baby was due and I said 10 days ago.

Second, as an antenatal teacher and a doula, I have also supported plenty of couples through this challenge. And plenty of women who, in their hearts, didn’t want to be induced, but consented reluctantly because of the pressure that came from everybody else, and first of all, from their medical caregivers. And many bitterly regretted it afterwards.

Third, my strongest desire is that pregnant women make truly informed decisions. And by pressuring them like this, we coerce them into consenting to intervention, and a decision isn’t informed if the person making it feels scared to say no. And I also find that it is very rare for women to be informed by their caregivers on the reality and the risks of induction. Yet the law is very clear that consent must be obtained, without undue pressure-read the birthrights factsheets about that.

We don’t really know what starts labour, but what we know from research is that it’s the baby’s maturity that starts the labour process. We know that there are many hormonal processes that need to take place (from complex chemical reactions in the lungs to prepare for breathing and to reabsorb fluids afterbirth, to brain maturity, to extra storage of nutrients in the liver and much more), all of which are designed to prepare the baby for the transition to the outside world as smoothly as possible. So there is no doubt that, on many levels, it’s best for labour to start on its own, because ONLY THEN do we know that the baby is ready to be born.

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So what is the reason we have induction policies? Surely there must be some seriously strong medical evidence behind that, right? Not quite. Induction policies are partly based on myths, partly based on debatable evidence.

The myths are twofold: one is that the placenta will start “failing” once the due date has been reached. Science tells us that it isn’t the case . In a paper called “Aging of the placenta” the author concludes that:

“A review of the available evidence indicates that the placenta does not undergo a true aging change during pregnancy. There is, in fact, no logical reason for believing that the placenta, which is a fetal organ, should age while the other fetal organs do not: the situation in which an individual organ ages within an organism that is not aged is one which does not occur in any biological system. The persisting belief in placental aging has been based on a confusion between morphological maturation and differentiation and aging, a failure to appreciate the functional resources of the organ, and an uncritical acceptance of the overly facile concept of “placental insufficiency” as a cause of increased perinatal mortality.”

The second myth is that the baby will get “too big” and therefore more difficult to birth. Again there is no evidence that this is the case. Babies skulls mould to fit through the pelvis, and pregnant women’s pelvises, helped by the relaxin hormone, stretch and open to let the baby out.

Interestingly as pointed out by Dr Rachel Reed, in an excellent blog post on induction risks, these two myths also contradict one another-how is the baby supposed to get so big if the placenta is failing?

So we come to the third risk, the one behind which there is some “science” and on which the clinical guidelines are based. As explained by midwife Dr Sara Wickham, in her article “ten things I wish women knew about induction of labour” : “The post-term risk is later, lower and less preventable than people think

Namely the induction guidelines are based on the fact that the risk of an unexplained stillbirth increases from  1 in 926 at 40 weeks, to 1 in 633 at 42 weeks. That’s it. So it goes up from 0.1% to 0.15″. You hear health professionals say that the risks doubles (which isn’t quite technically true), and this triggers a 50% image in people’s minds. We do not know what explains this increase, and interestingly, the risk at 37 weeks is 1 in 645 (pretty much the same as the risk for 42 weeks), but you don’t see everyone being offered an induction then because the risk is higher than at 40 weeks then.

At this point I want to give a couple of disclaimers: one that I fully understand that the risks highlighted above may be unacceptable to you. And that’s fine. It’s your decision. I have no agenda, other than making sure that you have all the information you need to make that decision a truly informed one. Two is that I also have no doubt that sometimes, induction is the right course of action: if for example you are late in your pregnancy and there are signs that all is not well, or if you there is a medical condition that makes it safer for the baby to be born sooner rather than later, or even simply if your gut instinct tells you that this is the right course of action.

