Labor induction rates have risen dramatically in recent decades, and along with this and in part as a result, so have cesarean section rates and preterm births. We know that labor inductions are too often done unnecessarily and for inaccurate indications, and they may lead to a host of additional unnecessary interventions that increase risk for mom and baby.

A recent article even speculates that there might even be a relationship between labor induction with the hormone oxytocin (Pitocin) and autism.

While I absolutely don’t want any woman who has had an induction to feel judged or to judge herself as a result of this article, as a midwife and physician I do want to encourage and empower women to say no to unnecessary inductions, and help you be able to assess when induction is appropriate and how to minimize your risks.

Part 1 of this article looks at labor induction rates, reasons for induction, problems with induction, how to gracefully decline or delay an induction that does not seem to be medically indicated, and maximizing yours and baby’s safety if induction really seems necessary.

Part 2 (coming next week) discusses the safety, effectiveness, and risks of natural alternatives to labor induction.

A Story of the Induction that Didn’t Happen

Answering my phone one Friday morning in December some years back, I found Inga on the other end in a panic. She was just told she’d have to be induced in a few days because her baby weighed 10 pounds by ultrasound and her midwife’s physical examination. She said, anguished, “I’ll only be 40 weeks tomorrow. I wanted to have a natural birth. I’m so worried about an induction and they say I might have to have a cesarean because I might not be able to get this baby out vaginally. They’re not even really giving me a chance. I don’t want to be induced but I want to do what’s best for my baby. I just don’t think an induction is best!”

I’d met Inga about 6 months prior. I was teaching a course on herbal medicines in pregnancy at a prominent nurse-midwifery program. She was a student in the program. Now, not only did she find herself being pressured to be induced, but to complicate matters, her midwives were her professors in her training program so she didn’t really feel like she could argue. They told her that if she did not go into labor within a few days, she was going to have to be induced.

She was desperate for a second opinion. I invited her to my office to talk.

At 5’10” and 180 pounds at nearly full term of her pregnancy, Inga was a vibrant, athletic, strikingly good-looking Nordic woman with shoulder-length blond hair and bright blue eyes. Only her furrowed brow revealed a problem. I listened to her concerns and asked if I could palpate (feeling her baby’s size and position) her belly. Based on my exam, backed by 15 years of midwifery experience at the time, I estimated her baby’s weight to be closer to about 8 and a half pounds rather than the predicted 10. The baby was in a perfect head down position. She had no other pregnancy problems and had been preparing to give birth in the birthing center rooms of the hospital affiliated with her program.

I gave Inga a grand pep talk about how, from a size perspective, she could absolutely birth her baby vaginally. I emphasized that if I, at 5’3” and 135 pounds at full term could birth an 8.5 pounder in 4 hours, she should easily birth an even bigger baby should the baby prove bigger than my estimate. We reviewed the data on the natural length of pregnancy being 42 weeks with minimal increase in adverse outcomes in women who go the full length and even into 42 weeks. At her request, I also shared a few natural approaches she could try at home to get labor started if “push” came to induction, as this is one of my areas of expertise, though told her to save these as a last resort as natural is not always safe.

She went on her way with a resolve to birth her baby naturally if possible, to speak directly with her midwife-professors, and with a plan to see what might happen over the next few days. She thought she might try the natural remedies come mid-week if the induction became imminent.

The week came and went, and having not heard from Inga, I finally gave her a call. “Aviva,” she said, answering the phone cheerfully, “I was just sitting here composing a letter to you. I’m so glad you called! Let me read it out loud.” It went like this:

“Dearest Aviva, After I left your office I felt such a sense of relief. It was the first time a midwife or anyone ever said ‘You can do this.’ I felt up-lifted and confident. I went in for an ultrasound Monday and baby looked great. Then I went home, took a hot bath, rested, and went into labor! I never needed any of the natural remedies. My baby was born the next day weighing 8 pounds 4 ounces. I had only 8-hours of active labor with about 2 hours of pushing.  I did it all naturally and never even needed the herbs or other methods! My daughter is healthy and beautiful! She’s right here in my arms. Thank you so much for your support and encouragement, and most of all telling me I could believe in myself.”

Inga’s is just one of the numerous stories story I could share about women who were told they would need to be induced or told they would not likely not be able to give birth naturally and spontaneously, often because of the baby’s estimated size or for other reasons, for example, that it is too dangerous to allow the pregnancy to go much past the due date. Inga was fortunate to be able to have the experience she hoped for. Sometimes medical reasons do necessitate an induction. Too often, however, they are done unnecessarily, leading to a domino effect of additional interventions including intravenous medications, epidural pain relief, and even a cesarean section.

Are There Too Many Inductions?

Yes, unequivocally, there are too many labor inductions. Even the leading obstetrics organization in the US, the American Congress of Obstetricians and Gynecologists (ACOG), is trying to curb unnecessary and potentially harmful inductions – especially those done prior to 39 weeks of pregnancy, which increase the rate of preterm deliveries.

In 1990 the rate of labor induction in the US was less than 10%. By 2006, it soared to more than 23% of births, and is as high as 44% in some communities, according to the Centers for Disease Control and Prevention and other researchers. Thus, at least 1-in-5 women has her labor induced, maybe more. While some of these inductions are medically necessary, most are only marginally indicated and as many as 40% are unnecessary – or elective. This means that the doctor or midwife suggests it, or the pregnant woman requests it, for reasons of scheduling convenience.

Why the Increased Induction Rate?

