Things for prospective mothers to think about(Contains scientific info on stillbirth)

Hannibal Smith

I didn't think we were allowed ask for the background of other posters? I did it before and ended up getting a mod warning for bringing the thread off topic

Moonbeam

I think in this situation it benefits the thread rather then taking it off topic.

Hannibal Smith

I don't see how. But nevermind...I'll come back to the thread when the interviewing is done and the interesting discussion that was going resumes

Cat Melodeon

I don't think it's particularly important what someone's background is. We are all capable of reading medical journals. Some of us do it for a living, some of us do it because we are particularly interested in the area. Anyone with a modicum of intelligence and a measure of analytical skill or training can assess the worth of any given study or journal article - you do not need a medical degree for that, suggestions to the contrary are entirely elitist.

Research should be evidence-based. Qualitative evidence is just as important as quantitative evidence when it comes to health research. The social context within which the study takes place (eg the geographical disparities in section rates and general health outcomes in Ireland) must be taken into account. It should place emphasis on the health of the mother & baby rather than the 'success rates' of the doctor & hospital. Blind statistics based on subjectively completed medical files do not tell the full story.

Ayla

Deleted User wrote: »

Way, way too much emphasis is placed on anecdotal evidence in this forum.

James, if this is what you believe, could you please provide some concrete, up-to-date and widely reputed statistical evidence of the cost/benefit analysis of delivering a child at average term (ie: 40 weeks) vs. overdue (ie: 43 weeks)? I think everyone here takes this issue very seriously and would greatly appreciate your non-anecdotal input.

GoerGirl

got sent this link today, its interesting and relevant - about Gestational Diabetes as a stillbirth risk.

http://www.rcm.org.uk/midwives/news/video-highlights-diabetes-risks-in-pregnancy/?utm_source=twitterfeed&utm_medium=twitter

cynder

GoerGirl wrote: »

got sent this link today, its interesting and relevant - about Gestational Diabetes as a stillbirth risk.

http://www.rcm.org.uk/midwives/news/video-highlights-diabetes-risks-in-pregnancy/?utm_source=twitterfeed&utm_medium=twitter

Not Gestational Diabetes, its diabetes type 1, someone who already has diabetes.

I say all female diabetics are aware that pregnancy carries risks and have a support team. In ireland there a diabetic woman can attend a pre pregnancy clinic.

GoerGirl

apologies - yes that was a typo the link refers to pre-existing diabetes not gestational diabetes - though gestational diabetes is a risk factor for stillbirth.

Ayla

Ayla wrote: »

James, if this is what you believe, could you please provide some concrete, up-to-date and widely reputed statistical evidence of the cost/benefit analysis of delivering a child at average term (ie: 40 weeks) vs. overdue (ie: 43 weeks)? I think everyone here takes this issue very seriously and would greatly appreciate your non-anecdotal input.

Here, is a meta-analysis that concluded the following:

"A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes."

Contradicts much of what's been said in this thread.

Ayla

Ok, reasonable data source (even considering it's 8 years old). But this is the part that gets me...

Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99). Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), this difference was not statistically significant. Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores.

Since you started this thread discounting the birth experience (against the ultimate success of the delivery), the lower c-section rate quoted in this study doesn't really come into play. Yes, most women would prefer to avoid a section (and all the complications/inconveniences that can arise from it), but if you're not concerned w/ the "experience" of childbirth then it doesn't matter that rates can drop with routine induction.

The part that gets me, though, is that fact that the outcome - the ultimate goal of any delivery - remains virtually (or "not statistically significant") the same regardless of the induction vs. expectant management.

Also, this study doesn't relate to what you were trying to demonstrate in your original post - that stillbirth rates "skyrocket" after 40 weeks.

Ayla

Ayla wrote: »

Ok, reasonable data source (even considering it's 8 years old).

Also, this study doesn't relate to what you were trying to demonstrate in your original post - that stillbirth rates "skyrocket" after 40 weeks.

8 years old is not that old when it comes to research papers in this area. There are newer, but none that I can find that are available for free online.

Also "skyrocket" is a very dramatic term of course. Would you be happier if I said that there is a significant increase in the relative risk of stillbirth once a pregnancy is overdue?

This is precisely what that graph showed, and is precisely what every current textbook on obstetrics says. The consensus view is that the risk of fetal death increases sharply past 40 weeks, and inreases even more sharply after 42 weeks.

Of course those that disagree with this consensus for whatever reason can cherry pick the few papers that agree with their stance and present this as concrete evidence, conveniently ignoring the much larger body of evidence that contradicts them.

Ayla

Deleted User wrote: »

Also "skyrocket" is a very dramatic term of course. Would you be happier if I said that there is a significant increase in the relative risk of stillbirth once a pregnancy is overdue?

I'm just hesitant to claim that an increase of any significance occurs. As per your chart, the rate is 0.5/1000 at 40 weeks and up to 0.8/1000 at 43 weeks (when, in fact, the pregnancy is "overdue"). That is not a massive figure.

