The Doula Files: Induction
Using Discernment to Determine If & When Induction is Medically Necessary.
Introducing a *new* newsletter called The Doula Files which highlights real life experiences providing education and hands-on support to birthing clients. All of these stories hold complexity and are beautiful, lived-in illustrations of how the birthing process uniquely unfolds for each body.
When I first met Lauren she told me that she grew up in Germany. “A midwife comes to your home for checkups after the baby is born,” she said.
“I wish the same comprehensive support was built into perinatal care for women in the United States”, I thought to myself.
Lauren admitted how leery she is to give birth within the American medical system and explained that she wants to be given a fair shot at having an unmedicated birth in the hospital. When I asked her who she had chosen as her medical provider, I felt it was my responsibility to tell her about my experience with that particular doctor. “I have only ever encountered him with clients that he considered to be high risk. The clients that I supported who have given birth under his care were all induced.”
It led us into a deeper conversation about what makes someone high risk. I said it really depends who you ask. It is difficult to talk about risk assessment without also talking about liability. I explain to her the concept of defensive medicine. The definition which resonates with me deeply is “a clinical practice that is driven by the physician’s perception of legal self-interest… rather than by concern about expectation of patient benefit”.
Therefore, I tell her, it is important to choose your audience wisely. Here are some possible risk factors.
Age. Some doctors believe that age (35+) classifies someone as high risk, while other providers do not believe age is inherently a risk.
Fertility Treatments. Depending on the provider, fertility treatments, whether it’s a straightforward IUI or 5 complicated years of IVF, can automatically label a patient as high risk even if their pregnancy is healthy and normal.
Preexisting health conditions prior to pregnancy could flag someone as high risk.
Going past 41 weeks. Some doctors presume every patient, whether they are considered “high risk” or not should be induced at 41 weeks, while other providers evaluate each patient on an individual basis (reviewing the patient’s medical record, discussing with the patient how pregnancy is going overall, etc); carefully considering the mother’s constitution as well the health of the baby. The reason for this is due to the relative risk of stillbirth after 41 weeks gestation which is roughly .80-1.66 out of 1,000.
At the beginning of her pregnancy, Lauren communicated with her doctor that she would like to have an unmedicated hospital birth with the least amount of medical interventions. He enthusiastically agreed with her. She relayed to me how receptive he was to her wishes and how that made her feel like he would be a collaborative provider in her birthing experience. I am used to doctors promising the sun, moon and stars to their patients only to coax them into being induced. Still I was cautiously optimistic for her. “I’m glad he was receptive but I want you to continue to listen to your body during your prenatal visits with him. If you feel any red flags come up, let’s talk about it” I say to her.
About six months into pregnancy Lauren started to sporadically experience itching in the evening hours. It was inconsistent but it was present enough that she brought it up with her OB who was concerned that it could be a condition called liver cholestasis. According to the Mayo Clinic, cholestasis of pregnancy is “reduced or stopped bile flow. Bile is the digestive fluid made in the liver that helps break down fats. Instead of leaving the liver for the small intestine, bile builds up in the liver. As a result, bile acids eventually enter the bloodstream. High levels of bile acids appear to cause the symptoms and complications of cholestasis of pregnancy”.
Lauren’s doctor had her complete lab work which indicated that her bile acid count was within normal range. Although the lab work appeared normal, her doctor advised that she continue to monitor the bile acids through weekly lab work. He told her that if the itching persists or worsens and the bile acids rise then she may need to be induced. The reason for labor induction, he said, was to prevent unwanted complications such as preterm labor or respiratory issues after birth. Lauren agreed with her doctor that the bile acid count was something to monitor at her weekly appointments and remained open and flexible with what her body may need to birth her baby safely.
After a few weeks of monitoring her bile acids, it became clear that Lauren’s case was unusual. The bile acid count was fluctuating weekly, going up ever so slightly and then down to normal again. The itching would flair up occasionally just as it would mysteriously disappear. According to the scientific literature Lauren was reading, her bile acid count did not meet the criteria of a proper diagnosis of liver cholestasis. Lauren went to her prenatal appointment with a printed copy of the research study she found that indicated that with such low bile acid levels, an induction is not necessary. He dismissed her and said that the scientific journal from which she found the published article (the Lancet) is unreliable.