By all conventional medical standards, the length of a normal human pregnancy extends all the way to the end of the 42nd week of pregnancy. So why do so many OB’s and family doctors want to induce well before this? Statistically, there is a slightly increased risk of stillbirth after 41 weeks of pregnancy. This small risk represents a major legal concern for doctors who deliver babies. An obstetrician can expect to be sued 3 times in her career, is legally liable until a child turns 18 years old for any problems that can be attributed to a birth she attended, and the stakes of a lawsuit, in addition to the stress, can be financially and professionally devastating. Induction has become the answer addressing risks to baby. Who can blame a doctor for wanting to protect babies?

Further, because the risks of induction have been minimized for the past 20 years, it has become the “new norm” to the extent that many women request labor induction for personal convenience.  It allows siblings to share a birthday, it allows family member from afar to time their presence at a birth, it allows women to maximize maternity leave (which, by the way, is far shorter than in many other nations that also coincidentally have lower induction rates!) and it reduces mom’s stress of wondering when the “big event” is going to happen. In our own desire for convenience and control, we have contributed to the problem!

Moreover, many pregnant women feel pressured to undergo obstetric procedures, according to the latest  Listening to Mothers III  national survey of 24oo mothers who gave birth in US hospitals from mid-2011 to mid-2012.

According to Maureen Corry, MPH, the executive director of Childbirth Connection, New York City, the organization that commissioned the survey, “We also found that the women report being pressured by their healthcare providers to have induction and cesarean sections.”

Eugene Declercq, PhD, professor of obstetrics and gynecology at the Boston University School of Public Health and the survey’s lead investigator, told Medscape Medical News that he was surprised by the large number of mothers who felt pressure to receive interventions such as inductions, epidurals, and cesareans.

Houston, we have a problem!

How is Labor Induced?

Labor is induced in one or a combination of several ways including the use of an intra-cervical balloon filled with water to mechanically dilate the cervix, rupturing the membranes, and medications including hormones to soften or ripen the cervix to get it ready to dilate, misoprostol placed in the cervix to soften and dilate it, and most commonly, Pitocin, which is administered intravenously to stimulate contractions. Typically, more than one method is applied, with Pitocin ultimately given in as many as 70% of inductions.

Is There a Problem with Labor Induction?

One major problem is that too often it is medically unnecessary, so any risk associated with it is an unnecessary risk for mom and or baby. Each method of labor induction carries its own small to more significant risks. Balloon catheterization and rupturing the membranes increases risk of infection to mother and baby, misoprostol increases the risk of uterine rupture, and Pitocin can cause a number of medical problems – most notably fetal distress – and generally requires an epidural to reduce the pain from Pitocin-induced contractions. Epidurals also carry risks.

Induction requires you to be in the hospital, which increases your risk of exposure to hospital infections just by being there. Once induction begins you may be prohibited from eating, moving around, and you will likely need to have an IV placed – all of which increase risks of medical problems and complications. You will be subject to repeated vaginal exams, which also increase your risk of infection. You will likely be placed on an external fetal monitor, which is an independent risk factor for an increased cesarean rate due to false positive reporting of problems with your baby’s heart rate or rhythm.

Inaccuracies in estimating due dates increase your baby’s risk of being born preterm if labor is induced, especially if done prior to 41 weeks of pregnancy increase your risk of having a C-section. In fact, the high national cesarean rate, now close to 33%, has in part been attributed to escalating rates of labor induction. A study published in the journal Obstetrics & Gynecology found that among nearly 8,000 first-time mothers, labor induction doubled the likelihood of a C-section compared to women who went into labor on their own. Cesarean sections significantly increase risks of complications for mothers.

High cesarean rates and high rates of preterm births have become such a major problem that some hospitals have now prohibited all but medically necessary inductions prior to 39 weeks gestation. Some hospitals are requiring doctors to provide written medical documentation of reasons to induce labor.

Does Labor Induction Cause Autism?

A recently published paper associates labor induction and augmentation (the use of Pitocin to speed up a stalled or slow labor, which I will discuss in a subsequent article) with increased risk of autism. The large study looked at 625,042 live births linked with school records, and included more than 5,500 children with documented autism.

Compared with children born to mothers who received neither labor induction nor augmentation, children born to mothers who were induced and augmented, induced only, or augmented only had higher rates of autism after controlling for factors such as socioeconomic status, maternal health, and pregnancy-related events and conditions. Male children were more likely to have autism.

One possible explanation for the relationship between autism and induction is through exposure to exogenous oxytocin. Approximately 50% to 70% of women who undergo labor induction receive Pitocin which is a synthetic oxytocin. Biologically, oxytocin signaling plays important roles influencing social behavior and cognitive function.. Exposure during labor induction or in labor may have a yet unidentified genetic or epigenetic effect.

While the jury is still out on the association between autism and induction, which is most likely caused by multiple factors in genetically vulnerable children, it is interesting to note that the increase in labor induction in the past 2 decades has paralleled the increase in autism rates. It should at least give us further pause to avoid unnecessary induction and augmentation, and treat it as a medical intervention with potentially serious consequences, rather than something to be done routinely or electively.

The Myth of the Too Big Baby: When is Labor Induction Truly Necessary?

Medical indications for labor induction include any medical circumstance in which you or baby is safer with baby out than in. These include preeclampsia, eclampsia, HELLP syndrome, diabetes, fetal growth restriction, infection of the amniotic membranes (called chorioamnionitis), and placental abruption.

