Induction for Obstetric Fear (aka large for dates)
(July 2018)
The criteria for inducing the onset of labour in pregnancy seems to be widening, with the term ‘high risk’ having an increasingly broad net. However one term which has remained steadfastly clinically contraindicated and yet still widely practised, is ‘induction for large for dates (LFD)’.
NICE guidance is clear on the issue (NICE CG70 July 2008):
Furthermore a systematic review of RCTs concluded that there was no statistical significance in the health outcomes of babies or women between expectant management of women with suspected macrosomic babies and those who were induced. NICE stated that the very fact that it is problematic even determining macrosomia means that induction of labour in this group of women is NOT recommended.
(https://www.nice.org.uk/guidance/cg70/evidence/full-guideline-pdf-241871149)
Why then is it still happening?
I would suggest that it is very much tied up with the current culture of fear surrounding obstetrics, my previously mentioned widening net of high risk has even become a term that women use about themselves, embedding that belief that birth is an event to be feared, that pregnancy is only normal in retrospect, that womens bodies are not to be trusted.
It would be wrong to diminish the risks associated with birth but it is very important to understand them for what they are and be mindful of the language used when discussing them. Even replacing the word risk with chance is better, even better would be using the numbers as they are often more meaningful.
Treating all women individually should not be seen as a goal too high. Information needs to be available for all, ranging from the most basic and accessible to all but by no means ‘sanitised’, through to a deeper level for those who wish to access it. Women can (and must) be trusted to judge which level they feel most comfortable accessing and bear no assumptions either way from the health professionals who are often seen as the gatekeepers of such information.
A quick bombshell: Health professionals are human. Humans judge other humans all the time. The difference between those who act on those judgements and those who keep their judgements to themselves are the people who have added kindness, intentional non-judgementalism, professionalism and even unconditional positive regard to their character. So you might disagree with a womans’ analysis of risk and subsequent choice, but you will support her in that choice and advocate on her behalf on the basis that she is human and worthy of trust. In this way and in this environment, informed choice is truly empowered.
NICE guidance is clear on the issue (NICE CG70 July 2008):
So first of all, what is large for dates? Clinically speaking it is a baby born with a birth weight of equal to or more than 4kg. This occurs in 2-10% of births in the UK, however, and this is a significant ‘however’, as the diagnosis of macrosomic babies is notoriously variable in sonographic accuracy with a range of 15% to 79%.1.2.10 Suspected fetal macrosomia
1.2.10.1 In the absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic).
Furthermore a systematic review of RCTs concluded that there was no statistical significance in the health outcomes of babies or women between expectant management of women with suspected macrosomic babies and those who were induced. NICE stated that the very fact that it is problematic even determining macrosomia means that induction of labour in this group of women is NOT recommended.
(https://www.nice.org.uk/guidance/cg70/evidence/full-guideline-pdf-241871149)
Why then is it still happening?
I would suggest that it is very much tied up with the current culture of fear surrounding obstetrics, my previously mentioned widening net of high risk has even become a term that women use about themselves, embedding that belief that birth is an event to be feared, that pregnancy is only normal in retrospect, that womens bodies are not to be trusted.
It would be wrong to diminish the risks associated with birth but it is very important to understand them for what they are and be mindful of the language used when discussing them. Even replacing the word risk with chance is better, even better would be using the numbers as they are often more meaningful.
Treating all women individually should not be seen as a goal too high. Information needs to be available for all, ranging from the most basic and accessible to all but by no means ‘sanitised’, through to a deeper level for those who wish to access it. Women can (and must) be trusted to judge which level they feel most comfortable accessing and bear no assumptions either way from the health professionals who are often seen as the gatekeepers of such information.
A quick bombshell: Health professionals are human. Humans judge other humans all the time. The difference between those who act on those judgements and those who keep their judgements to themselves are the people who have added kindness, intentional non-judgementalism, professionalism and even unconditional positive regard to their character. So you might disagree with a womans’ analysis of risk and subsequent choice, but you will support her in that choice and advocate on her behalf on the basis that she is human and worthy of trust. In this way and in this environment, informed choice is truly empowered.
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