Tomorrow is my due date. Its common for first time mothers to give birth anytime around the “due date”, plus or minus about two weeks. However, it is much less common for multiple gestation pregnancies, like my twins, to go all the way to term. Like many women, I’m now confronted with the question of whether or not to induce labor. Below I review some of the freely accessible medical literature on this question and conclude that there is no “Answer” to how an educated consumer of medical care would answer this question.

First, though, the added factor that I’m carrying twins complicates an already complicated issue in a couple of ways. There’s an increased chance of stillbirth with at-term twins, so getting them born is a higher priority. Twins are hard to carry, so hanging on to them longer has an deleterious impact on my fitness and health. And, I’m already at risk for an increased c-section rate, so I’m not sure whether to give additional risk greater or lesser rate (if its going to happen anyway, who cares vs. its already bad why make it worse).

Second, I should say that I would just schedule the c-section or induction if the babies would be healthier with it, even if the choice would compromise my ability to care for them right after their birth. The end result you are looking for is healthy babies, healthy mom. But these babies are perfectly fine, and the non-stress test they are submitted to every week shows health and liveliness. So we’re talking about health risks in the absence of evidence of any problems.

My natural childbirth teacher and the midwife community rejects induction. I respect this view, but I do think it tends to be based on a quasi-religious belief that “natural” is better than “medical”. Without getting too deeply into this opinion, I’ll just say that the metaphor they always use for birth is what a cat does when it goes into labor. But we are not cats. Human babies have disproportionately gigantic heads. This causes a different set of problems than a mama cat faces.

My doctor, like many doctors, recommends induction at 41 weeks. This is because a 1999 study shows that induction at 41 weeks (versus waiting for spontaneous labor at 42 weeks) has no effect on c-section rates and decreases the stillbirth rate. I respect my doctor, trust her, and think she’s very competent. But, I think she’s trained to believe that the application of her skills increases the chances that everything works out ok, as opposed to doing nothing. I don’t believe that this medical view takes into account all the relevant health and emotional factors for either mother or babies, it is intended to maximize survival regardless of other costs. Which is great if survival is at stake. But what if its not?

For example, induction and an unnecessary c-section has far less of an impact on her than on me. Induction means being connected to an IV and to fetal heartbeat monitoring devices. That means being pretty restricted in terms of movement, which means that a lot of the labor management techniques I learned in childbirth class will not be available to me. As a result of the more powerful contractions brought on by induction drugs and the limitations on my movements, I’d be more likely to need the epidural, which has its own risks and rewards.

More troublesome for my decision making, there are studies that reject my doctor’s conclusion:

Here’s a 2005 study saying that induction at 41 weeks means longer labor, more epidurals and no outcome benefits for babies or mother.

Plus, there are several other studies that show that elective induction increases the risk of C-section in first time mothers:

October 2000

February 2002

In short, you can basically find a study to support either view about the risks and benefits of induction. To determine which is right, or perhaps “righter”, you need to look at the methodology of each in a much more in-depth way that is appropriately the domain of professional scientists and medical professionals, and not the casual medical consumer like myself. I can look up critiques of each of the studies, but even there I’m just going by what someone else says, since there are criticisms on both sides. Do doctors and scientists have a consensus, because if so, its not clear to me, and consensus is often wrong.

In the end, I feel left with not much more than gut instinct. What do I follow, my doctor, or my anecdotally-based prejudice against induction? Whatever I decide, anything could happen. Take a simple game, like Blackjack. You play according to the odds, but sometimes you lose and sometimes you win. The same is true with medical decisions, and could be true for me. But I won’t have the mantra I recite to comfort myself when I lose at Blackjack, which is “at least I have the satisfaction of knowing that I played correctly”.

For the pregnant woman, there’s no odds cheat sheet to pull out of your wallet when you’re sitting at the green felt table.