Surprisingly, given its prevalence, there is a paucity of high-quality evidence proving the benefits of induction for specific medical and pregnancy conditions. However, the above indications are generally very legit.

Pregnancy with twins and multiple babies might be an indication for induction in some cases, but should be evaluated individually based on the health of mom and the babies.

Induction for convenience-sake is never a medical indication and is best avoided.

One of the most common reasons for induction is going past your due date, particularly if the pregnancy gets to 1 week past due. At this point, you’re also probably sick and tired of being pregnant, so may readily agree when an indication is proposed. There is evidence of a small increase in stillbirth in pregnancies between 41 and 42 weeks and another small increase between 42 and 43 weeks. However, between 41 and 42 weeks gestation it would take 527 inductions to prevent one stillbirth. That’s a lot of inductions, and most women, left to the natural course of pregnancy, will go into labor by 41 weeks.

The good news is that pooled data from a lot of studies show that getting induced after 41 weeks gestation does not increase the risk of cesarean section compared with a wait and watch attitude.

Another common justification is that “the baby is getting too big, so we should induce now.” The reality is that ultrasound sizing is only as accurate as the person doing the ultrasound, and even with highly skilled docs, midwives, and techs, there is a wide margin of error – often erring with baby being on the larger side. And many women can give birth to babies weighing 8, 9, and 10 pounds without a problem. Even first babies. The hormones of late pregnancy and the design of the pelvis ingeniously allows the pelvis to “give” to accommodate the baby’s head. So unless mom is diabetic leading to an excessively large baby as a result, and other complications are arising, baby’s size alone is not usually a good reason for induction and as discussed earlier, inducing early can lead to risk of prematurity.

Increased and regular monitoring of the baby with ultrasound to measure amniotic fluid and non-stress testing is commonly recommended once pregnancies reach 40 weeks and a few days. However, there is really no evidence for any specific type of monitoring improving outcomes for mom or baby. If any problems arise with baby’s heart rate or there is too little amniotic fluid, induction in the hospital is recommended for optimal safety.

Saying No to Induction

There is rarely a need for an emergency induction, so there is generally time to have a conversation with your doctor, do your homework, and make an informed choice. Are there alternatives? What are the real risks of waiting? Is induction likely to be successful (see below)? It’s your body and your baby so you have a right to ask questions and make an informed decision.

A lot of obstetric providers are really scared of nature. I’m serious. Because in their eyes, nature can be dangerous for mom and baby. And “bad births” lead to a lot of grief for everyone. So to them it seems safer and smarter to induce – because that’s controllable and legally defensible (please remember, I am sharing this as a physician it’s not jaded propaganda).

But what if you’re not comfortable or in agreement with your doctor’s assessment or suggestions? Sometimes this can get tricky and rarely it can even get legal, but most of the time, a reasonable conversation can be had and buy you time. Try to approach the conversation in the spirit of partnership. A good OB, family doctor, or midwife is going to want to make sure everything is safe, but ideally will also want you to feel comfortable and satisfied with your birth. Start by acknowledging your appreciation for her concern for you. Then ask if she really thinks the induction is absolutely medically indicated and if it has to be done right away. If she says yes, ask for a clear explanation of the reason(s). Ask her if she would consider waiting a few days, and what would make her feel comfortable doing so, for example, if you came in for an extra ultrasound in a couple of days and everything looked good would this reassure her?

If your OB or other provider really sticks to her guns on the need for induction, it could also be that it really is indicated. It could also be that she previously had a bad experience in a similar situation to yours and is afraid to repeat it. Again, try to talk it out.

If you cannot reach a resolution that you feel good about you’ll have to decide whether to acquiesce or take your birth elsewhere. You could at least obtain a second opinion if you have good reason to believe that the induction in not indicated.

Wait and Watch Past 42 Weeks?

Many midwives and natural birth proponents encourage letting nature take its course, even if pregnancy extends well into or beyond 42 weeks gestation. In most cases things turn out just fine. But things don’t always come up roses.

Births past a full 42 weeks are sometimes longer, with more challenging labors, and have more complications including increased risk of bleeding for mom and greater need for emergency resuscitation of the baby. Not all homebirth midwives are experienced or skilled in handling these complications effectively. If you are planning a home birth and are post due, please make sure you truly understand the risks and make sure your midwife actually knows how and is prepared to handle complications that could arise.

Making an Informed Decision and Maximizing Your Safety

If labor induction is truly indicated, there are ways to maximize its success while minimizing risk to you and your baby.

One of the most important indicators of success is how ready your cervix is for labor. It has to be both very soft (effaced) and ready to open (dilate) for induction to happen readily. Your midwife or doctor can use a simple scoring system called the Bishop’s Score to see if you are ready. The better your Bishop’s score, the more likely you are to be induced successfully. If your Bishop’s Score is low, ask your doctor for the best options to help your body get ready for labor – but don’t just let them start pitocin against an “unripe” cervix – this is a common recipe for failed induction and need for cesarean.

Some methods of induction are more effective than others. Cervical ripening with medication before attempting to induce contractions may be more effective than starting out with Pitocin.

Rupture of membranes is commonly recommended to facilitate labor and regular vaginal exams are commonly done to see if you are progressing. Neither are recommended as they increase your risk of infection.

Request that you be allowed to keep up your nutrition, keep your loved ones and doula nearby, move around during labor, and have your vision of how you’d like to birth be respected as much as possible (i.e., quiet at the time of birth, delayed cord clamping, baby to momma’s breast rather than warmer).The more you maintain your power over decision-making and the less you succumb to the role of “patient,” the more likely you are to feel empowered by your experience in the end. And empowerment is ideally a natural outcome of birth and a positive feeling with which to enter motherhood.