At 37 weeks, Lauren’s doctor said that he thinks she should schedule an induction. “I had another patient with liver cholestasis and her baby was stillborn. But it is your choice. We can continue to monitor your bile acid if you choose not to be induced.” Lauren felt uncomfortable hearing the word “stillborn” but had learned that the use of the word stillbirth was a possible fear mongering technique to get her to consent to the induction. However after much deliberation, she agreed to have the induction. She did not want to put her baby at risk.
Later that week, she ended up calling a friend in Germany who happened to be a medical provider. Her friend explained she does not clinically meet the criteria for the diagnosis of liver cholestasis and that it would be her choice if she wants to elect an induction. Even more, Lauren learned that the clinical criteria of the medical diagnosis for liver cholestasis was much more conservative in the United States than it was in Germany. She was hesitant and conflicted about what she should do.
At her 38 week appointment, she communicated her reservations about being induced with her doctor. Since her bile acid count was not meeting the threshold of diagnosis of cholestasis (both in the US and in Germany), and she did not feel comfortable moving forward with the induction. Lauren proposed that they wait another week to see if the bile acids go up further before entertaining the idea of induction further.
Her doctor was furious. He said he did not recommend they wait any longer. His tune drastically changed from “let’s wait and see if the numbers go up” to “we need to induce no matter what”. He said he will not be able to keep her as a patient if she does not agree to be induced at 38 weeks. He then told her that he was going to refund her the extra concierge fee of $4,000 that she paid to guarantee his presence at her delivery. She was shocked by his threat to abandon care, especially as she was nearing the end of pregnancy.
She said “after consulting with another medical provider, I am willing to be induced at 39 weeks”, which fell on a Friday. He scoffed and said that the hospital does not schedule labor inductions on Fridays.
She stepped out of room to call me. “Of course the hospital has availability for inductions on Fridays - but they won’t schedule an induction on a Friday unless it is truly medically necessary because most providers do not want to be working over the weekend” I tell her.
After pressing him on changing the induction date to 39 weeks, her doctor finally offered to wait until the following Monday, at 39 weeks and 3 days. When Lauren and her husband learned that he wanted to induce her at 38 weeks was not solely due to her bile acid count but because he had family visiting from out of town, he lost all credibility. Even worse, Lauren lost all trust in his ability to care for her.
My thoughts as her Doula are as follows:
The emotional rollercoaster my client Lauren endured from her doctor practicing defensive medicine was beyond negligent. Her birth experience was overshadowed by her doctor’s demeaning attitude so much so that she had a difficult time trusting her own ability to choose what feels right for her. I believe it was deliberate on the part of her doctor to make her confused and scared so she would be more suggestible and trust his opinion.
His family visiting from out of town limited his capacity to provide proper care and he was willing to lose business from his patient. Perhaps his medical opinion to induce Lauren was more motivated by his personal life than her bile acid count.
My intention with sharing Lauren’s birth story is not to “out” her doctor. Rather it is about empowering birthing people to ask questions in order to determine how they may be treated both in pregnancy and in the delivery room.
The ability to feel safe both internally as well as externally from the provider and the surrounding environment has everything to do with how someone’s birth experience is colored.
No matter how certain a provider may seem, no one can eliminate all risk. Bringing life into the world is fundamentally risky. How can we be comfortable and at peace with the mysteries of birth (and life in general)?
While Lauren’s provider faltered her ability to feel relaxed and confident, she defied the odds and birthed a healthy baby girl. She made the best choices she could given the information she had. She remained focused and worked her ass off. I was so proud of her.
It feels too easy to reduce birth to good or bad. But it’s not so black and white; the experience holds far more complexity than we often give it credit.
Moving forward I will make sure I do my damn best to avoid this provider like the plague and continue to help steer future clients away from unnecessary interventions.
Lauren, her husband Elliot and their baby girl are happy, healthy, recovering and bonding at home.
Photograph taken of Lauren, Elliot and their baby girl taken by me at their one week postpartum visit.
Further reading on pregnancy liver cholestasis can be found here and here.
If you know someone who is pregnant and may be seeking guidance through their pregnancy and birthing experience, feel free to share this with them.
I offer 1-1 birth preparation online worldwide. You can find out more here.
I love this new column! You share from such a balanced perspective 🤍 it’s so hard to know what to trust when navigating medical care and I just so appreciate your nuance