Induction and Informed Consent

Ez - posted on 08/16/2011 ( 33 moms have responded )

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Kathleen Rice Simpson, PhD, a professor of nursing and 30 years experience as a L & D nurse, has done extensive research on the management of labour, communication between nurse and doctor, and induction. On the topic of elective induction she says:

'I firmly believe that mothers are not informed enough to know that this is not a good idea, and that any woman who has the right information would not want to have her baby induced.'

'When I admit a patient, I say, 'So what brings you in today?' And they say, 'Well my doctor told me I'd have a baby today.' I say, 'Oh well, what's the indication?' 'Well my doctors just told me.' They don't have any knowledge of the risks of induction.'

Thoughts? Have you had any experience with this? If you were induced, do you feel the procedure of informed consent was followed?

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Mary - posted on 08/17/2011

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Yes, Erin, some really don't want to know all that is involved, or all of the possible scenarios that may result from an "artificial" induction. Many women really wish to remain clueless about labor overall. As a nurse, I can see a little bit where SImpson is coming from; it's frustrating when a patient comes in and appears uneducated or ill-informed about what is about to happen to her and her baby. However, years in L&D have taught me that more often than not, it really is not about the provider failing to adequately explain the process, but rather, a deliberate ignorance on the part of the woman. It can be frustrating, because this is a mindset that I just don't "get", but ultimately, it is their choice to know as much or as little as they choose. The only time this really bugs me is when someone whines afterwards that "nobody told me this might happen", when I know damned well that someone tried to do just that.

The same is true with the epidural. Every anesthesiologist I have ever worked with has tried to explain, in detail, just how an epidural may work, and the possible complications. Even when they try to speak to a patient proactively (meaning, before the patient is requesting it, or is in pain), many of them really don't care - they just want it to work they way that they expect). Many are shocked when it doesn't make them completely numb, or are surprised when they are too numb, or whatever.

As well, I have found that only about 60% of women at my hospital took any type of prenatal classes ( we asked this question at some point during the admission process).

Mary - posted on 08/17/2011

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As an L&D nurse with (only) 15 years of experience, I cannot completely agree with her statement. It may have been true years ago, but I certainly don't think it is today, at least not in any hospital in my region. It's hard to have this discussion in an international forum, when practices vary so widely, so I can only comment on my knowledge of what is common in the greater Baltimore area.

Where I worked, it was (about) 2007 when a separate two paged consent form was introduced specific for the induction of labor. The expectation was that, after a physical exam in the doctors's office, this form would be reviewed with the patient. It included the findings of the cervical exam (including the Bishop's score, which, for an elective induction without medical indication, must be > 6), gestational age (and how, precisely, this was being determined), as well as an explanation of all possible induction methods, and their associated risks. It was clearly marked on the form which method was to be utilized. This form was signed by the patient, provider, and a witness. In order for an induction to be initiated, this detailed consent form had to be present.

Now, as a nurse, I find it almost funny when Ms Simpson talks about a patient saying "Well, my doctor just told me". I cannot tell you how many times I have witnessed a practitioner extensively and exhaustively explain something to a patient and/or family member, and then heard that patient's synopsis of that explanation was. More often than not, the differences are startling, and with regards to induction, the summary is often along the lines of "they are going to give me medicine to make my contractions start, and then I'll have the baby".

Now, I don't mean to imply that the patient in question is either stupid or inattentive. Often times, it is more that they assume that I, as their nurse, should know what the deal is, so they don't need to spell it all out for me. Sometimes, though, it is that they just don't care. Numerous times, I have watched a provider try to explain induction to a patient, including all of the possible risks, only to have them respond "Doc, just do what you have to do to get this kid out now".

Ez - posted on 08/17/2011

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Congrats Heather!

I also thing Mary touched on something important. Not all women have the inclination to learn about birth. Some genuinely have no interest in knowing the ins and outs of what will, or could, happen. They just want the baby out. Those women are much more likely to hear only what they want to hear from the doctor. The doctor may explain the procedure, the reasons (if there are any) and risks, and all they hear is 'yay! This pregnancy will be over and I can meet my baby'.

Jenni - posted on 08/17/2011

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My OBGYN did have me sign informed concent. But she was always so rushed she didn't really take time to go over it with me. My OBGYN began planning my induction at my 40 week check up. It came across more like she was telling me when I would be induced (at 41 weeks). I think the only thing she really covered was that inductions can lead to a higher risk of emergency cesarians. So she scheduled me for 41 weeks and 3 days. She had wanted it for exactly 41 weeks but I told her I preferred (if I had the option) to wait until after the weekend when my husband wasn't working.