Coming in Part 2: Are There Natural Alternatives to Medical Labor Induction?

Wishing you a healthy, joyous pregnancy and an empowering birth,

AJR-Sig

53 Comments

  1. “If any problems arise with baby’s heart rate or there is too little amniotic fluid, induction in the hospital is recommended for optimal safety.”
    Aviva could you speak specifically to the risk of induction versus waiting it out with a diagnosis of oligohydramnios. This is a common reason for induction; Can you shed some light on your analysis of the evidence supporting (or not) this practice?

    • Hi Emily,
      It depends on how low the fluid is, and the reasons for it being low. If momma can be well hydrated and retain that fluid (might take IVs to do it) then sometimes watch and wait is ok. If the fluid is very low, then I would usually keep up with biophysical profiles — even though the data isn’t great — it is some assurance. And if needed, this would be an indication for induction. The later past due the pregnancy goes, often the lower the fluid… Aviva

  2. Great synopsis of the problems with inductions! As a childbirth educator, I strive to really help moms see past just the birth, as important as it is, and envision what they want life to look like on the other side. If they want to have the best possible start to breast-feeding, if they want the majority of pain and discomfort over with once they’ve birthed their baby (so they can move on to enjoying and bonding with their little one), if they want to avoid risks to their baby’s health and development, if they want to emerge more confident and ready for mothering… then it is certainly better to let nature take it’s course – it’s best to decline induction and epidurals and episiotomies, etc. Envisioning life on the other side, as a new mom, often helps women to know their own minds and make more informed decisions regarding their birth. Thanks Aviva, for this great information. Looking forward to part 2.

  3. Fetal growth restriction may be a medical indication for induction but the accuracy of ultrasound in such cases is also unreliable.

  4. Thank you for writing on this topic so much of it hits home with my first baby which I hope to not repeat a second time. Live and learn right? It’s nice to hear both sides of things.

  5. Thank you for this, Aviva! I am 36 weeks pregnant with twins and have already had to refuse 2 cervical exams, have been sent to Labor & Delivery for a follow-up NST and am already hearing about my “38 week due date” and the possibility of induction. We had a no-intervention, natural birth with our first daughter who was 41 weeks gestation and 9 lbs, 10 oz. and my goal is to do the same for the twins….but I already feel the uphill battle that we’re facing. You’ve given some GREAT suggestions for having a non-confrontational, productive conversation with our OB. Thank you – your timing was impeccable! Looking forward to reading Part 2 – when can I expect it to be posted?

  6. In the paper you reference connecting autism and induction rates (Gregory et al. 2013), the authors recognize in their introduction and discussion that labor induction and augmentation is a beneficial process that reduces the rate of c-section, nicu admission, and other health complications. You contradict those statements throughout your article, do you have other references backing those claims?

    • Yes, I believe I mention in the article that PAST 41 weeks there is no increased rate of cesarian — and of course reductions in nice admissions, etc, happen when babies the NEEDED to be induced ARE induced. This is not the case for unnecessary inductions and elective inductions — nor inductions done prior to 40 weeks.

  7. Being pregnant with my first and having seen many of my friends go through inductions, etc…the details of our rights to choose and to question our OB’s decisions (and how to do it in a proactive way) is empowering for me and helps make it less daunting as it does seem like the window of 40-42 weeks could deem some panic as it is a short window. Myself being very concerned with the possibilities of autism and it’s rise, your article has helped give me yet another factor to consider and attempt to rule out while still being safe.

  8. As usual, you present a wonderfully balanced approach between patient advocate midwife and understanding the physicians perspective. This can be such a difficult issue and discussion with your physician.

    Many Ob’s may not agree with your risk assessments (I do agree with them, and your approach).

    There is a big challenge in seeking a new care provider at term, for women who decide they must seek another care provider because their’s is insisting on induction. Most Ob’s I have known (after practicing Ob/Gyn 22 years) will not accept a patient transfer at term.

    Thanks for this wonderful blog I am so enjoying. Looking forward to part 2.

    • Namaste you wonderful OB! 🙂 And yes, I agree — it can be tricky to find another provider close to term. Nearly impossible, in fact….Love to hear your thoughts on post dates and safety issues. Big hugs, Aviva

  9. HI Dr. Romm-

    Along these lines of making decisions between more natural vs. mainstream medicine during pregnancy, I wanted to know your thoughts on the Rhogam injection? I am pregnant with my 4th child and have had a very healthy pregnancy. I am struggling on whether or not to get the injection while pregnant. I did have the injections during my last pregnancy, however I was not as educated on the topic as I am now. I know you cannot provide me medical advice, I was just curious what your thoughts were on the issue. Thank you so much for all you share!
    Stephanie

    • If antibody titers are all negative and risk factors are low, and one has had Rhogam appropriately in the past, waiting can be acceptable — but definitely have the Rhogam after regardless. That said, overall I consider it a relatively benign intervention that has prevented harm to many babies. Best wishes! Aviva

  10. Thank you for this. I am anticipating my third birth Sept. 1 and don’t expect to be late but appreciate being forearmed with the info! I just discovered your GBS seminar which was very helpful as I did test positive and have been doing many of the things you discussed, ; hopefully we have kicked it out. Can you please clarify, should one choose for Hibiclens (which I am leaning against but wish to be prepared), how you feel it should be used. You said it should not be done as a douche. Thank you again.

