Why do Drs induce at 41 weeks?

Rainbow17

I've noticed that the standard (in my area anyway) is that if you are having a hospital birth, doctors will induce you at 41.  Why is that?  I just feel like the baby would come out when its ready. 

margaritachikita

Ignorance and convenience. The average mom goes 41.5 weeks, not 40 weeks which is the misconception. That's average, and can be plus or minus 3 weeks. Induction almost doubles the risk for cesarean, with few proven benefits. There is a slight increase risk of stillbirth after 42 weeks which is my best guess as to why inductions are so prevalent. But the risks that go along with induction itself are to my mind worse than the risk of continuing pregnancy when mom and baby are healthy. I would never agree to one unless there was concrete evidence that myself or my baby were in some kind of trouble. Going past due is not a good enough reason to subject someone to an induction.

sschwege

To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

LilTiger15

Like @sschwege said--mostly due to liability reasons.  They prefer C-sections anyway, regardless of if they will admit it. 

My son was born at 41 weeks 2 days.  I saw the OB the day before.  They did an ultrasound to check on cervical fluid.  They said the amount was still a safe amount and the baby was not in danger.  They also did fetal heart rate monitoring for an hour--no problems there either.  However, the OB still told me I had to naturally go into labor within 48 hours or they would induce.  Thank the Lord, I literally started labor contractions about 1 hour after leaving the doctor's office.  I guess the baby heard the doctor and realized my fear of induction.  He was born the next day after a 20 hour adventure

 

iris427

sschwege said:

To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

I'm betting that while yes, lawsuits are a real concern for OBs, most of them are erring on the side of caution because they care about mothers and their babies.  Stillbirth rates rise every week at term, and going past 41 weeks has been found to increase complications for the baby.  There are studies showing that inducing at 41 weeks has equal or better outcomes than waiting.  

And no, OP, not all babies come when they are ready.  If that were the case, there would be no preemies or postterm babies, both of which are at increased risk of death.  If you really want to know why OBs induce at 41 weeks, ask one of them.  When I went past 40 weeks with my first baby, my OB explained very clearly to me why she thought inducing at 41 weeks was better and cited medical evidence for her reasons.  Bottom line, she wanted me to take home a healthy baby.  And yeah, my induction was no walk in the park and I had a cesarean because of fetal malpositioning, but in the end I did take home a healthy baby.

sschwege

iris427 said:

sschwege said:

To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

I'm betting that while yes, lawsuits are a real concern for OBs, most of them are erring on the side of caution because they care about mothers and their babies.  Stillbirth rates rise every week at term, and going past 41 weeks has been found to increase complications for the baby.  There are studies showing that inducing at 41 weeks has equal or better outcomes than waiting.  

And no, OP, not all babies come when they are ready.  If that were the case, there would be no preemies or postterm babies, both of which are at increased risk of death.  If you really want to know why OBs induce at 41 weeks, ask one of them.  When I went past 40 weeks with my first baby, my OB explained very clearly to me why she thought inducing at 41 weeks was better and cited medical evidence for her reasons.  Bottom line, she wanted me to take home a healthy baby.  And yeah, my induction was no walk in the park and I had a cesarean because of fetal malpositioning, but in the end I did take home a healthy baby.

The ACOG defines late-term pregnancy as one which extends beyond 41w and post-term pregnancy as a pregnancy that goes beyond 42w.  I think it needs to be a conversation between provider and patient based on the risks and benefits to that specific patient.  Not a blanket statement such as, "We induce at 41w."  There are very real risks to induction as well.  I'm curious to know if the studies supporting induction at 41w factor in the age of the mother.  Women are having babies later and later in life, perhaps that is swaying the data in favor of induction?  Do you have more information on the studies you cited?