I know we're splitting hairs, but taking into account the study you just quoted, showing no significant difference in the health of the newborn if the labour is induced or allowed naturally at 41 weeks, and taking your chart from your first post, which doesn't (in my opinion) show significant differences in stillbirth rates, I'm just not feeling reassured that it's necessary to push labour into a tight timeline.

Ayla

Ayla wrote: »

I'm just hesitant to claim that an increase of any significance occurs. As per your chart, the rate is 0.5/1000 at 40 weeks and up to 0.8/1000 at 43 weeks (when, in fact, the pregnancy is "overdue"). That is not a massive figure.

I know we're splitting hairs, but taking into account the study you just quoted, showing no significant difference in the health of the newborn if the labour is induced or allowed naturally at 41 weeks, and taking your chart from your first post, which doesn't (in my opinion) show significant differences in stillbirth rates, I'm just not feeling reassured that it's necessary to push labour into a tight timeline.

That's a 60% increase in risk. This has been replicated in many other studies of large size. How much increased risk do you need?

Also the cornerstone of the argument against induction on this thread seems to be the supposed belief that it is more likely to result in C section. All the papers I've found thus far contradict this.

Edit- In the post dates scenario, due to the fact that waiting for spontaneous labour can result in macrosomia and subsequent C section.

Comparing all labours, induction has been shown to increase C section rate.

Ayla

Deleted User wrote: »

That's a 60% increase in risk. This has been replicated in many other studies of large size. How much increased risk do you need?

60% of not much is still not very much. As a woman who's been preg twice, if someone told me I had a 0.0005% chance of delivering a stillborn baby at 40 weeks, and 0.0008% chance if the pregnancy continued to 43 weeks, truthfully I wouldn't be overly concerned. Yes, of course it happens, and it's tragic when it does, but I don't think it's right to base a decision to induce on such small chances.

SanFran07

Deleted User wrote: »

Also the cornerstone of the argument against induction on this thread seems to be the supposed belief that it is more likely to result in C section. All the papers I've found thus far contradict this.

I thought the main argument against routine induction on the thread is that it starts a cascade of intervention which can be damaging to both Mum and baby. Maybe more individualised care would be helpful rather than blanket inductions - why induce a woman with a Bishops Score of 1?

Ayla

Ayla wrote: »

60% of not much is still not very much. As a woman who's been preg twice, if someone told me I had a 0.0005% chance of delivering a stillborn baby at 40 weeks, and 0.0008% chance if the pregnancy continued to 43 weeks, truthfully I wouldn't be overly concerned. Yes, of course it happens, and it's tragic when it does, but I don't think it's right to base a decision to induce on such small chances.

Yes but, there are risks other than death presented to the foetus in going over 42 weeks. From an earlier post of mine on this thread:

Problems during labour due to larger fetus (25% >4000g)
Fetal skull more ossified and less easily moulded
Passage of meconium (25-42%)
Neonatal death 3x more likely
Neonatal seizures 10x more likely

(Source: Oxford Handbook of Clinical Specialties)

So in summary:

Going over 42 weeks poses significantly increased risk to the foetus, both in terms of mortality and morbidity.

Waiting for spontaneous labour vs induction does not decrease chances of having a C section.

Ayla

And from an earlier post of mine, no one here's advocating going over 42 weeks! Most everyone's pushing for more personalized care, better dating practices and use of technology as those dates approach to accurately assess the baby's condition.

SanFran07

Deleted User wrote: »

Yes but, there are risks other than death presented to the foetus in going over 42 weeks. From an earlier post of mine on this thread:


Fetal skull more ossified and less easily moulded
Passage of meconium (25-42%)

The fetal skull may be more ossified (if the dates are accurate) but the Mothers pelvis is not fixed - the ligaments are designed to stretch and move as long as the Mother is in an upright position and not confined to bed which is more likely if she is induced.....

Meconium isn't always a sign of distress as you know there are different grades of mec and it can be simply a sign of a mature gut.

Ayla

Ayla wrote: »

60% of not much is still not very much. As a woman who's been preg twice, if someone told me I had a 0.0005% chance of delivering a stillborn baby at 40 weeks, and 0.0008% chance if the pregnancy continued to 43 weeks, truthfully I wouldn't be overly concerned. Yes, of course it happens, and it's tragic when it does, but I don't think it's right to base a decision to induce on such small chances.

...

Ayla wrote: »

And from an earlier post of mine, no one here's advocating going over 42 weeks! Most everyone's pushing for more personalized care, better dating practices and use of technology as those dates approach to accurately assess the baby's condition.

This will be my last post on this thread. I do not expect to change the minds of any of the regular posters on this thread, you are far too deeply entrenched in your positions. However, I fear that impressionable eyes may be reading this, anxious to know what's best for them and their child, and be swayed by some of the dubious claims and assertions that have been made.

Everytime I provide evidence to refute a claim that is made, a new claim appears, is refuted by me, and then an earlier already refuted point appears again. In other words this is going around in circles.