    • Douching in pregnancy can lead to amniotic fluid embolism – a rare but dangerous complication. A wash with a gauze done by a midwife is preferable. Best wishes!

  11. Aviva,
    Thank you for this article. I had my first baby just one short month ago.
    My clinic has multiple doctors and does not encourage seeing the same one each time “because anyone could be on call when you go into labor”. At my 39 week appointment I saw a doctor I had only seen once before. She didnt know I take a natural path to my health. I cried out in pain during the cervical exam. She said she was just stripping my membranes and it would be over in a second. I was furious! I had declined the procedure the week before and soldified my decision not to have it done after doing some research. I felt utterly disrespected that she did not bother to ask me how I wanted my body and my baby handled! When I stopped her, she acted like I was being ureasonable for not wanting the procedure.

    I believe that this doctor hopping mentality has a very pretty sales factor: every woman wants to know the person at the other end of the delivery bed. But after many experiences similar to this in six months (this was by far the worst), I will never again allow myself to get shuffled between a half dozen doctors. I want to build a relationship with my care provider so that a wholistic life picture exists in their mind (not on a chart!). I believe medical care would be more accurate if it didnt rely so much on the patient knowing what information was medically relevent.

    The more I read your blog the more I feel empowered to respectfully demand this relationship with my medical team and replace anyone who isnt of a similar mindset. I am worth it, and more importantly my darling daughter is worth it!

  12. Avila,

    Thanks for your insight! With my first, my water broke a week before my due date but labor and contractions never started. After 12 hours of walking, waiting and trying natural options my Dr. suggested we start Pitocin as she said it was safer to deliver within 24 hours of water breaking. In your opinion, would labor have eventually started on its own or is this one of those times that it is better to intervene? I’ve always wondered. I don’t regret what happened I just wonder if my body would’ve started labor…

    • Data by Mehl et al in the 80s showed that unless there was already infection present, or multiple vaginal exams were done, there was no increased risk of waiting — however, sometimes water breaks because there is GBS or other infection. In my clinical experience, waiting 48 hours after water breaks is reasonable if there are no underlying problems, and I’ll often try natural things to encourage labor to start. Statistically, most women go into labor naturally within 24 hours of ruptured membranes, another percentage by 48, and those that don’t by then usually need induction. You can’t second guess when you’ve made a decision that you thought was best for baby at the time! 🙂 Aviva

  13. The encouraging thing, for me, is that Diane Kent, Medical Herbalist, in Toronto has recently had excellent results treating a 9 year old diagnosed with autism, with gingko. Anyone else had a similar experience?

  14. I love this article! Thank you so much. I was induced with my 1st child because my water was “leaking” (this was 8 days before my EDD). After 8 hours of waiting not much had changed. I am pregnant with my 2nd now and have been doing some reading just in case the same thing happens again. What is your opinion on avoiding vaginal exams and waiting for 24 hours after water breaks?

    Thanks again!!

  15. Thank you for this honest summary. I would love to see research numbers included when you bring up the higher possibility of stillbirth, so much of the rest of the post seemed to have specific studies or findings tied in but that part seemed lacking “proof” which can be helpful in talking with providers. Also surprised there was no mention of dystocia regarding big babies since that seems to be a lot of where the fear based practice comes in. Thanks again! Excited to share with clients!

    • From Up To Date (submission by Errol Norwitz, MD).
      The perinatal mortality rate at ≥42 weeks of gestation is twice the rate at term, increasing four-fold at 43 weeks, and five- to seven-fold at 44 weeks. Neonates born at ≥41 weeks of gestation experience one-third greater neonatal mortality than term neonates born at 38 to 40 weeks of gestation. However, the absolute risk of fetal or neonatal death is low.

      I had dystocia in but took it out — too many details. Ultimately it contributes to increased need for neonatal resus, which I included. It’s a miserable complication though interestingly, I think one midwives handle more effectively than other providers.

  16. My son was born at 42 weeks weighing 11 lbs, 6 ozs and measured a full 24″ inches. Our midwife always told us we were having a big baby, and he ended up being the biggest baby this second-generation midwife had ever delivered! I know if I had been in the care of a medical doctor at the time my son was born I wouldn’t have been permitted to attempt a natural delivery, nor would I have been allowed to carry him as long as I did.

    • Wow thank u for sharing your story. I am in a similar situation with a big baby at 40 weeks and no signs of labor at all. They want to induce me but I refused it… Ur story gives me power to still believe in my body to do it natural in upcoming days…

  17. I am currently 27 weeks, first pregnancy, due in November. I had a large DVT in 2010, I have Factor V Leiden, and take one 40mg/.4ml of Lovenox SubQ daily. Planning to switch to Heperin at 35 weeks. I have been told by my MFM practice that it is standard procedure to induce at 39 weeks in pregnancies with this condition to prevent bleeding issues. More or less to know 100% without a doubt when the last heperin shot was taken. I am not comfortable with the idea of induction, or the epidural which normally comes along with it, I am espically in fear of the possiblity of a C-Section if the induction doesn’t work. It seems like this “standard procedure” is just setting me up for more blood clots. What do you think about this practice? Is it more important to plan it out to prevent bleeding issues and possible transfusions at delivery or just know your body, and don’t take the shot if you feel a contraction, maybe get a Vitamin K shot during labor to thicken your blood?