  

 

MrsNash37212

Iris is correct (as usual) that the reason OB's generally induce at 41 weeks is because outcomes are better. The stillbirth rate at 42 weeks is double that at 40 weeks and actually induction at 41 weeks is LESS likely to result in a c-section than expectant management. You can read about some of the studies here:
https://www.aafp.org/afp/2005/0515/p1935.html

Also, not all OB's prefer c-sections. Yes, some do and deserve that reputation, but there are plenty of wonderful OB's. For example, my OB with DS delivered his granddaughter by emergency c-section at 10am the morning after I went into labor. She had to be transferred by helicopter to a higher level NICU. And bless that man, he stayed at the hospital with me while I labored until 2am the NEXT morning to ensure I got my vaginal birth because he knew the on-call doc was c-section happy. That is an OB who cares about his patients and he's not the only one.

carafern

iris427 said:

sschwege said:

To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

I'm betting that while yes, lawsuits are a real concern for OBs, most of them are erring on the side of caution because they care about mothers and their babies.  Stillbirth rates rise every week at term, and going past 41 weeks has been found to increase complications for the baby.  There are studies showing that inducing at 41 weeks has equal or better outcomes than waiting.  

And no, OP, not all babies come when they are ready.  If that were the case, there would be no preemies or postterm babies, both of which are at increased risk of death.  If you really want to know why OBs induce at 41 weeks, ask one of them.  When I went past 40 weeks with my first baby, my OB explained very clearly to me why she thought inducing at 41 weeks was better and cited medical evidence for her reasons.  Bottom line, she wanted me to take home a healthy baby.  And yeah, my induction was no walk in the park and I had a cesarean because of fetal malpositioning, but in the end I did take home a healthy baby.

I actually asked my midwife when I joined the practice because I knew their policy is to induce at 41 and 4. And she said exactly what PPs have said, that the evidence points to greater success inducing then than waiting, and for them success means vaginal birth, well actually success always means healthy baby, but this is a practice that is very pro-natural vaginal birth. I'm hoping it doesn't come to induction.

edit because I posted before I was done!

sschwege

carafern said:

iris427 said:

sschwege said:

To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

I'm betting that while yes, lawsuits are a real concern for OBs, most of them are erring on the side of caution because they care about mothers and their babies.  Stillbirth rates rise every week at term, and going past 41 weeks has been found to increase complications for the baby.  There are studies showing that inducing at 41 weeks has equal or better outcomes than waiting.  

And no, OP, not all babies come when they are ready.  If that were the case, there would be no preemies or postterm babies, both of which are at increased risk of death.  If you really want to know why OBs induce at 41 weeks, ask one of them.  When I went past 40 weeks with my first baby, my OB explained very clearly to me why she thought inducing at 41 weeks was better and cited medical evidence for her reasons.  Bottom line, she wanted me to take home a healthy baby.  And yeah, my induction was no walk in the park and I had a cesarean because of fetal malpositioning, but in the end I did take home a healthy baby.

I actually asked my midwife when I joined the practice because I knew their policy is to induce at 41 and 4. And she said exactly what PPs have said, that the evidence points to greater success inducing then than waiting, and for them success means vaginal birth, well actually success always means healthy baby, but this is a practice that is very pro-natural vaginal birth. I'm hoping it doesn't come to induction.

edit because I posted before I was done!

Inducing at 41w4d is not the same as inducing at 41w though, 4 days may not seem like a lot, but it can a world of difference at the end.  My MWs induce at 41w6d, but I wouldn't consider that inducing at 41w. 

iris427

iris427 said: sschwege said: To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

I'm betting that while yes, lawsuits are a real concern for OBs, most of them are erring on the side of caution because they care about mothers and their babies.  Stillbirth rates rise every week at term, and going past 41 weeks has been found to increase complications for the baby.  There are studies showing that inducing at 41 weeks has equal or better outcomes than waiting.  

And no, OP, not all babies come when they are ready.  If that were the case, there would be no preemies or postterm babies, both of which are at increased risk of death.  If you really want to know why OBs induce at 41 weeks, ask one of them.  When I went past 40 weeks with my first baby, my OB explained very clearly to me why she thought inducing at 41 weeks was better and cited medical evidence for her reasons.  Bottom line, she wanted me to take home a healthy baby.  And yeah, my induction was no walk in the park and I had a cesarean because of fetal malpositioning, but in the end I did take home a healthy baby.

The ACOG defines late-term pregnancy as one which extends beyond 41w and post-term pregnancy as a pregnancy that goes beyond 42w.  I think it needs to be a conversation between provider and patient based on the risks and benefits to that specific patient.  Not a blanket statement such as, "We induce at 41w."  There are very real risks to induction as well.  I'm curious to know if the studies supporting induction at 41w factor in the age of the mother.  Women are having babies later and later in life, perhaps that is swaying the data in favor of induction?  Do you have more information on the studies you cited?