There has been much talk here that the decision to induce should be made on a case by case basis rather than adhering to a formula or rule.

The problem with this is that all available forms of fetal monitoring determine only fetal health at the precise moment in time they are performed. They have no predictive value.

In much the same way as it has been decided that 140mm/mg systolic blood pressure is the point at which the benefits of treating hypertension outweigh the risks, it has been decided that ~42 weeks is the point at which the increased risk of adverse fetal outcomes are enough to warrant intervention.

Can you say that someone will definitely have a stroke when their BP is 141, or that they won't if it's 139? Of course not, but a line has to be drawn somewhere.

As for dating practices, I would urge women to get an early dating scan if possible. Some centres are better than others in this regard.

SanFran07

SanFran07 wrote: »

The fetal skull may be more ossified (if the dates are accurate) but the Mothers pelvis is not fixed - the ligaments are designed to stretch and move as long as the Mother is in an upright position and not confined to bed which is more likely if she is induced.....

Meconium isn't always a sign of distress as you know there are different grades of mec and it can be simply a sign of a mature gut.

I know I said I'd made my last post but that was before I read this. The ligaments stretch and move just as well at term as they do post term. This is not a variable. The variable is the size and compressibility of the foetal head, which increase and decrease respectively post dates.

As for meconium, yes it is not always a sign of foetal distress, but it is always a bad thing, due to the fact that it can lead to meconium aspiration syndrome.

SanFran07

.

MAS is a rare complication – around 2-5% of the 15-20% of babies with meconium will develop it. Of the 2-5% of the 15-20%, it will be fatal for 3-5% of those infants.

SanFran07

SanFran07 wrote: »

.

MAS is a rare complication – around 2-5% of the 15-20% of babies with meconium will develop it. Of the 2-5% of the 15-20%, it will be fatal for 3-5% of those infants.

You stated that meconium was harmless and "just a sign of a mature gut". Now you seem to agree it isn't harmless.

Ayla

Ok, since the OP isn't going to comment any further on this thread, I won't ask him any further questions. But I think it's important to summarize the points that were made throughout this threaad in case there are "impressionable" minds out there:

1) Pregnancy term is generally defined as 38-42 weeks, and delivery within this period is generally considered safe. Overdue technically refers to 42+ weeks, although many people commonly refer to it as 40+ weeks.

2) After 40 weeks, there are some changes to the baby's weight, bone structure and organ maturity which can cause complications during delivery and in the post delivery stages. According to the study provided by the OP, these complications can occur whether the baby is delivered "naturally" or by induction at 41 weeks.

3) Stillbirth is always a possibility, and there are many reasons for it. There is an increased chance anytime after 32 weeks, and it goes up to 0.5/1000 at 40 weeks, up to 0.65/1000 at 42 weeks, and up to 0.8/1000 at 43 weeks.

4) There is a vast range of care received based on the particular health professionals and hospitals attended; one consultant may or may not recommend the same treatment as another. Scans are done irregularly and the undertaking of them is not standardized. The later in a pregnancy a scan is done, the less effective it is for accurately determining the EDD & estimated birth weight.

5) In some cases, delivering a child (through induction or otherwise) can lead to a "cascade of interventions," possibly (although not always) concluding with a c-section. All of these interventions can pose a risk to mother and baby.

OP - I'm not exactly sure what your intentions were when you started this thread; I'd imagine the responses you got were not what you'd envisaged. But the women who have shared all of their "antecodal" evidence are real women who have been pregnant and had the responsibility for carrying a child and delivering that child as safely as possible. No one's taken this thread lightly, and yes there have been disagreements but how can there not be when so much is at stake?

There is a risk for treating every woman's pregnancy against a standardized system; pregnancy is not like blood pressure, there are just too many variables.

GoerGirl

Deleted User wrote: »

Also the cornerstone of the argument against induction on this thread seems to be the supposed belief that it is more likely to result in C section. All the papers I've found thus far contradict this.

In the post dates scenario, due to the fact that waiting for spontaneous labour can result in macrosomia and subsequent C section.

Comparing all labours, induction has been shown to increase C section rate.

The cornerstone of the argument is not with regards to caesarean section, it is regards to the increased risk of routine induction vs the increased risk of waiting for spontaneous labour.

I fully accept there is an "increased" risk from 40 weeks for stillbirth, however, these risks are still relatively small. And it is difficult to assess comparatively the risk of routine induction vs going post date. For this reason, many hospitals have adapted their policy for non medically indicated induction - ie induction for postdates alone - until 42 complete weeks, where the risk of stillbirth increases enough to consider it of benefit for the baby to be born rather than continue to wait.

with regard to macrosomia, I have already addressed this issue. The research has shown us that macrosomia alone is not medical indication for induction of labour. There is also research which shows us that the professional beliefs of the care provider with regards to macrosomia will determine the birth outcome rather than the estimated birth weight. IE. consultants who regularly induce or section for macrosomia based on professional opinon rather than medical indication. We also have evidence which support that macrosomia alone is not reason for induction.