    • Hi Emily,
      Well, that’s a stressful load to bear! Once your pregnancy is that high risk the stakes change. I think your concerns, however, are very legitimate, and immobility after cesarean does increase your risk of clots. I would sit down with your OB and as articulately as you did to me, lay out your concerns. Being on the heparin is the wild card. I wonder, though, if you agreed to an induction, let’s say, a week later if no go, and also if you have ANY contractions to come right to the hospital. That will be a comfort level conversation between you and your OB (I assume MFM?). Also, should induction be inevitable, see if your OB will do some cervical ripening techniques first, for example, cervadil, to facilitate things. Be well, be smart. This is an exceptional situation that warrants conservative medical care. If you DO need a cesarean, ask for a gentle cesarean (see articles by Dr William Caiman on the internet)to at least ease things for you. And move around as quickly as you can afterward. But hopefully, that won’t be an issue! Wishing you the absolute very best birth! 🙂 Aviva

  18. Hi Aviva,

    My baby came on her exact due date. I went into labor the day before and 24 hours after my water broke my contractions were strong enough so I could not sleep but things were progressing pretty slowly (which was fine by me, but not the hospital). I was already in the hospital because I was GBS positive and receiving antibiotics. The nurses and my doctor were pushing pitocin on me shortly after I arrived at the hospital. I ended up doing pitocin (at my own decision, not the doctor’s) because I was worried of infection and I was extremely tired and wanted to get things moving. Was risk of infection a legitimate concern because of my broken waters?

    • Well, you made the right decision for you at the time – so there’s no second guessing or going back in time :). If you have had 24 hours of rupture but got antibiotics there should have been no rush to get the baby born. The risk of GBS to the baby is really small, and negligible with antibiotics on board.

  19. I thought that this article was amazing to say the least. My first child was induced. I was a little over 40 wks, felt labor but apparently could have been sent home. Instead they said that with my scheduled induction just a few days away for being late they would just go ahead and do it. The same thing happened at 39 wks with my second. I felt labor (not painful labor) and they went ahead and induced me. I wish I had known then what I know now. My first child has Autism Spectrum Disorder. Many of his issues were issues I can see in myself when I was a child and as an adult. My Mother was induced for me as well because she wanted my father to be there for my birth so they scheduled it and that was back in 1983. Looking at some correlations, I can’t say specifically it is related to Autism because my second child is not Autistic. But what I can say is that this time around for my 3rd I will do my very best to not be induced. I wish someone would have told me those first 2 times that I didn’t need to be induced and could and should have waited. It is something that I am not happy I ever agreed to but I was not educated on it at the time. Now that I am…I can at least prevent it from happening again.

  20. Hi Aviva,

    I am a Newla (new doula) and Herbalist. My experience with women in labor and birth have been great thus far. Recently, at a birth I attended the doctor induced my client because her platelet levels were at 99 a week prior, when they retested they were at 115. They still recommended to induce and broke her water (at 1cm dilation as well as put her on a small amount of oxytocin). I did let her know she had a choice but didn’t want to cause conflict with her or the hospital staff. Do you have any insight on this? I did see you mention a blood clotting disorder can be a reasonable indication for induction… To my knowledge she didn’t have any history of a blood clotting disorder just low(ish) platelet levels… In any case she did VERY well and didn’t have any other interventions:-)

  21. I recently gave birth to my first child and tried everything I possibly could to avoid an induction. I’m 41 years old, in perfect health, had a picture-perfect pregnancy with 8/8 scans every week past 32, and I’m married to an OB/GYN.
    I started fending off the inductions at 38 weeks as that is “standard” for AMA at the academic center where I delivered due to increased risk of stillbirth.
    I just assumed I’d go into labor at 40 weeks and agreed to regular US so everyone was happy. Well, 40 weeks came and went and so did 41 and I could no longer hold them off. My husband and my actual OB and the MFM were all applying pressure and citing stillbirth stars as well as lack of increased csection rates.
    I tried walking for hours a day, evening primrose oil both ways, sex, spicy food, eggplant, pineapple, massage, acupuncture, chiropractic, but drew the line at castor oil! I kept having lots of contractions, but they never progressed or intensified. My cervix was high and closed at 41.5 weeks, even after all my attempts at natural induction. I was devastated but resigned to giving up my ideal, natural birth and heading for a hospital/interventional birth if it meant making sure my baby was safe.
    After cervidil my membranes ruptured spontaneously and I was thrilled! But after 8 hours no contractions so of course pitocin came out. I tried to refuse but now the clock had started and no one was willing to wait even though I was GBS negative. Pitocin was one of the worst experiences of my life, and I lasted nearly 6 hours at escalating doses without any anaesthesia. Then I begged for the epidural. The entire 14 hours of heavy labor was hideous. I was vomiting the entire time, in extreme pain, even with the epidural, and pushed for 4 hours. 36 hours of induction later, I did manage to have a vaginal birth (which the entire hospital had never seen, apparently, in someone “so old” and “so unfavorable”). And my little girl is perfect. Midpoint through labor we realized she was OP instead of OA as I had always been told, and luckily my OB managed to turn her manually (that was fun as the epidural had worn off!), which I credit for being able to have a vaginal birth. I wish things could have gone differently, and I wonder if her posterior position contributed to my lack of cervical change and failure to go into/maintain labor? I guess we will never know. My cousin had also had a stillbirth at 27 weeks midway through my pregnancy, which scared me even more.
    If I ever do have another child, I will do everything in my power to avoid an induction as it basically ruined my experience of childbirth, turning something natural and amazing into something that I’d rather forget.