With my second I was more adament about waiting to be induced. I had a horrible experience the first time around.



So when I went to my 40 week appointment, and she began pushing me again to induce (because it suited *her* schedule) in my 41st week, I asked her what the hospital policy was on inductions. She said 42 weeks but if I was induced then, she was unlikely to deliver me on that weekend. Funny, because despite planning my last induction on her schedule, she wasn't available to deliver me.



So I told her I didn't care who delivered me, that I wanted to avoid an induction and wait as long as hospital policy would allow me to.



I was scheduled for an induction right at week 42. Disappointingly, I still had to be induced and it ended with another emergency c-section.



Inductions suck. I don't wish them on anyone if it's at all possible to avoid them.

Becky - posted on 08/16/2011

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I was induced, but it was medically necessary, not elective. But I honestly do not remember being well-informed about the risks involved with induction. They told me it could take a few days, because my cervix was still closed, but that was all I can remember being told. I guess maybe they - and I - were more concerned about the risks of not delivering the baby, as I was developing Pre-E, than the risks of early induction. Not to say that I would've refused if it'd been more fully explained, because you do have to weigh the risks in situations like that, but I don't feel it was really informed. I have since informed myself and would not consider an induction unless I was very overdue or it was medically necessary.

33 Comments

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Constance - posted on 08/19/2011

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I truelly believe that it is not only up to the Drs. to fully inform you of the risks with an induction but also they mother should do her own research on the pros and cons. Expecting moms have a wonderful advantage to getting all the information they need the internet. Yes you have to research several sources but you will get all the information you need to make a clear headed decision. Being informed from early on helps you to make better decision when the time comes. We always have to remember in most cases Drs. make the decisions for their patients because they feel it is the best for the patient. Yes there are Drs. that make decisions based on what is best for their golf game not their patients.

Sarah - posted on 08/19/2011

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I was induced with my youngest.
I was 15 days overdue. I was fully informed about everything. I went in and they burst my waters.

I ended up having an emergency C-section, but it was unrelated to the induction, my daughter was an undiagnosed breech.

I've never heard of anyone not being informed about inductions, here in the UK, I don't think women are induced usually until they're 2 weeks overdue. When they are induced, they receive a leaflet all about the risks etc, and the midwives/nurses/doctors talk it all through with you too.

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I was not informed when i went in for my induction. I did not know the risks of a c-section were greater. If i were informed beforehand, i would have let nature take its course.

Melissa - posted on 08/18/2011

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i feel like i was informed on both my c-sections, my first, i had gestational diabeties and preclampsia, and i was extremely swollen the day before i had him. My dad even stayed home thinking i wasn't staying off my feet watching me, making sure all i was doing was getting up to go potty, and get food or a drink. So he knew pretty much the next day at my doctors appointment i would be told i would be having a cesarian because my son was breach, and i was high risk due to other reasons too, not just ones listed. My daughter, she was also breach, she was 2nd child, and i had previous scar tissue from both the 1st child and another previous surgery from 20+ years ago, so there was no turning her around. Also i had a lot of pain in my stomach and no movement from her. so to be safe they moved up my c-section 2 days because of this. They were going to do the c-section on the tuesday because of high risk and breach position anyways but with little movement and pain in my belly they moved it up!!

Lady Heather - posted on 08/17/2011

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Second induction for SIL yesterday because her BP went way up. I now have a new nephew, no c-section required! yay.

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I have no idea how informed I was since it was almost 10 years ago and my memory sucks. I just knew the girls HAD to get out, so I begged them to induce. There were many reasons to go ahead w/ it and no real reason not to. It didn't work though, so a semi-emergency c-section got them out quickly and probably saved baby B's life.

Constance - posted on 08/17/2011

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I asked for my induction due to the pain I was in with my second. I was only 37 wks and was in labor for less than 4 hrs when he was delivered. I also pushed for my third because I knew in my gut something was wrong and I was right ended up wih an emergeny c-section.

I knew what I was getting into before I did it. I had to sign a ton of paperwork plus I read everything.

Stifler's - posted on 08/17/2011

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I had to sign a consent form aswell. Then when I was drugged up on gas I had to sign a consent form for a c-section. They could have been signing me up for euthanasia and I wouldn't have cared less.

