Doc trying to force friend into an induction this Friday. Suggestions please.

[harli]

My friend is now 41 weeks 5 days along and is receiving a LOT of trouble from her OBGYN about inducing.

At first they INSISTED that she be induced the day she hit 41 weeks.  She argued and said before she will induce she wants an NST test that shows there is a problem first.  They weren't happy and threw the dead baby card at her.  They've been doing NST tests and she has been passing with flying colors until yesterday.  Yesterday she woke up late, jumped out of bed and ran to the doc's office.  She didn't have a chance to eat or drink yet, plus her baby is normally sleeping that time of day.  She went in for the NST and it showed babies HR at a steady 130 but they couldn't get her to move.  They did an US and it showed baby was doing just fine but still quiet with AFI levels at an 8.  They tried telling friend that she needed to rush to L&D right now because baby is at risk due to being sluggish and with low fluid levels.  She asked if they would do a membrane sweep first.  The CNM told her she is not comfortable doing this since baby has low fluid levels.  She said baby won't be able to handle contractions as well and that she needs to be in L&D with pitocin???????  My friend said she first wanted to talk to some other people and see what they thought.  CNM got very mad at this and wanted to push her to sign an AMA form.

She came back later in the day to talk to them about the AMA form.  The form was blank.  When my friend told them she wouldn't sign a blank form and that she wanted to know the medical reason for the induction.  They said they lost the test results.  She then told them that it wasn't her problem they lost the results and to order another NST.  This time her baby was awake and lively and passed the NST with flying colors.  She then questioned the CNM again and with no apology was told they could forget the AMA form 'for now'.

She had a long standing appt. with a different care provider at the same office for a membrane sweep.  Friend likes this OB only today she wasn't that friendly, made friend wait in the waiting room for well over an hour (her appts. are usually no longer then a 10 min wait).  She was then pretty much talked down to.  Yesterdays AFI levels magically changed from an 8 to a 6 and they induce no questions asked at a level of 5.   She was also told she "is not allowed" to go over 42 weeks and "will have to have" an induction this Friday when she hits 42 weeks 1 day.

They have also set up another NST for Thursday and the induction for Friday.   She's worried about the low AFI levels (assuming she's not being lied to).   Is it possible to read the AFI levels herself off the monitor of the US machine?  

I told her to just not show up for the induction.  But is there any other suggestions you have for my friend.  These are the only doc's she can see and in case it matters she will be delivering at Hershey Medical Center (who has a c-section rate of 37%)

On a funny side note.  These same doc's admitted that cervical checks aren't really necessary other then for 'practice for delivery'. 

[Tumble Bumbles]

I have this in my files that may put your friend at ease a bit:

Low Levels of Amniotic Fluid No Risk To Normal Birth

Besides, amniotic fluid fluctuates based on how much mama is drinking too. Staying very hydrated will help with that.

She can simply refuse. I mean, it sounds very simplistic, but it's true. She has the legal right to refuse. They cannot refuse to deliver her baby at the hospital because she refused an induction. She could also choose not to show up for the induction.

No one can "allow" or "not allow" anything. No one can do anything "no questions asked". They cannot drop her from their care legally, without securing alternative care (I believe they have to give 30 day notice in most places).

It may not seem like it when she's being bullied, coerced, and threatened with the 'dead baby' card, but your friend really does have the upper hand here, legally.

FWIW, my babe (now school-aged) came at 42w 5d and is healthy as can be.

[tracymom1]

I agree with the PP.  Especially about drinking - get that mama to drink as much water as humanly possible!!  And yes, she can just refuse the induction and then show up at the hospital when she is in labor.  Most likely she would just be assigned the OB who is on call for the unit that day (what we call 'doc in the box').

I would say that it might be worth looking into some more natural methods of induction - nipple stimulation, frequent intercourse, EPO, herbs, etc... if she can get labor going on her own, it might make things easier all around.  Sending her lots of happy baby vibes!