  

 
@sschwege Sure, that's what informed consent is.  A discussion of risks and benefits.  And I imagine that's how it plays out in reality much of the time.  I know that's how has gone for me. You still have to consent, it's not like they strap you down and force Pit in your veins as soon as you hit 41 weeks. I'm aware of how ACOG defines late term and post term but terminology doesn't change the fact that stillbirth rates rise every week at term. 

Do I have studies?  You asked me this like 2 months ago and I gave you several, but I'll just C&P my response last time:

Here's a few I found from a quick Google.  It's not a new thing because when I had my first baby 6 years ago, my OB had already changed her recommendation from 42 to 41 based on the literature.

https://www.ejog.org/article/S0301-2115(04)00486-5/abstract

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3231911/

https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004945.pub3/abstract

https://www.sciencedirect.com/science/article/pii/S0029784403003429

That said, I'm sure you can also find studies that show it's better or just as good to wait until 42.  I think either way, with proper monitoring, it's low enough risk to go to 42 weeks that either option is reasonable (personally, I wouldn't feel comfortable past 42.  At that point I think the risks to the fetus far outweigh any benefits from staying pregnant).  And of course, these are just general discussions, and one has to take into account their own medical history, parity, how favorable their cervix is, what their doctor/MW says, etc.  But I guess my point is that inducing at 41 weeks usually has good outcomes and isn't an automatic ticket to the OR or anything like that, so I think it's worth considering.

Here's another study that just came out finding induction in term and postterm pregnancies reduces cesareans, reduces fetal deaths and NICU admissions, and has no impact on maternal deaths:

https://www.cmaj.ca/content/early/2014/04/28/cmaj.130925

And here's one that even found elective induction reduces cesarean rates and maternal/fetal morbidities, even in nulliparous moms or mothers with an unfavorable cervix:

https://www.ajog.org/article/S0002-9378(14)00221-X/abstract

I don't know how maternal age factors in, that's a good question to ask a doctor.  Generally a study comparing two groups should try to have them be similar in things like pregnancy risk factors, maternal age, parity, etc.  

sschwege

iris427 said:

iris427 said:

sschwege said:

To answer honestly, I think a lot of it has to do with fear on the part of the doctors.  Nobody disputes that the placenta starts to age as the pregnancy progresses, as my MWs say it's the only disposable organ.  At what point, no one can really know for sure as it would depend on so many factors.  I think in a doctor's mind they are thinking better to err on the side of caution, after all, which scenario is more likely to develop into a law suit?  My MWs induce the evening of 41w6d, if you decline induction they ask you to sign a waiver.  Providers are in the business of protecting their patients' interests, but also themselves, there's a reason their liability insurance is so high!

I'm betting that while yes, lawsuits are a real concern for OBs, most of them are erring on the side of caution because they care about mothers and their babies.  Stillbirth rates rise every week at term, and going past 41 weeks has been found to increase complications for the baby.  There are studies showing that inducing at 41 weeks has equal or better outcomes than waiting.  

And no, OP, not all babies come when they are ready.  If that were the case, there would be no preemies or postterm babies, both of which are at increased risk of death.  If you really want to know why OBs induce at 41 weeks, ask one of them.  When I went past 40 weeks with my first baby, my OB explained very clearly to me why she thought inducing at 41 weeks was better and cited medical evidence for her reasons.  Bottom line, she wanted me to take home a healthy baby.  And yeah, my induction was no walk in the park and I had a cesarean because of fetal malpositioning, but in the end I did take home a healthy baby.

The ACOG defines late-term pregnancy as one which extends beyond 41w and post-term pregnancy as a pregnancy that goes beyond 42w.  I think it needs to be a conversation between provider and patient based on the risks and benefits to that specific patient.  Not a blanket statement such as, "We induce at 41w."  There are very real risks to induction as well.  I'm curious to know if the studies supporting induction at 41w factor in the age of the mother.  Women are having babies later and later in life, perhaps that is swaying the data in favor of induction?  Do you have more information on the studies you cited?


  

 
@sschwege Sure, that's what informed consent is.  A discussion of risks and benefits.  And I imagine that's how it plays out in reality much of the time.  I know that's how has gone for me. You still have to consent, it's not like they strap you down and force Pit in your veins as soon as you hit 41 weeks. I'm aware of how ACOG defines late term and post term but terminology doesn't change the fact that stillbirth rates rise every week at term. 

