Pregnancy is one of the most monumental journeys in a woman’s life. Everything is eagerly awaited, from the first ultrasound, to hearing the baby’s heartbeat, to finding out the gender, and finally, to the birth of a highly anticipated and longed-for arrival. Pregnancy involves a lot of waiting, however, what happens when the waiting period continues beyond what was anticipated?
When a woman finds out she is pregnant, she is usually given a due date by her care provider. This due date can be based on the date of the woman’s last period, or if she knows the date of ovulation, it can be calculated by that. If an ultrasound is performed, this date may be based on fetal growth. For this reason, an ultrasound dating is often more accurate than the date of the last period. For the average woman, pregnancy lasts somewhere between 38 and 42 weeks, however, a woman’s due date is based on the assumption that pregnancy is 40 weeks. Many women deliver before 40 weeks, however, what happens to women who are still playing the waiting game beyond 40 weeks?
The vast majority of women are misinformed and believe that, barring any other health conditions or risk factors, that the risk of complications or stillbirths drastically increases after the pregnancy has reached the 40 week mark, and often become concerned with induction. However, this is an inaccurate belief. In fact, according to a Canadian study of 654,621 babies, the rate of stillbirth was higher in babies born at 38 weeks (2.5 deaths per 1,000 births) than babies born at 42 weeks (2.0 deaths per 1,000 births).
Many women become discouraged, and often times depressed upon hitting their due date and not having had their baby yet. It becomes quite clear, that many of these women are unaware that it is perfectly normal to carry a pregnancy to 42 weeks. These women often look into induction, sometimes by the suggestion of their caregiver, other times, of their own initiative and their desire to meet their long-awaited arrival. Many doctors are comfortable with inducing labor at the mothers request, while other doctors will not do so without medication indication for induction of labor.
Induction is a complicated process, often involving drugs like cytotec (which is not approved by the FDA for use as a labor-inducing agent), cervadil, and intravenous pitocin (a synthetic version of oxytocin, the hormone that initiates and continues labor). Cervadil and cytotec are often inserted into the vaginal canal and work by “ripening” the cervix (affecting effacement, the thinness of the cervix, and dilation, the openness of the cervix). Once the cervix is adequately ripened, pitocin may be started through an intravenous drip, bringing on contractions that are much more intense and often more painful than natural, oxytocin-induced contractions. The goal of induction is to “ripen” the mothers cervix enough that the contractions are effective in completing dilation, leading to the birth of the baby. However, the success rates of induction vary.
Before a woman considers an induction, she should ask her caregiver for her Bishop Score. The Bishop Score assigns a number 0-3 for each of five factors (dilation of the cervix, length of the cervix, consistency of cervix, position of cervix and the station of the baby’s head). When the Bishop Score is less than 4, the likelihood of a successful induction is minimal. When the Bishop Score is greater than 6 the likelihood of a successful induction is around 75%. When the Bishop Score is greater than 9, the likelihood of a successful induction is around 95%. A failed induction often leads to an unplanned cesarean section (a surgical birth) due to fetal distress or other complications brought on by induction methods. Not every doctor will check a woman’s bishop score before offering or attempting to induce. It is pivotal, that before considering an elective induction, that a woman request her Bishop Score be determined, in order to aid her in making the best possible decision for herself and her baby.
One very common complication to arise during an induction is fetal distress. The contractions that result from a pitocin induction are much stronger, and often more frequent than contractions that naturally occur. This extra force can often affect the baby’s heart rate, leading to a diagnosis of fetal distress. Fetal distress, in turn, often necessitates a cesarean section, thus leading to even more health risks, including hemorrhage and four times the risk of death, a much longer recovery time and the increased likeliness of post-partum depression.
Labors induced using pitocin are much more painful and intense than natural labors. The more intense pains may lead a woman to utilize pain management methods that she may not have wished to use, such as narcotics or an epidural, or the intensity may lead her to request them sooner than intended, or sooner than recommended. Pain management methods, such as epidural analgesia and intravenous narcotics, come with their own set of complications and adverse affects, such as spinal headaches, less alert babies, respiratory issues, and much more.
One very common danger of induction is iatrogenic (doctor induced) prematurity. This can be especially true if the woman is induced before forty weeks, and even at forty weeks. The last few weeks that the baby remains in utero are critical to lung development, and a baby born before the lungs have matured often face respiratory difficulties and may require intensive hospital treatment to address respiratory concerns. Iatrogenic prematurity is often resulted from inaccurate due dates.
Uterine rupture (a tear in the uterus) is more likely to occur during an induced labor than a natural labor. This is especially true if the woman has had previous cesarean sections or other uterine scars. Uterine rupture is life-threatening for the mother and child and when suspected, a cesarean section must be performed immediately for the best chances of preserving both the mother and child’s lives.
Most hospitals, when managing an induced labor, require that the patient remain on electronic fetal monitors. The monitors may be placed externally using elastic bands around the stomach, or they may be placed internally, by attaching a rod into the baby’s scalp. When using internal monitors, if the water has not yet broken on it’s own, it must be broken to place the monitor. Once the waters are broken, many doctors have a “24 hour rule,” that the baby must be delivered by the time the waters have been broken for 24 hours, even if a cesarean is needed to do so. This “rule” is intended to prevent infection, but breaking the waters too soon may cause more problems with progression of labor than allowing it to break naturally. In addition to breaking the waters, the monitors often require that the mother remain lying down throughout her labor. This can be detrimental towards cervical progression, as the use of standing, kneeling, squatting and walking have been shown to drastically help cervical progression and the effectiveness of contractions by the use of gravity.
Unless induction is medically indicated, such as cases of toxemia (also known as preeclampsia) or intrauterine growth restriction, induction carries a great deal of risk for both the mother and baby. Induction is often the starting point that leads to many other interventions and complications. Induction is not medically indicated simply because a woman has hit her due date. It is perfectly normal and safe for an uncomplicated, low-risk pregnancy to continue to 42 weeks, and in some cases, past that. Before choosing induction be sure to discuss all of the risks with your caregiver as well as any safer, much more mild, alternative methods of induction, such as walking, exercise, acupuncture, and even sexual intercourse. Medical inductions may seem like a great way to jump start things, however, in many cases they are not what they seem.