[AlexisT]

You can't just measure AFI by looking at the screen. It's actually quite tricky to measure and it's possible to get it wrong.

[Jane93]

I'm a little confused -- if she wants to engage in a risker behavior that increases risks of stillbirth by 3x, why shouldn't she be willing to sign an AMA form?  I mean, it seems like it shouldn't be able to be both ways -- that she is saying "I want to go engage in behavior that has is statistically higher risk AND hold the CPs responsible for my choice."

[mommato5]

http://www.americanpregnancy.org/pregnancycomplications/lowamnioticfluidoligohydramnios.htm

What is oligohydramnios?

Oligohydramnios is the condition of having too little amniotic fluid. Doctors can measure the amount of fluid through a few different methods, most commonly through amniotic fluid index (AFI) evaluation or deep pocket measurements. If an AFI shows a fluid level of less than 5 centimeters (or less than the 5th percentile), the absence of a fluid pocket 2-3 cm in depth, or a fluid volume of less than 500mL at 32-36 weeks gestation, then a diagnosis of oligohydramnios would be suspected. About 8% of pregnant women can have low levels of amniotic fluid, with about 4% being diagnosed with oligohydramnios. It can occur at any time during pregnancy, but it is most common during the last trimester. If a woman is past her due date by two weeks or more, she may be at risk for low amniotic fluid levels since fluids can decrease by half once she reaches 42 weeks gestation. Oligohydramnios can cause complications in about 12% of pregnancies that go past 41 weeks.

What causes low amniotic fluid?

Birth defects – Problems with the development of the kidneys or urinary tract which could cause little urine production, leading to low levels of amniotic fluid.

Placental problems – If the placenta is not providing enough blood and nutrients to the baby, then the baby may stop recycling fluid.

Leaking or rupture of membranes –This may be a gush of fluid or a slow constant trickle of fluid. This is due to a tear in the membrane. Premature rupture of membranes (PROM) can also result in low amniotic fluid levels.

Post Date Pregnancy- A post date pregnancy (one that goes over 42 weeks) can have low levels of amniotic fluid, which could be a result of declining placental function.

Maternal Complications- Factors such as maternal dehydration, hypertension, preeclampsia, diabetes, and chronic hypoxia can have an effect on amniotic fluid levels.

What are the risks of having low amniotic fluid?

The risks associated with oligohydramnios often depend on the gestation of the pregnancy. The amniotic fluid is essential for the development of muscles, limbs, lungs, and the digestive system. In the second trimester, the baby begins to breathe and swallow the fluid to help their lungs grow and mature. The amniotic fluid also helps the baby develop muscles and limbs by providing plenty of room to move around. If oligohydramnios is detected in the first half of pregnancy, the complications can be more serious and include:

• Compression of fetal organs resulting in birth defects
• Increased chance of miscarriage or stillbirth

If oligohydramnios is detected in the second half of pregnancy, complications can include:

• Intrauterine Growth Restriction (IUGR)
• Preterm birth
• Labor complications such as cord compression, meconium stained fluid and cesarean delivery

[GOPLawyer]

Originally Posted by Jane93 

I'm a little confused -- if she wants to engage in a risker behavior that increases risks of stillbirth by 3x, why shouldn't she be willing to sign an AMA form?  I mean, it seems like it shouldn't be able to be both ways -- that she is saying "I want to go engage in behavior that has is statistically higher risk AND hold the CPs responsible for my choice."

Welcome to MDC.  Take a look around…I think you’ll like it here.  Lots of supportive and well educated  Mamas who are well versed in evidence-based pregnancy/birth decisions.

1)      Upon what do you base your label of “riskier behavior”?

2)      I would NEVER sign a blank forum.  Good for her for refusing their ridiculous version of an AMA forum. 

Personally, I would cut all contact with them.  She has no obligation to put up with their harassment.  No Mama should be bullied like that.   SHE is the one who has the power to make decisions…they are solely hers to make.

[GOPLawyer]

BTW....does she have a doula?  It's not too late and it sounds like an especially good idea to have one w/ this particular practice.

