Am I Right to Accept Induction?

I can still say no to this. Right up to the moment that they actually start the medical process, I can decline to be induced. With forty-eight hours to go, it’s something that my mind still keeps returning to.

I know that I’ve had the best blood glucose control of my diabetic life in the last nine months. I know that my blood sugars have averaged similar to a non-diabetic, with very few major spikes. I’ve essentially had an uncomplicated pregnancy. I feel like I’ve mitigated the risks from being diabetic far better than I could ever have imagined, and the numbers suggest that my chances of problems at this late stage cannot far exceed those of a “healthy” woman. If I’m honest, I feel I deserve a straightforward birth experience as much as any one else.

I know that many women don’t get anything like their ideal, or straightforward birth. But I can’t help feeling that by accepting induction, I’m not giving myself the best chance.

I don’t want to be induced because I know that it carries risks. Chief amongst them, the increased risk of needing a caesarean section. And we know that I don’t want that . In fact several studies have suggested that increased induction rates are the single biggest reason for the rising caesarean birth rate. Even if caesarean is avoided, there is a greatly increased chance of other interventions including episiotomy, ventouse or forceps delivery. Induced labours generally require continuous fetal monitoring, which restricts the options for active birth, further increasing the risks of needing assistance.

These are all things which don’t sit well with my ideals for birth. And then add to that the fact that induction can also lead to breastfeeding difficulties and you can probably understand my personal apprehension. Furthermore, yet more evidence is also beginning to come to light that babies born between 37 and 39 weeks gestation are at risk of more health, developmental and behavioural problems than those born after 39 weeks. Unsurprisingly, the internet is littered with articles urging women not to be impatient and to let labour start of its own accord.

But…. I’m not doing this for convenience reasons, or solely because I’m impatient to meet our baby. I’m doing it because its what my medical team have advised me is the safest thing.

And the medical reasons to induce are, at least at first glance, extremely compelling. And particularly now I’ve managed to carry this little life safely inside me for almost nine months. I’d obviously never forgive myself if something went wrong right at the end that could be avoided. The bottom line is that if I decline induction, anything that goes wrong after that point will lead to me wondering if an induced labour would have avoided that problem. Ergo I feel somewhat obliged to go with what is, after all, the medical standard.

It’s the medical standard for a reason. Contrary to popular belief, big babies  are not the primary reason for early induction, although it does follow that delivering a big baby early avoids the opportunity for it to increase yet more in size and so decreases the chance of delivery complications including shoulder dystocia.(In reality, this is still questionable.) The most important reason, however, is the increased risk of stillbirth.

Yeah, that’s something that doesn’t bear thinking about.

Pre-existing diabetes in particular, and especially that which has been long standing, is associated with vascular changes that can lead to more rapid deterioration of the function of the placenta. If the placenta fails and the baby is not born within minutes…. Well, you get the picture.

And of course if you start asking questions about whether the risk is correlated with glycaemic control during pregnancy, or what the actual percentage risks are of stillbirth if waiting until 41 weeks, no one can tell you. Because early delivery is the standard of care. Because the potential risk exists, no one is going to give ethical approval to a study to quantify it which would mean putting women and babies at that risk. In fact, a recent systematic review of the evidence to support reasons for induction conspicuously excludes type 1 diabetes, mentioning only gestational diabetes, which it puts in the category of having no solid evidence to support routine induction. In fact, it concludes that there is little evidence for the majority of reasons given for induction.

But even if a study were carried out which proved that the risk of stillbirth in women  with type 1 diabetes waiting until beyond 40 weeks was, say 10%, that’s meaningless if you’re the one in ten and your world comes crashing down. To be honest, once you’re aware of the risk, it’s hard to do anything but contemplate getting the baby born safely as soon as possible.

To look at it another way, though, as an individual you’re still extremely unlikely to suffer adverse complications. As one article puts it:

“Fortunately, it is uncommon in this day and age for a baby born at full-term to die around the time of birth or experience serious illness or injury. However, these outcomes still occur despite advances in obstetric and neonatal care. Doctors or midwives may recommend inducing labor as a way of lowering the chance of these problems happening. However, it is impossible to know which women should be induced because injury and death are often unpredictable. As a result, thousands of women may have labor induced to prevent just one injury or death, and all of those women and babies will be exposed to the risks of labor induction, which may include cesarean surgery, instrumental delivery (assisted by forceps or vacuum extraction), and newborn breathing problems.”

I wish there were more definitive tests to establish individual risks. I wish that this process of giving life weren’t so fragile and precarious. I wish I could just let it go and accept that what will be will be, rather than continuing to agonise over choices that don’t really exist. It was different before I was pregnant and I could indulge in being idealistic, with my image of a “normal” pregnancy and natural, spontaneous labour. I naively thought that so long as my control was good, I could be managed like a healthy person, rather than an ill person.

That was before I had a second heart beating inside me. Before I knew the kind of love and powerful, instinctive protection you can feel for someone you’ve not yet met.

My reasons to decline induction are largely selfish, and now that I’m about to be a mum, I can’t be selfish anymore. I don’t want forceps or a caesarean, but the risks of these procedures to my child seem less than the potential risks of not getting labour going sooner rather than later. I don’t want anything bad to happen to my baby either way.

Am I right? I’m right, right?

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