  22. I was 41w6days when my son was born. I live in Iceland. Here an elective induction is not possible, but is offered at 42 weeks. I read eth I could get a hold on regarding risks of >42 delivery. I hardly found any scientific reasoning that it was risky. Who says >42w means longer or harder delivery? First time reading it here. I finally decided going 42+ was no riskier than giving birth at <38w. Worked for me. So I would have waited a few more days if I hadn't gone into labor naturally. I'm pregnant again and expecting the same this time around 🙂

    Also, women of America, you should always be able to change your health provider at any time if you don't like the look of things.

  23. Hi Aviva, i’m a midife in Ireland in a hospital setting and do 1to 1 antenatal classes. A few days ago i wrote a little article on my fb page exactly about the same topic!!! Not as good as your offcourse. Looking forward to part 2!! My clients will b very interested 🙂

  24. It is nice to see a doctor who’s somewhat sceptical of induction, although you avoided saying whether routine induction at an arbitrary date e.g. 42 weeks is good.

    I would say no, and suggest that the recent paper by Mandruzatto ( http://www.pqcnc.org/documents/sivbdoc/sivbeb/16MgmtofposttermpregnancyguidelinesJournalofPerinatalMedicine2010.pdf ) be used as the main citation to oppose routine induction. It includes all the newest RCTs and makes the stronger conclusion that, quote: ‘It is not possible to give a specific GA at which an otherwise uncomplicated pregnancy should be induced.’

    Ressearch cited there, and elsewhere, suggest that the risks in a truly uncomplicated pregnancy are even lower than implied here. TO answer one specific point, Mandruzatto has shown that certain changes in fetal heart patterns past due are normal and not associated with adverse outcomes.

    It seems that your Part 2 never showed up, but I’m highly doubtful that ‘natural’ methods of induction are generally safe or preferable to medical ones.

    k_over_hbarc at yahoo dot com

  25. Hi, my EDD is march 15, 2015. On 36 week scan I had AFI-9.2 cms, FHR 144 BPM, on 37 week scan AFI 7.6 cms, foetal weight 3071 gms, my doctor is suggesting me to c section, is that amniotic fluid is enough, for normal delivery, if i wait for normal delivery does amniotic fluid still gets reduced, how much fluid is considered as low n risky,just want your thoughts on it, please.

    • hi! i don’t check blog comments daily so sorry — just saw this today. also, being your personal doc, it’s pretty difficult giving any medical opinion. below 8 is considered too low…sometimes i try to hydrate if everything else looks good, but hopefully your doctor has a good reason for suggesting the cesarean…
      hope everything is going well or that you’ve happily had baby and everything went beautifully.
      aviva

  26. i was 42 weeks postmaturnity when i delivered my son by c section. unfortunately, my doula recommended we didn’t have any form of induction during labor. my son had not yet descended nor had my water broken. he was also asynclitic. if we were to have ruptured the membrane, i believe i could have had a vaginal delivery because that sometimes helps move the baby into the right position. it doesn’t seem like i will never be able to forgive my doula.

  27. Hi, Well done article, thank you. I’ve had two c-sections already and I’m planning to vbac with this baby, I’m only 16 weeks now though. At the birthing center the midwives mentioned that for me because of c-sections they would push to have me be induced at 41 weeks. She said that vbacs are less likely to succeed after 41 weeks. I’ve never seen that anywhere else though and it makes me nervous because I wanted to wait until 42 weeks and I had pitocin in both my other labors and my body doesn’t seem to respond well to that. I was hoping to get your thoughts on being induced due to vbac.

  28. Hi Aviva,
    I wish I found this article before I had my baby. Firstly thankyou for the article. I was approaching the birth of my baby with a positive attitude. Believing that being a women it is the most empowering thing we are truly capable of. Believing my birth would be a positive, active birth I was excited to experience it naturally. However this all changed when I believed that i had no choice but to trust what I was being told was necessary. At 40 weeks it was suggested I be induced, I stated that I didn’t think it was necessary considering baby and I had been healthy for whole pregnancy and managed to delay induction until 42 weeks (estimated due date based on U/S only.) At 41 weeks 3 days my waters broke and was told to present to the hospital. Again I was told an induction would bring the baby on however I again said that I didn’t feel it was necessary and asked to go home, which was agreed to however I was to call and present the following morning. When I arrived it wasn’t really discussed with me what was happening and next thing I was hooked up laying on the bed with intravenous Syntocinon and the monitor. After 8 hours on the highest level of dosage and no progress I went against what I was being told and asked for the induction to be stopped. I felt that I was not doing the right thing from the way the midwives and doctors were acting towards me however I decided that I was not comfortable with the way it was all going. I was moved to a room in the ward and was not check until the next morning some 10hours later. Fortunately for me the midwife who turned up for her morning shift took a stand and asked why I was not check on through the night and my baby was not checked on a monitor until something like 15hours after the induction was stopped. I felt let down when realising the risks associated and not being medically monitored after the induction as it felt like I had done everything they had suggested I should and the minute I started taking back control of my birth I was left on my own With no medical observation. My cervix was not ripened nor ready and as I know now the induction was bound to fail. Long story short from my waters breaking and giving birth I had 4 days of mixed emotions and eventually requesting a csection as I was totally exhausted. After having the two lots of induction procedures,it turned out the doctors observation while undertaking the csection my cervix had not dilated and the baby was quite stuck up high, (with a doctor required to push from my chest down to assist the baby out during the csection. I am determined for future births to continue to view it has an empowering experience and despite my difficult experience this first time the main thing I can take from it was that i felt empowered by taking some control of what I felt comfortable in and standing up for my baby and my choices. If I could give any other women advice it would be to take ownership of your birth experience and yes you might have reservations about whether you made the right decisions after, at least at the end of the day you did gain somewhat of that empowering experience even if your birth is intervened
    medically.