[Tumble Bumbles]

Amen.

Quote:

Originally Posted by GOPLawyer 

Welcome to MDC.  Take a look around…I think you’ll like it here.  Lots of supportive and well educated  Mamas who are well versed in evidence-based pregnancy/birth decisions.

1)      Upon what do you base your label of “riskier behavior”?

2)      I would NEVER sign a blank forum.  Good for her for refusing their ridiculous version of an AMA forum. 

Personally, I would cut all contact with them.  She has no obligation to put up with their harassment.  No Mama should be bullied like that.   SHE is the one who has the power to make decisions…they are solely hers to make.

[Jane93]

Hi --

I base my statement of riskier behavior upon studies that show inducing at 41 weeks reduceds perinatal mortality versus expectant management. For example:

http://www.ncbi.nlm.nih.gov/pubmed/10234344?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=5&log$=relatedarticles&logdbfrom=pubmed  
 

Also, this one that shows going past 42 weeks increased stillbirth risks 3x for first time mothers:  
http://www.ncbi.nlm.nih.gov/pubmed/16956710?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed  
Also, this one, which states:

 
"When calculated per 1000 ongoing pregnancies, the rate of stillbirth increased six-fold from 0.35 per 1000 ongoing pregnancies at 37 weeks to 2.12 per 1000 ongoing pregnancies at 43 weeks of gestation."  
"http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1998.tb10047.x/full"  
 
 Obviously, if she wants to choose a riskier behavior that is her choice.  However, I don't think its fair that her CP should be held liable. 

[GoBecGo]

My thoughts:

An 8, in late pregnancy, is NOT a "low" reading.  <5 is "low", 5-25 is "normal".  So she is normal.  So she does not require induction!  They know this, her baby is passing the NST's, but let's face it, they have not scheduled to have her give birth next week, so her baby might cost them money if they don't force her out now.  Hence the induction.  AFI levels are notoriously hard to ascertain - like looking up from below at a person in a small glass bathtub and guessing how much water there is around them.

Signing a blank form is VERY VERY RISKY especially when the people asking one to do so are combatant and aggressive.  They can write whatever they like on there whenever they like, including after they injure or kill her or her baby with imprudent medical "care" to "cure" her over-long pregnancy.  She was absolutely right to refuse to sign it.

Jane93 stillbirth risk increases after the 43rd week, but i think you will find it is therefore the BABY which is engaging in "risky" behaviour by not beginning labour.  Not the Mama.  The mama is doing all she can to protect the baby from post-dates complications (by submitting to frequent NST's) AND the morbidity associated with the complications commonly occurring due to induction for no good medical reason.  It is therefore ridiculous to ask the Mama to take responsibility for the baby NOT being ready to be born yet!  It is not the Mama's job to tell the baby when it is fully grown and developed and ready for birth based on a calendar, a guess and a prayer (same goes for the obstetrician).  To do so is considerably more risky than waiting, especially when the baby is passing NST's as this one is.

In her place i would call them and tell them "sorry, a relative just died, i cannot possibly book in for an induction now unless the baby ACTUALLY becomes compromised, i have to help arrange the funeral.  I'll see you when i go into labour".  She will probably find that a few days "off" from the stress of having to deal with it all lets the baby build the oxytocin levels enough that things kick off.

[wombatclay]

big hugs and hopes for an easy birth, soon!  :)

In regards to signing a legal form that was, in any way, blank?  Um.  No.  If a care provider is offering me an AMA form then they should be doing so after providing the information necessary to ensure "informed consent".  Which means they should be offering studies like the ones Jane has provided (citing risks of being post date) as well as studies like those pp have provided (citing the risk of induction and/or inaccuracy of the diagnostic being used).  If they have gone to the effort to provide a true informed consent presentation then they will certainly have more than a blank form available for signature!  I'm not against a care provider covering their legal bases, but to ask a patient to sign an incomplete form and then try to excuse that incomplete status by suggesting they'd "lost the results"?  That's not cool.