Sara - posted on 08/17/2011

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I was induced for medical reasons with my first, and my doc did discuss the possible risks to me and baby with me prior to me deciding to go ahead and go on with the induction. It is scary, and I don't think it should be taken lightly to be induced.

Carolee - posted on 08/17/2011

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I was induced with both of my kids. The first one, my son, was medically needed. I had borderline preeclampsia.

The second one, my daughter, I fought for. I had been in premature labor (where they had to give me meds to stop labor) twice. I was in so much pain that I knew she was getting too big for my body. My doctor, husband, and I had a very lengthy conversation about the risks. I followed my intuition and was induced 12 days before her due date. Her clavicle broke on the way out. If she had been much bigger, I would have needed a c-section. She was born completely healthy (other than the broken bone).

I was very well informed for the first induction as well.

Tara - posted on 08/17/2011

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I agree with some of the statements made, however like Mary I know that patients don't often listen as attentively as one would assume, nor do most patients care at all about how or why they are being induced but simply want the baby OUT.

I had an induction with my third baby. She was 4 days past due, my doctor did not give me informed consent. He told me I would be induced at the hospital in the AM by the consulting OB. The reason he gave me for my induction was my fundal height was measuring 2 cm past what it should at 40 weeks. I told him this was the same way with my other two babies, but because the first was born on his due date (today actually, happy 18th birthday to my oldest son Jonah!) and the other was a week early, he felt I should be induced to avoid a possible section.

He knew I did not want a section, he also knew his vacation started the day after my induction, and if he let me go naturally or even waited another few days, he would not be the one to deliver me.

So she was born after a cervical gel was placed on my cervix in the AM on the 10th of March, 5 hours of really intense fast and painful labour and she was born naturally after 1 push.
She was 6 pounds 6 ounces, a full 1.5 pounds less than my previous baby. The nurses all said she look premature not post dates.

After that I had midwives and homebirths for the last 3 babes.

I think informed consent should be mandatory but it doesn't guarantee that patients will be informed.

Merry - posted on 08/17/2011

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I was close to an induction with Fierna, I was 9 days over and my midwife wanted me to go in for a non stress test. I felt like if I did I would be snowballed into s hospital birth so I took castor oil and had hubby help me along (sexually) and the combination did make my pre labor contractions hurt more, but when iwas checked I was still at 1cm, but when the midwife left my waters broke and real labor started! Maybe as she checked me she stimulated my cervix enough to get it moving :) 4 hours later Fia was born.
I'd avoid induction at all causes especially if I'm planning a home birth. Hopefully my next baby will come on it's own a bit easier like Eric did.

Stifler's - posted on 08/17/2011

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That is fairly true, Mary. People sometimes don't care about the methods or risks they are just like "GET THE BABY OUT NOW!"

Sal - posted on 08/17/2011

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i have been induced twice, my 2nd was a week over and due to the extreme heat (she was a jan baby in western nsw) and the distance to hospitail it was decided waiting it out wasn;t the best option for me, my labour started almost imediatly when the gel was applied which makes me think it was all going to happen then anyway, it was a normal labour, and my third was induced on her due date as there was another medical emergency going on in my fam at the time and i wanted (and the dr was happy with it) to have her safely delivered before anything else happened so i wasn;t traveling to see my sick mum, or extra stressed about mum while i was going into natuaral labour, and also as we were living remote i needed to have her while i had someone to babysit the other kids, my mum had come to look after them and she ended up being medivaced out the day before she was born....it was a slow and painful labour so i;m guessing she wasn't quiet ready...

Ez - posted on 08/16/2011

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Heather, I took the comments to be in reference to inductions without medical indication. But I still tend to disagree with the statement. There are some women who are well aware of the risks and cascade of interventions involved, and still choose it (and although I thoroughly disagree with the choice, I support their right to do so). So I think her assertion is too general. But there is clearly an awful lot of women, like Laura above, where the process of informed consent has been ignored.

Lady Heather - posted on 08/16/2011

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I wasn't induced. My SIL was a week and a half ago. I think it was explained very well to her. The reason was she'd been having blood pressure problems. They explained to her what the risks were and made her aware that it might not work, etc. But they only gave her the gel treatment so when it didn't work she didn't have a c-section. They decided to just keep monitoring her blood pressure instead. I think they are trying another induction tomorrow because she is very nearly two weeks overdue. I think in that case she will have a c-section if it doesn't work, but I definitely think her obstetrician has done everything he can to see this baby come out on his own. Must be comfy in there.