      • Hi. Hope you are well. Tommorrow I will be 40weeks. Baby head turn right, everything well with him. However baby was still high. My gynae immediately said he wil give me 5days time, if I did not go in labour, he wil give me a c-section. This is one thing I’ve been avoidinging, its my first born and really want to give normal birth. I need your advise urgently please.

  29. I am a very healthy, just-turned-41 year old woman 38.5 weeks pregnant with her first baby. To give brief background, my husband and I conceived the first week we tried, the pregnancy has been completely healthy, active, comfortable, and well. I have a wonderful marriage and a supportive, loving husband. and we have continued to enjoy our sex life throughout the entire pregnancy. I eat well and stay active. All the doctors in the OBGYN practice at the hospital have been trying to push an induction on me, first they wanted to do it at 38 weeks but now they all seem to think we’re inducing me at 39 weeks. The past few days I have been getting REALLY increased braxton-hicks in both strength and frequency, and I believe my body is getting ready on its own. All tests and scans show the baby has been in BEAUTIFUL health, I have been tested via DNA and had half a dozen ultra-sound scans due to my “advanced maternal age” they also make me get fetal nonstress tests twice weekly. So even though I never get sick, I’ve never even had a cavity, and don’t even get headaches! I didn’t have morning sickness or even back pain this pregnancy. They say I should be induced simply because I’m 41 years old, and therefore am two-fold more likely to have a stillbirth if I go late. But I did the research, which says women my age have a 1 in 500 chance of stillbirth at 41 weeks (as opposed to 1 in 1000). To me, that is NOT a very big chance. And I am not even late yet! I don’t know if I’m dilated or effaced yet and I FEEL very wrong about induction. I have to tell them no. They are not going to like it. But it’s my body and I think they’re wrong. I think it’s riskier to force this baby out early than to just wait a week, and continue to keep my doctor appointments (I have to go in like 3 times per week just because I’m 41!). Please… I just can’t believe that, in excellent health, with the baby in excellent health, I need to be induced early because a 1 in 503 chance I could have a still born. That’s more than 99.9% chance I will NOT. I’m more concerned forcing labor will cause problems.

  30. Hello
    I’m ,36 weeks and two days. I have lupus. This is 3rd pregnancy. First one I had low fluid and was induced 36 weeks because placenta died. Second pregnancy was on lovenox for protein s deficiency was induced at 38 weeks high bp and was given mag and few weeks later had surgery to clean put uterus from some retained placenta. Now I’m 36 weeks pregnant and was told lasts week my fluid is going up not down and my cervix shortened to 1.7. For 8 days now 6 of them I’ve been in hospital on I’v fluids, pepcid, promethazine, and zofran and Regan g f with benadryl I can not keep anything down baby has perfect heart rate the only thing they say is she’s not doing breathing exercises and with amniotifluidgoing up I’m worried why won’t they take her she’s 6 lbs and I’m miserable they don’t know why I can’t even keep ice down

    • Hi Kiki, I would so love to help — but this very complex and I would need to have a full appointment with you in my office to be able to help. I know that’s not likely at this time in your pregnancy — and given how serious things are — you really need to follow the medical advice you’re being given. You can ask your doctors to also consider cannabis — it improves appetite and quells nausea and for medical use in late pregnancy is safe. They might not go for it — and you might not have access — but it’s the direction I’d go in my patient….Best and I hope things calm down and you can enjoy a healthy birth and baby close to your due time!!!!

  31. Hi Aviva,
    Firstly thank you for such an inspiring post! I came across your artical a few days before my natural delivery with b/g twins at 40 weeks minus two days. I was encouraged to be induced at 38 weeks which I refused. In the end, I was pushed to make an appointment for induction at 40 weeks which I finally agreed to for 6am with a broken heart. I went home eagerly that night from the hospital, hoping to get some rest before my induction. I couldn’t rest until I came across your post, I read it open heartedly and agreed completely! A few hours later, my water broke naturally at home and 7 hours later my twins were born vaginally with epidural in the OR. I am thankful that I listened to my heart and trusted my body 100%. You are an inspiration to me therefore, I named my daughter “Aviva” after you 🙂

  32. Aviva,
    Thank you so much for your insights. I’m currently 27 weeks along with my 4th baby and already fighting the uphill battle with OBs as I’m considered “high risk” at age 44 and they want to induce me around 39 weeks as they are concerned about stillbirth. I have a healthy pregnancy, the baby’s tests have been perfect, and have delivered vaginally 3 healthy babies. I think my body knows “what to do” and should be allowed to do it without tons of medical interventions that the OBs these days seem to encourage. You are a blessing and I was so inspired after reading this article to defend my rights as a woman and a mother. Thank you.

    -Christi

  33. All this sounds nice and happy until you have a still birth at 41 weeks, when your baby was moving and kicking the day before and you refused an induction. It sucks then…you need to be truthful there is not only a slightly higher risk for stillbirth at 41 weeks but it’s drastically higher.

    • Statistically speaking, there is only slightly higher risk, but when it’s your baby that something happens to, that risk is then 100%. Sorry if you had a sad experience. That’s incredibly painful and thank you for sharing…

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