What bugs me however, is that few people are given the information to make that decision in a truly informed manner. What I hear and witness as standard is women being told that they’ve been booked for an induction, without any discussion about consent having taken place. Women tell me “they didn’t let me go past 42 weeks”. The consent rests with you, and you are the one doing the allowing. But it’s kind of hard when you’re being presented the induction date as a fact (I have met many women who didn’t even realise they could decline the induction that was supposed to be “offered” to them). I have even sadly, heard plenty of stories of women, who chose to decline induction, only to be told that their baby might die if they didn’t consent.  How on earth are you supposed to be in the right frame of mind to decide when you are already feeling fed up and fragile and you hear something like that?

thinker

The other part of the consent discussion that doesn’t seem to take part, is that women are informed of the risks of not inducing, but they aren’t usually informed of the risks of induction. There are two risks categories in my view: 1-induction can be a long and not particularly pleasant process which limits your birth choices (this doesn’t usually get explained either), 2- induction seriously increases the risk of interventions, and in particular the risk of needing a caesarean.

Having an induction can be very long and tiring. You get admitted to a ward, and a pessary of prostaglandins is inserted into the vagina to soften and ripen the cervix. You then have to wait for either contractions to start, or your cervix to be open enough for your waters to be broken. This can take 24h, 48h or more, during which you won’t get much sleep as you’ll be in a ward with other women being induced around you (if your local hospital offers outpatient induction, I suggest you look into this option-being at home waiting for labour to start maybe more relaxing for you). Your partner is usually sent home at night. When things process to the next level, you are transferred to the labour ward to have your waters artificially broken. Induction restricts your birthing options as only the labour ward is open to you (so no home or birth centre options-though you could choose to stay at home if you wanted to), and constant monitoring is recommended which restricts your mobility. Unless you have gone into active labour with the pessary and water breaking alone, at some point a drip of artificial oxytocin is inserted into a cannula in your hand to create contractions that mimic the pattern of active labour. There is no build up like in normal labour so many women find this harder to cope with than normal labour, and request more pain relief, which itself can result in more interventions. I have seen this process taking a long time (over another 24h) before the woman was fully dilated. Finally, if after all the induction steps have been taken and you aren’t fully dilated, or your baby doesn’t cope well with the contractions and gets distressed (induction increases the risk of the baby not coping well with labour), then the only option is a caesarean. This may happen after several days of labour. This risk is seriously increased, despite some papers claiming that induction doesn’t increase the risk of caesarean, an in depth analysis of the literature and recent research shows that induction of labour more than doubles the risk of caesarean. In my area, the rate of caesarean for first time mothers who are being induced is about 45% (compared to 28% for the general population).

I am sorry to depict such a gloomy picture, but these are the possible realities of induced labour. Dr Rachel Reed and Dr Sara Wickham have also written excellent articles about it, if you would like to read more and access more references.

What confuses me further is that the Cochrane review on induction states this:

A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections (….)

However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction).”

And yet I haven’t seen this applied in practise.

So what does that leave you with?

Inform yourself, do your research and know what is right for you. In may go as far as suggesting you think about the possibility of your baby being late as part of your birth preferences preparation. Again in my area, over 35% of first time mothers are induced, the majority for being “overdue”. It’s much easier to negotiate your way through the medical minefield of postdates pregnancy if you have thought about it ahead of time.

Also always remember that if you were in a real emergency situation, you would be offered a cesarean, not an induction.

PS: I have written a “sequel” to this blog, more specifically about what happens during an induction. It’s called: “Induction of labour – do you know what you are letting yourself in for?”

If you are pregnant and feel drawn to work with me, here over here. If you are a birthworker and this resonates with you- look here.