Do I have studies?  You asked me this like 2 months ago and I gave you several, but I'll just C&P my response last time:

Here's a few I found from a quick Google.  It's not a new thing because when I had my first baby 6 years ago, my OB had already changed her recommendation from 42 to 41 based on the literature.

https://www.ejog.org/article/S0301-2115(04)00486-5/abstract

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3231911/

https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004945.pub3/abstract

https://www.sciencedirect.com/science/article/pii/S0029784403003429

That said, I'm sure you can also find studies that show it's better or just as good to wait until 42.  I think either way, with proper monitoring, it's low enough risk to go to 42 weeks that either option is reasonable (personally, I wouldn't feel comfortable past 42.  At that point I think the risks to the fetus far outweigh any benefits from staying pregnant).  And of course, these are just general discussions, and one has to take into account their own medical history, parity, how favorable their cervix is, what their doctor/MW says, etc.  But I guess my point is that inducing at 41 weeks usually has good outcomes and isn't an automatic ticket to the OR or anything like that, so I think it's worth considering.

Here's another study that just came out finding induction in term and postterm pregnancies reduces cesareans, reduces fetal deaths and NICU admissions, and has no impact on maternal deaths:

https://www.cmaj.ca/content/early/2014/04/28/cmaj.130925

And here's one that even found elective induction reduces cesarean rates and maternal/fetal morbidities, even in nulliparous moms or mothers with an unfavorable cervix:

https://www.ajog.org/article/S0002-9378(14)00221-X/abstract

I don't know how maternal age factors in, that's a good question to ask a doctor.  Generally a study comparing two groups should try to have them be similar in things like pregnancy risk factors, maternal age, parity, etc.  

First of all, thank you for the links.  I now do remember you posting them and I saw that you did, but forgot to go back and read them.  Thank you again!

Of course there is informed consent, my issue is how many women don't realize they have that right.  How often do we have women use the term, "My doctor won't allow me to go past X date."  "My doctor won't allow me to labor without X" or "Can I refuse this or that?"  That is scary to me, that someone would even have to ask.  So no, I don't think that's how it plays out the majority of the time.  Of course that is how it should be!  But that's a whole different post.

jennypolkadots

I've known several women personally who planned an induction simply because they were tired of being pregnant or to make sure their doctor was the one on call that day. These inductions are more likely to end in cesarean since the woman isn't in natural labor. Then she is told that something about her is deficient - her cervix won't dilate, her pelvis is shaped wrong, or after many hours of waiting the doctor offers to let her meet her baby now instead of waiting longer which of course is enticing. I have seen all of these scenarios play out, and it makes me sad for the mothers who really believe their bodies were broken somehow when they should have not been induced. Induction saves babies and is a great tool when needed, but it is used way too often. A lot of women are very misinformed about induction and consent without understanding certain things. I have been shocked by how many women consider 36 or so weeks to be full term, but some statistics cited here confirm the widespread misinformation: https://www.childbirthconnection.org/article.asp?ck=10650

Knowing my conception date and knowing my EDD is correct, I would allow my midwives to induce if they deemed it necessary. I know they don't take it lightly and want the best outcome, just like all doctors I have met. The methods are just different in that midwives are trained in normal labor and believe in a woman's body, while doctors are trained in things going wrong and tend to provide care proactively when sometimes it's best to do nothing at all. One of the reasons I switched to midwives is because my OB told me she never lets a mother go over 41 weeks citing that it's too dangerous and the baby gets too big, which I don't believe to be true for most women. 

The best thing every mother can do is learn as much as possible about birth and interventions, and be ready to make informed decisions. The risks involved in childbirth are yours to make, not your care providers. You can sign a waiver for anything pretty much, and they can not force you to do anything you don't want to. I think the most important piece of the puzzle is having a care provider that you truly trust is making the best recommendations for you and your baby, so that you don't have to fight them every inch of the way. 

margaritachikita

Someone mentioned the risk of stillbirth doubling from 40 to 42 weeks, but it should be noted that the relative risk is still extremely low.

HeavenBlessedMom

Safety
The placenta ages and nutrients need to be available for the fetuses.