Friday, May 27, 2016

ACOG Induction

On May 16, the American Congress of Obstetrics and Gynecology (ACOG) met for an Annual Clinical and Scientific Meeting where they discussed several matters with regards to their practice. In this meeting, they discussed recommending routine induction at 39 weeks for all women. The birth community at large was in an uproar about several of their more controversial statements, including:

“This is a no-brainer. Why are we even having this debate?”
“39 weeks is the solution. Rescued by birth.”
“Think like a fetus. There is no benefit to staying in after 39 weeks.”
“Nature is a lousy obstetrician.”

The general conclusion was that recommending induction at 39 weeks for every woman was a good idea, though no recommendations have officially been made as a result of their discussions. Still, many in the birth community are now nervous about what may happen to the field of obstetrics and how, if this recommendation is made official, its going to change the way obstetrics is practiced.

There are a few things to note about ACOG. It is merely a private member organization, not a government entity with any authority over the practice. The recommendations that are put out by the organization can not dictate the way an OB/GYN member practices. (Hospitals and insurance companies are the ones that dictate practice). 

If a physician recommends a procedure just because ACOG recommends it, that does not mean that it is good practice. A systematic review of ACOG's policies revealed that only one third of the recommendations put out by ACOG are based in sound evidence. The other two thirds are based on either limited evidence or “consensus and opinion” (what everyone else is doing). Read here about this review of ACOG practices.

Evidence has shown over and over again that waiting until a baby is ready to be born, while carefully monitoring the pregnancy in the final weeks, is usually the safest route. In addition, a woman is not considered to be clinically “post dates” until she is 42 weeks. That means that an induction performed at 39 weeks could potentially cause a baby to be born three weeks before they were ready. This can be very dangerous for a baby. Due dates can be off, not all babies grow and develop at the same rate, and a 39 week induction could be very risky to a baby whose lungs are not yet developed. Induction itself also carries risks for both mom and baby and those are too numerous for this post.

One thing that evidence is very clear about is that a baby should gestate for at least 39 weeks. That does not mean that 39 weeks is the magic date that a baby should be forced from the womb. Stillbirth risks begin to climb after a baby has reached 42 weeks, so most care providers consider the 39 week to 41 week time frame to be an optimal window for birth. Still, even though the stillbirth risk rises, the incidence is still extremely low, and a baby may still have crucial development happening at 39 weeks and beyond.

So what is a woman to do if she finds herself with a provider that recommends induction at 39 weeks - just because?

Understand that you can always change your care provider. ALWAYS. Many women have changed doctors or midwives in the final days of pregnancy. If your care provider is not answering your questions to your satisfaction or practicing with the standard of care that you feel comfortable with, switch right away. In general, midwives tend to approach birth with a more hands off approach. They only intervene if a problem arises rather than stepping in before a potential problem could surface. Simply switching from an OB to a midwife may change the entire outcome of your birth. Study about the difference between active management and expectant management (and watch for a blog post about it) and find a provider that lines up with the one that fits you best.

You have the right to informed consent, but you also have the right to informed refusal. Informed refusal is not a term that is widely used, but it should be. Informed consent usually looks like this: “I inform you and you consent.” Informed refusal on the other hands simply asks the question, “What happens if I choose not to move forward with this plan?” That is a viable option for you.

Do your own research. Take an independent childbirth class so that you can learn about all the risks and benefits. Make the best decision for you and own it. At the end of the day, your doctor does not deal with the consequences that arise from interventions. You and your baby do. Be aware of what the risks and benefits are and move forward with what you feel is best.

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