 

 

  1. Helen on August 10, 2016 at 10:22 am

    This is a very well-argued and important piece, I think, Sophie. I’ve had three ‘overdue’ babies – 21 days, 10 days and 14 days past their ‘due dates’. First one I was rather clueless except for instinctively resisting induction. Ended up with being treated as an inducee anyway by panicked doctors culminating in a very traumatic c-section. Second, insisted on home birth and labour started when I hung the final lampshade in his room and gave myself permission to accept another c-section if that’s what it came to (it didn’t). Third time I was way more confident but still, the insistence of friends, family and medical professionals who treated me as if I was pretty much a baby murderer for not submitting to the protocol was very difficult at a vulnerable time.

    • sophie on August 10, 2016 at 10:33 am

      I am sorry to hear this, Helen. It is pretty hard to trust one’s instinct when everybody else is telling you that you are wrong…

  2. Kati Edwards on August 10, 2016 at 1:12 pm

    I’m confused whether induction does or doesn’t cause complications. Hannah Dahlen at the MAMA conference was saying when labour is managed, health staff are more relaxed and confident knowing they’ve got it covered rather than letting nature take its course and not knowing what’s going to happen. So she says this is why c-sections are reduced with a managed labour.

    • sophie on August 10, 2016 at 1:25 pm

      I hadn’t heard that one before. I can see how sometimes with some staff it might. But in practise, there is both observed and published evidence that induction (especially in primips) results in much higher cesarean rates. When I look at the stats in my area, it seems the main two reasons for this are “failure to progress” (which makes sense when you know that oxytocin receptors only increase on the uterus surface once the baby is ready to be born-throwing artificial oxytocin in this context is like throwing lots of keys-but there is no lock!), and fetal distress (it is well documented that syntocinon causes more fetal distress than natural hormones).

  3. Daniela on August 11, 2016 at 3:08 am

    Hi Sophie,
    What a great well-articulated and researched article. We met once at your baby-sling meet.
    I am local to you and went “overdue” with my first baby by 20 days and then eventually gave into an induction due to all the pressure around me, even though I knew instinctively that my baby was just fine in there. In the hospital, the obstetrician kept saying he’d never seen anyone so overdue in his 8yr period at the hospital(!) and when my little boy had to stay in NICU with an infection, everyone looked at me puzzled when reading on the notes “42+6”! I’m proud of having waited so long even though I still ended up being induced and needed a forceps delivery and episiotomy. However, the whole thing was over in under 12hrs and it is my belief that was because baby was basically ready and “at the door” as they said in hospital (my waters actually broke naturally the morning of the scheduled induction but then nothing happened – not surprisingly when you’re on a hospital ward!)

    This time round my official NHS due date based on the scan is today in fact so we shall see what happens…. (though we have been wiser this time and haven’t told any family or friends the actual due date! My biggest bug bear last time was receiving texts asking me “any news???”) Helps that it’s summer too and most people are away on holiday! I had a private scan done too this time and that due date isn’t until Sunday and if you take the date based on LMP it would be Saturday so I fully agree with you about due dates being a con. There is also the research which shows how only 5% of women give birth on their due date so it’s a complete fallacy. The due date is purely for medical management as I guess they have to go on something. My biggest advice for first time parents would be….. Don’t tell ANYONE your “due date”!!!! I also definitely agree that going overdue should be part of your birth planning/preparation and being informed as much as possible. We’ve done a few things differently this time and my body has done it once before but it will be interesting to see what happens. In a way I’m less confident in my instincts as I’m not so in tune with baby this time having to run around after a toddler as well.

    Thank you for writing the article I would have loved to write after my first pregnancy/birth. How funny that it just published yesterday. It’s good to know that you will be passing on these words of wisdom in your ante-natal teachings.

  4. Manuela on August 15, 2016 at 2:22 pm

    Thank you SO much for sharing all this information. Simply thank you!

  5. Jane Angel on January 30, 2017 at 1:35 pm

    Thanks so much for this, I’ve been ‘told’ I’m being induced on the 15/2, if baby doesn’t come as it’s my due date but it concerns me to go down this route especially the increased risk of C-Section. Think I’ll be questioning this more now I’ve read your article.
    Thanks again.

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