Non-Medically Indicated Induction Before 39 Weeks

How I Practice Video Series
Laurie Gregg, MD, FACOG

HIP: Non-Medically Indicated Induction Before 39 Weeks from ACOG on Vimeo.

Mentioned in this video:

Also from the College:

  • Practice Bulletin 107 Induction of Labor (August 2009), (Replaces Practice Bulletin Number 10, November 1999; Committee Opinion Number 228, November 1999; Committee Opinion Number 248, December 2000; Committee Opinion Number 283, May 2003)

Transcript:

As a general obstetrician-gynecologist, I practice in a group of five individuals also obstetrician-gynecologists. We all discuss how we prepare for the potential "ask" at term from our patients and that "ask" is, "Will you electively induce me doctor?" We'll go in the room and start the visit with the patient, usually they won't start out with that "ask," but we'll go through how the fetus is doing and what their cervical exam is. I estimate the fetal weight for them and I also discuss in detail their cervical exam because that helps me counsel them on an elective induction. The cervical exam I discuss with effacement, which is a concept a little bit difficult for patients to understand, but the flattening of their cervix. I use my hand to show them that this would be a long cervix without any effacement (see video for hand movements), two fingers being 50% effaced, one finger being 70% effaced, and paper thin being 100% effaced. Dilation is a concept the patients understand easily (see video for hand movements). No dilatation, one, two, three. Station, I imitate the ischial spine with this hand and the fetal head with this hand (see video for hand movements). Zero station, one plus and two plus. Consistency, how soft or hard their cervix is, and position, whether it's posterior to the fetal head, mid-position, or anterior (see video for hand movements).

When they ask for an induction I certainly acknowledge their discomfort of a continuing pregnancy and I'm flattered by their desire to have me as their delivering physician, but point out to them that if I electively induce them, I'll be increasing their length of time in labor and their need for a cesarian section. The other point I certainly make is that if we do choose to proceed with an elective induction that it's never done before 39 weeks unless there's a strong medical fetal or maternal indication. If they still push me to do an elective induction at the time where I think it's not indicated I discuss the growth of the fetal brain at term. March of Dimes and the District IX Website have a great brain card that you can download or patient education material that shows fetal brain does 50% of its cortical growth between 34 and 40 weeks. Most of the time that makes that "ask" less persistent. I certainly show more compassion to the patients that are having a lot of discomfort in pregnancy and will even add an extra visit at term just to show them that I am compassionate, but don't want to decrease or diminish their outcomes because of that discomfort. This is how I practice.

 

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