Friday, October 8, 2010

Induction

So, here it is. This is the post where all my unresolved issues about the risks of induction compared to the risks of stillbirth come out.

My doctor asked me on Friday, at 38 weeks and 2 days, whether I wanted to be induced Wednesday or Friday of next week. Um, is neither an option? How about I go into spontaneous labor before then. That would be great. Yeah.

I was actually surprised by his recommendation, since at my first visit I had thought he was OK with me going to 41 weeks. My first son was born at 41 weeks. Last week, I thought I heard him he wanted to induce at 40 weeks, but I chose to ignore it and assume I had misunderstood, and see if he brought it up again this week. But today it was 39 weeks, and well, that surprised me. I used the "I need to talk it over with my husband" line to give myself some time to think and avoid an awkward, flat-out refusal (to be fair, I have done some serious thinking about it today).

So that brings me to the most important point, which is, why is it that doctors recommend induction for pre-gestational diabetics at 39 weeks? Nothing has changed about my health since I recovered from the migraine at 35 weeks. Blood pressure is slightly high but within an acceptable range. Blood sugars are great and stable. Baby is moving and growing. So what gives? Well, a lot of you probably know that epidemiological studies have shown an increased risk of stillbirth in pre-gestational diabetics. To boot, the risk of stillbirth also increases with gestational age beyond 37 weeks. Statistically speaking, it is more likely that my baby will die before he ever takes his first breath.

So some of you might then ask, why are you complaining about being induced? Seems like a no-brainer for something as serious and terrifying as stillbirth. Well, not so fast. A patient-friendly Mayo Clinic site describes the risks of induction, which include increased risk of fetal distress (due to unusually strong, long, and frequent contractions on pitocin), increased risk of c-section, greater risk of maternal or fetal/newborn infection, and risk of umbilical cord compression. More and more caregivers are recognizing these risks of induction. And while none of these seem all that bad compared to stillbirth, any of these risks may result in further complications or interventions that hurt me or my baby and may impair my ability to have more children in the future. Unfortunately, the possibilities for problems associated with these interventions are endless, which is why standard protocols such as "induce diabetics at 39 weeks" don't always serve mom and baby best.

So I'm trying to process all of this stuff for myself, and decide which risks I am more comfortable with, and which risks apply to my situation. Here's what I discovered.

RISK OF STILLBIRTH FOR PRE-GESTATIONAL DIABETIC WOMEN

This study, published in 2003, describes the rate of stillbirth in 130 pre-gestational diabetic births. Twenty-five ended in stillbirth, which is a rate of 19.7%. That is almost 4 times higher than the rate of stillbirth in a normal, non-diabetic population, which I read elsewhere as hanging out around 5.5%. Several notable things about this study, should give us some hope about our chances:

In half of the stillbirths, the cause was explainable. Fortunately, it was not a complete mystery why some of these women lost their babies. And furthermore, some of these situations may be preventable and/or detectable. Fetal malformations would likely have been detected at a 20-week, comprehensive ultrasound and possibly at growth ultrasounds after that (which are both recommended for diabetics). Intrauterine growth retardation can also be detected by growth ultrasounds, maternal weight gain and fundal height measurements. Ketoacidosis can be prevented by maintaining good, tight blood sugar control. Chorioamnionitis (infection, usually occurring after rupture of the membranes) can be prevented and monitored for, by limiting vaginal exams and cervical checks after the membranes have ruptured and keeping a close eye on mom's body temperature. Tobacco use is apparently associated with placental abnormalities, and those caused some of the other stillbirths, so not smoking may be another way to keep the risk of stillbirth at bay.

The women who experienced stillbirth had suboptimal health compared to the women who did not. Examples of suboptimal health included maternal obesity, smoking, and poor glycemic control. I've got a leg up thanks to nutritional habits I've learned, the terror of tobacco instilled in me from childhood, and an insulin pump (isn't modern medicine awesome sometimes?).

RISK OF STILLBIRTH FOR WOMEN PAST THEIR DUE DATE

It is actually quite common for doctors to recommend that even low-risk pregnancies don't go past 41 or 42 weeks, and for them to recommend induction at that point. This research debate, on the issue, from the year 2000, is quite informative about the risk of stillbirth in women whose pregnancies last until late-term and beyond their due date.

I am not entirely sure, based on the highly technical discussion, but I think that one point made here is that more pregnancies end in stillbirth between weeks 24 and 38 than between weeks 38 and 42 or 43. Which means that I am patting myself on the back for making it to 38 weeks without losing my baby, since my risk of stillbirth is reduced by this mere fact.

The other thing I learned from nosing around in the debate is that the risk of stillbirth increases most dramatically between 40 and 41 weeks. The risk of stillbirth increases from 0.2-0.4/1000 births to 1.2/1000 births during this single week of gestation (I think this is usually presumed to be from placental insufficiency...it gets kind of old and stops supplying the baby with nutrients).



So where does all this research leave me? Well, unfortunately, no one can tell me with certainty whether my baby will live or die, and no one can even tell me with precision what the risks of induction versus the risk of stillbirth is in my particular situation. Ultimately, I think I have good reasons to refuse induction or proceed, and I will just have to make the choice I am most comfortable with. I feel good that I have successfully delivered one healthy baby at 41 weeks, I feel good about the fact that I am generally in good health, including blood sugars that are well under control, and I feel good about the fact that I have already made it to 38 weeks. On the other hand, I respect my doctor and don't want to take a risk that is simply motivated by fear of the unknown (multi-faceted risks of induction and consequent interventions).

I guess all I can say is that I have some more thinking to do. Happy to entertain your thoughts, if you have any you'd like to share. Um, and not that anyone would take the blogosphere this personally, but just don't be offended if I decide not to follow your advice.

4 comments:

  1. I realized, after posting this, that my point about no pregestational diabetic pregnancies ending in stillbirth after 38 weeks is likely due to the fact that most diabetics are induced at 39 weeks, rather than the risk of stillbirth decreasing for diabetics at this point. So I removed it.

    ReplyDelete
  2. Thanks for sharing your though process on this, Beth. It's very helpful as well as the research you have discovered... I felt similarly about induction - but was also under the pressure of fear that my high risk docs loved to invoke. Todd and I opted for "natural" induction methods, although, I wonder if it was more God's providence than anything that it worked out for us so easily both times to go into labor when we tried? All that is to say, we are thinking of you all as you struggle with this decision! Best, Jenn

    ReplyDelete
  3. Thanks, Jenn. I have another appointment on Friday and will know more after I talk to my doctor then. For now, I'm being as diligent as I can about monitoring the little man's in utero movements (including when I wake up in the middle of the night and first thing in the morning!). But maybe my birth story will end up being about delivering without pain medication even when being induced? :)

    ReplyDelete
  4. Beth, I'll pray for you during the next two days that you will go into labor on your own. Thanks for your prayers for me too! I always get funny looks when I tell people I don't want to be induced. Glad someone else out there understands :-)

    ReplyDelete