Friday, 12 September 2014

"Big Baby" - Would you put money on that doc?

Induction of labour is a common but serious obstetric procedure. Induction is a big decision that can have serious effects on the health of both a woman and her baby. The research shows that for babies and many women, the best outcomes are when labour starts on its own. Induction for 'big baby' is a  common intervention in Irish maternity care practice. Recommendations of induction of labour for 'big baby' are often based on inaccurate predictive practices of foetal weight measurements; either clinically by a care provider or by ultrasound. There is also significant research which suggests that a care providers beliefs has a direct effect on the way a labour is managed and birth outcomes. In other words, if an obstetrician believes a baby is big, and believes that a 'big baby' is prescriptive of complications, the woman's labour is managed more medically, increasing risks of interventions and surgery, and sometimes contrary to a woman's own beliefs or medical indication.

"I was induced at 39+6 because my baby was measuring 7lbs at my 36 week appointment and they were really worried I would have a hard time as the baby was too big. It scared me and I thought the induction would be the best option. I had a really tough induction cause my body just wasn't ready. Gel, broke waters, and needed a drip. My daughter got into distress and I just narrowly escaped a section but had episiotomy, which then tore as well, and forceps. She was born at 40 weeks and I was really horrified when she was weighed and I was told she was only 7lb 8oz. I felt so cheated. I was told I must have had a lot of waters. My next baby was a homebirth and there was no discussion of weight and it was lovely to not have that fear hanging over me. I didn't doubt myself and had a gorgeous waterbirth at home at 41weeks giving birth all on my own to a healthy 8lb 4oz son."



Research has found that care providers and ultrasound predictions are inaccurate in estimating the size of a baby - predictions of a 'big baby' are wrong HALF of the time. (1)


There is also research to suggest that when women estimated their baby's weight they were more accurate than clinical estimates by care providers or ultrasound measurements. (2)

Despite this, many women report to AIMSI that care providers insist on their recommendations of induction based on clinical predictions which are shown to be inaccurate.

"I was told from about 35 weeks that my baby was measuring big and would be a 'good 10lber'. This was my first baby but I am tall and my mother had us all at home - we were all 9lbs odd - without any problems. My obs wanted to induce me from 39 weeks but I didn't think the baby was that big and I really felt I could do it...or at least try! He wasn't happy when I declined induction and told me that I was risking permanent damage. I gave birth to my son at 40+3 without induction and had a fantastic birth with a minimal tear. He weighed 8lb 4oz"

Induction of Labour is shown to increase the risk of needing a Caesarean Section, increases the risk that the baby will be admitted to NICU, increases risk of forceps or vacuum birth, and means that the woman's labour is now considered 'high risk' which changes how the labour and birth are managed. Recent research has shown that synthetic oxytocin, like Syntocinon or Pitocin, often used in induced labours, is an independent risk factor for distress in babies.

In fact, research has shown that induction increases the risk of Caesarean Section 2 fold in first time mothers. (3) ACOG 2009

Ireland's 'self-induced' strain on services

Research in the USA has shown that an uncomplicated caesarean section costs 68% more than an uncomplicated vaginal birth (Childbirth Connection 2011). Women with uncomplicated vaginal birth have shorter hospital stays, less instances of re-admission, and few infections. (3)

Over-reliance of medical interventions is a key component of strain on under-resourced maternity services in obstetric led maternity units in Ireland. It is vital that we reduce the medicalisation of the primary experience with first time mothers in order to reduce maternal morbidity rates and strain on services. Reduction in induction of labour for non-medical reasons is a start - as well as adopting appropriate care options for women such as midwife led care.

 The HSE's Mid-U report found that midwife led care is the most appropriate care option for the majority of women, uses less interventions - which in turn reduces caesarean section, is more cost effective than obstetric led care, and has high satisfaction ratings from women who used it.(5)

Would YOUR obstetrician put money on it?

Given what we know, AIMSI recommends a new tactic.

What if women asked the OB for €1000 for every ounce under the estimated birth weight the baby is born at?

Would YOUR obstetrician put money on it?


Evidence:

What is induction?

An induction of labour is when a doctor or midwife uses various methods to artificially initiate or accelerate labour such as:
  • a membrane stretch and sweep
  • a pessary or gel
  • artificial rupture of membranes (ARM)
  • a hormone drip
The Evidence Can Help You Make A Decision
“The National Institute for Health and Care Excellence (NICE) in the UK recommends that induction of labour has a large impact on the health of women and their babies, and so needs to be clearly clinically justified. “
If you are considering an induction of labour or have been offered an induction of labour without medical necessity, it is worth looking at the benefits & risks.

Induction of Labour – Benefits
  • You can arrange to be home for a specific event
  • Helpful in organising care for other children/work/help when you are home
Induction of Labour – Risks
  • higher rates of Caesarean section
  • increased risk of your baby being admitted to NICU (neonatal intensive care unit
  • increased risk of forceps or vacuum (assisted delivery)
  • contractions may be stronger than a spontaneous labour
  •  your labour is no longer considered ‘low risk’ – less choices in where and how you birth, restricted birth positions, continuous monitoring CTG, time limits for which to labour in.
Risks specific to your baby

Recent research has shown that the use of oxytocin in labour is an independent risk factor for distress in babies. This means that the baby does not tolerate labour as well when oxytocin is used. This can have implications on the way you give birth and on your baby’s condition after being born.
Other research shows that the use of oxytocin increases your chances of asking for an epidural. In a Cochrane Review, both oxytocin and epidural are discussed as having implications on breastfeeding your baby. You can read more about this here


1) Evidence Based Birth - Big Baby

There is tons of research on the inaccuracy of foetal weight prediction but this article from Evidence Based Birth is fantastic as it looks at all the relevant research, all of high quality, and clearly illustrates the findings all in one article.

On the article based on 'big baby' and the prevalence of induction or caesarean based on weight estimate prediction Rebecca looks at the most relevant quality evidence on 'big baby' and concludes:

  • Ultrasounds and care providers are equally inaccurate at predicting whether or not a baby will be big. If an ultrasound or a care provider predicts a big baby, they will be wrong half the time.

  •  If a care provider thinks that you are going to have a big baby, this thought is more harmful than the actual big baby itself
    • The suspicion of a big baby leads many care providers to manage a woman’s care in a way that triples her risk of C-section and quadruples the risk of complications.
    • Because of this “suspicion problem,” ultrasounds to estimate a baby’s weight probably do more harm than good in most women.
  •  Induction for big baby does not lower the risk of shoulder dystocia and may increase the risk of C-section, especially in first-time moms

  • A policy of elective C-sections for big babies likely does more harm than good for most women
    • It would take nearly 3,700 elective C-sections to prevent one permanent case of nerve injury in babies who are suspected of weighing more than 9 pounds 15 ounces
    • For every 3 permanent nerve injuries that are prevented, there will be 1 maternal death due to the elective C-sections

  • Full article here: http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/

    2) Women who had given birth before were able to predict their baby's birth weight more accurately than health care providers and ultrasound estimates. http://www.ncbi.nlm.nih.gov/pubmed/20795447



    3) Non-Medically Indicated Induction and Augmentation of Labor: http://onlinelibrary.wiley.com/doi/10.1111/1552-6909.12499/full#.VA4GvDPcDGs.twitter

    4) Quotes are from women contacting AIMS Ireland, used with permission, anonymously.

    5) MID-U study: http://www.hse.ie/eng/services/publications/Hospitals/midwifery%20north%20east.pdf
     

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