I don't think I agree with this nurse that any woman would agree she doesn't want to be induced. I know lots of women who have had successful inductions. Certainly it's not something you want to do "just because", but I think there's a place for it when getting the baby out is medically necessary.

Jurnee - posted on 08/16/2011

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I was not well informed about induction. The doctor told me that my 4th child was growing too large and I would not be able to deliver vaginally, and I was very afraid of a c-section. They induced me at almost 40 weeks, but no one told me till i got to the hopital what was really involved. Such as when you are on pitocin you cannot walk during labor. They also failed to tell me that an induction may not work,so I laid in a bed for 24 hrs, with IVs and somethng they used to soften my crvix, cant think of the word now, and I did not have any real contractions. So they sent me home. I did wind up having a c-section a week later because the sciatica was so severe I could barely walk anymore. the funny thing is all my other children were over 2 weeks late and I never thought to induce.

Lacye - posted on 08/16/2011

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I was not informed about inducing my labor but the doctors never brought up the fact that I should. I was eventually induced about a week early but that was because my water had broken and I was not dilating as I should have been.

Stifler's - posted on 08/16/2011

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I agree I just don't see why you would take the risk if you weren't even overdue. The doctor said to me that I could be induced at 40 weeks (he thought Renae was big too and sent me for scans etc.) and I was tempted but declined and the midwives agreed with my choice and said that people had given birth to big babies vaginally before. There is only a public hospital here and people are always fighting with them about being induced when they want and how it's their choice etc.

Ez - posted on 08/16/2011

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I have too Emma, though only ever in the private system. Our public maternity system is much less likely to try and actively manage labour.

In my case, I feel I was definitely well informed. So informed, in fact, that I declined the induction for 2 weeks! If my doctor hadn't been so honest in explaining the risks and how unlikely it was to work on an unfavourable cervix, I would have been induced just before my due date, and would almost certainly have ended up with an emergency c/s. They were willing to do it (suspected macro), but he flat out said he didn't think it would work. So I waited. And waited. I finally booked in when I was 4cm dilated, bulging bag of waters with inconsistent prelabour, but went into labour spontaneously the day before (41+3wks).

But I know plenty of women who don't realise that induction really is a crap shoot. And if they're not explicitly told (and some are not), then I don't see how it can possibly be considered to be informed consent. If all she knows (and more importantly, understands) is 'I'm close to/past my due date, and the doctor said I can have my baby today', that is a huge breach of ethics IMO.

Rosie - posted on 08/16/2011

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ok, i take that back, i know one. her husband was deployed in iraq, he had a two week leave planned for the week before she was due. i think they induced her like 3 days after he got home.

Stifler's - posted on 08/16/2011

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I have. A lot of women here have husbands on shift work in another town so they demand to be induced on his days off so he can be there for the birth instead of taking days off when he's meant to be at work. My husband just told his boss he was leaving when he got a call to say I was in labour.

Rosie - posted on 08/16/2011

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yes, i feel i was informed. my first induction i had an appointment, i was a day overdue, and his heartate was in the 200's AGAIN. my cervix was favorable, the constant non stress tests were rather stressful on me, and i was ready. they decided to induce me. i felt i knew why, and that my body was ready for it.
with my last one, i was 39 weeks 6 days according to my period, AND the fact that i know it was impossible for me to get pregnant any later than the day i did because my husband got into a car accident and broke both of his legs the day after i got pregnant. no nooky for us after that certain date.
his ultrasound dating however dated him at 39 weeks 1 day. they wouldnt induce me any earlier than 39 weeks, and they wanted to go by the furthest out due date that they had, incase the LMP one was wrong (even though i KNOW it couldn't of been). i was induced basically on my own insistance because i had SPD so bad, i was in agonizing pain, my child was large, and my cervix was once again favorable.
i honestly have never known a woman to just go in and be induced for conveinance, or whatever.

Stifler's - posted on 08/16/2011

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They discourage inductions here unless you're at least 10 days over.

Stifler's - posted on 08/16/2011

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They gave me an info sheet on the risks of being induced when I was overdue and it wasn't looking like the baby was coming any time soon. I got induced because I was 11 days over and it was horrible and the heartbeat wasn't good and I had to stay on the stupid monitor for the 8 hours of contractions and I ended up with an emergency caesarean. I would have rathered have an elective caesarean than go through that crap in the hopes of having a natural birth.

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