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  • Writer's pictureErin Stevens

Eviction Notice

Updated: Apr 22, 2022

39+ weeks during my last day at work. Labor started that night.

"How do you feel about inductions?"

I've heard some variation of this question several times from patients early in their pregnancies recently. It's a hard one to answer. It's like asking me how I feel about airbags. Do I want them to go off every time someone drives a car? Not really. Do I want them as an option when things get dangerous? Absolutely. Does that mean I looooove them or "feel" any particular way about them? *Shrug*

I often tell patients that in obstetrics, we prepare for the worst and expect the best. The main intention of the way we practice is to follow evidence and prevent poor outcomes. Most inductions are pursued for medical indications. People may enter pregnancy with existing medical conditions or develop disease states associated with the pregnancy itself. Generally if those conditions are well-controlled, things go well. BUT things CAN go poorly. For people with diabetes - particularly for Type 1 - it's common for blood sugar levels to become extremely difficult to control near the end of pregnancy, sometimes resulting in seizures from severely low blood sugars or a condition called ketoacidosis from very high blood sugars, both of which can be life-threatening or cause permanent compromise (for the pregnant person and the baby). I've had a patient technically die due to complications of preeclampsia - a condition related to blood pressure elevation which can adversely impact essentially every organ including the placenta - requiring a stat C-section right in her hospital room while I and others performed chest compressions. Intrahepatic cholestasis of pregnancy - a liver condition - carries a significantly increased risk of stillbirth. I could go on and on.

Beyond medical conditions, other factors surrounding the pregnancy might come into play. The risk of stillbirth (and other neonatal morbidity) begins to rise with increasing gestational age at term, most significantly so after 42 weeks. There are patient factors - including age over 35 and particularly even moreso over 40, elevated BMI, IVF pregnancy - that contribute to a similar risk level occurring even sooner. Issues specific to the pregnancy - like a baby that is growing very small - also contribute to greater risk.

Babies that are growing very large have a higher potential of a shoulder dystocia, when the body gets stuck after the head delivers. Some of the most panic-inducing, heart-racing moments as an OB are those working to assist the baby out in these situations. Classically, OB/Gyn oral board certification courses prepare physicians to be presented a hypothetical shoulder dystocia case on their exam, with the expectation to be led down the path of every possible intervention being required - including modifying the position of the birthing person, trying to manipulate the baby's position in various ways, intentionally causing a collar bone fracture to the baby, intentionally cutting the cartilage where the bones come together at the front of the birthing person's pelvis - ending in the baby actually dying and requiring decapitation for then delivery of the body via C-section to save the birthing person.

Once the bag of water breaks, we discuss induction of labor if labor doesn't occur spontaneously as risk of infection that can harm the pregnant person and the baby increases with increasing time. A patient once arrived to the hospital a few days after her water broke carrying diapers she'd been wearing that were filled with pus. I was worried the baby wouldn't make it. It survived but needed a lot of extra care.

Do I expect that every pregnant person and their future baby is going to die if we don't plan and pursue an induction of labor? No. Some people might read all this and say that I'm fear-mongering and over-exaggerating. Opponents of the medicalization of birth are quick to point out that the increased risk of stillbirth with gestational age past 42 weeks - although statistically significant - is less than a percentage point. The very worst outcomes are luckily incredibly rare. But I certainly hope to avoid it ever happening. Ever ever. Almost every OB has had to tell a patient at the end of pregnancy "there's no longer a heartbeat". It's devastating news to deliver, and the cries of a parent hearing that information are unforgettable. I legitimately cannot imagine that life-altering heartbreak as a mother. Some of us have had a pregnant or postpartum patient die. It's tragic. Other than death, permanent medical problems/damage/dysfunction may develop. So we set and follow some parameters to avoid terrible outcomes. Assessing the risk to benefit ratio of continuing pregnancy vs pursuing delivery in the setting of medical indications helps create guidelines for safe birth timing.

For a long time, inductions outside of specific medical indications were not recommended. Enter the ARRIVE trial. This study published in 2018 compared induction of labor at 39 weeks vs continued pregnancy in low-risk patients pregnant with their first babies. They found a lower rate of C-sections, lower risk of hypertensive disorders of pregnancy, and shorter duration of needed respiratory support for babies in the group that had been induced without significant differences in other outcomes. Although this study has been questioned and criticized by some groups, various obstetricians, practices, and hospital systems have used this information in different ways. Some offer or encourage all patients to have an "elective" or "risk-reducing" induction at 39 weeks. Others have a lower threshold to discuss planned inductions in the setting of "close call" medical situations. This also makes it easier for some to schedule inductions for life situations that may lend to a patient preference for controlled timing of delivery. Maybe the pregnant person lives 6 hours from the hospital, has had fast labors before, and doesn't want to end up having a baby in their car after they enter labor. Maybe their spouse is deploying in the armed forces and has the potential to be out of the country if otherwise waiting for spontaneous labor. Maybe a grandparent-to-be is on hospice and everyone wants an opportunity for them to meet the grandbaby. Maybe parental leave is terrible in our country and someone wants to maximize time with a newborn postpartum and plan work obligations accordingly. I had personally scheduled an induction at 39 weeks 5 days with my first pregnancy but then forced myself into labor at 39 weeks 2 days (the night of my last day at work). I'll probably schedule an induction in the 39th week of my current pregnancy (as long as I again evade medical issues for which an earlier induction would be better).

There are many patients who are happy to pursue an induction in the setting of medical issues. There are many patients who are eagerly asking for an induction for planning purposes or just to get pregnancy over with already (not everyone enjoys it!). There are also plenty of patients who are hoping to avoid an induction at all costs. I want to support every patient in the best way I can while prioritizing safety. When it comes down to it, all we can truly do as physicians is provide recommendations. I can't force anyone into an induction. I can share that based on expert opinion of risk and benefit data we might want to plan delivery at a certain point. Generally for those patients who strongly oppose a medically-indicated delivery, our alternate strategy is very close monitoring of the pregnancy.

One big thing I want patients to know is that I'm never going to push for an induction because it's convenient for ME. I'm not trying to plan anyone's birth experience around getting my nails done or heading out for vacation (inductions can be unpredictable processes anyway; I couldn't necessarily make that work if I tried). I'm not money-grubbing and looking to pad my paycheck by scheduling a delivery at a particular time (honestly, I'm not financially savvy enough to optimize a scheme like that). I'm not trying to get rid of one pregnant patient a little earlier to replace with a new one (I have a comfortable schedule of patients and am not so booked that that's even how it would work). I promise you that even though there are shitty obstetricians in the world who practice in ways that are greedy or selfish or harmful, most of us are out here deeply caring for our patients and working hard toward healthy outcomes.

So how do I "feel" about inductions? I feel like I should talk with each pregnant person about their specific circumstances and make a plan together for what makes most sense.

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