Maybe you’ve read a few commentaries (or at least a few headlines!) about a major study called the ARRIVE Trial that came out about a month ago in the New England Journal of Medicine. In that study, the authors concluded that there was a lowered risk of Cesarean Birth in first-time, low-risk Mommas who were induced at 39 weeks gestation compared to those in the expectant management group.
You can read the abstract from that study here. Here’s a few other resources to check out including the response from ACOG and this infographic. A lot of the coverage that’s been circulated in the media has been either about defending the findings, or poking holes in the study. That’s not what my post is about.
I’d like to focus my attention on YOU and how your birth experience will change if you decide to be induced — especially if it’s not medically indicated — at 39 weeks or at any other time, really.
The reason I want to use this lens to discuss the study, is that I remember all too well what it’s like to be a VERY pregnant woman. And the thought of being able to end that pregnancy early can be incredibly appealing! But an induced labor is entirely different from labor that starts on its own. I want you to know what you’re getting into, before you hitch a ride on the “Get It Outta Me! Express.”
“But, scheduling the day of birth sounds soooooooo great!”
Women who find themselves pregnant today are not as surprised as they have been in generations past. This pregnancy may be a planned event down to the point of knowing exactly when the baby was conceived (even more so, if IVF was a part of the process.)
Here’s my message to all the planners out there — you know who you are — the schedulers, the folks who prefer a life that’s organized and controlled. While it is comforting to have a scheduled plan for when your baby will be born, I hate to be the one to break this to you…
Whatever kind of organized, controlled schedule you’ve enjoyed up to this point, gets broken, or at the very least, really bent out of shape, once you become a parent! The sooner you can get your head and heart wrapped around that reality, the easier it will be for you to move into your role as a new parent.
This doesn’t mean that all organization and scheduling go away — don’t freak out! It just means that it gets more challenging to stick to a schedule, and this can make new parenting more frustrating than it has to be if you’re not prepared for that. So, not knowing when your baby will be born is a crash course in surrendering that tight grip of control!
I know that you want to feel completely ready for your little one’s arrival. But, trust me on this, you’ll never feel completely ready for your little one’s arrival. So, breathe. And stop trying so hard. It’s exhausting, and believe me new parenting is already exhausting enough!
“But – I’m soooooooo sick of being pregnant!”
There’s HUGE appeal to getting the baby out — even a week early! I get it. My babies were, in order of appearance, 10 days, 2 days, 3 days and 12 (TWELVE!) days “late.”
I have quote marks around the word “late” because my babies were not technically late. They were just past their due date. Ahh, the due date… that magical date that tells you nothing about when your babe will actually arrive! Erase that date from your memory, or better yet, read THIS blog post to understand why pregnant folks should focus on their due month, instead.
But regardless of your baby’s arrival being “early”, “late” or “right on time” unless it’s medically necessary, the labor process should begin spontaneously, if at all possible. There’s a complex interplay of hormones that occur in those last weeks and days of pregnancy that initiate the process. You can read about that in much more detail, here.
At 38 weeks of pregnancy, every woman who’s ever been pregnant, begins silently chanting (even subconsciously) over and over again: “GET IT OUT! GET IT OUT! GET IT OUT!”
Your hips will hurt (way more than they do right now), your heartburn will go into overdrive (the mere thought of eating a taco will do you in), you’ll look at your belly and think your skin couldn’t possibly stretch more (and, yet, it does), you’ll need to pee more often (approximately every 17 seconds), and you won’t be able to sleep nearly as well as you currently do. You might ask, “How is that even possible? I’m not sleeping well now! (I know… but it gets worse.)
I’ve established that I’d like to be crowned “The Queen of Realistic Expectations” (and I’d like my crown to be sparkly, and purple, and not mess up my hair too much!) But I hope I’ve also established, that I don’t provide these realistic expectations in order to scare you or make you dread what’s to come… I want you to feel prepared and to know there are good reasons for all that’s coming at the end of your pregnancy.
If your sleep has been interrupted, even if you think it’s been SUPER interrupted, it hasn’t. Not in the way it will be directly after your baby is born. Your little person has a stomach that’s the size of their closed fist. This will help you understand why they need to eat every 2-3 hours around the clock. It’s NOT because they’re a tiny, screaming, torture device… it’s because they’re growing exponentially, and they need food!
You cannot go from getting 5+ hours (or more) of uninterrupted sleep at night to having to wake every two hours to feed your baby and have that look pretty! So Mother Nature tries to “help” you by making it harder to sleep in those last weeks of pregnancy for all of the reasons listed above. That way, those first few days and weeks are a little bit easier to handle.
“But I’ve quit work and everything’s ready! Let’s just make this happen NOW!”
While it’s true that sometimes it’s the babies who need a little extra time to cook before the labor process starts, sometimes it’s the Mommas who need more time to prepare mentally and emotionally for their baby’s arrival.
It’s rare that a baby goes on strike and demands a negotiation team to set up shop just outside the uterus, only to end up being taken out by force! But it can begin to feel like that — a weird tug-of-war game. On one side, you’re desperate for pregnancy to end, but on the other side, you’re scared to death about what life will be like when the baby’s no longer safe and sound inside of you, but a real-life human being that you’re now responsible for 24/7!
Those last days and weeks of being a pregnant person are the ideal time to sit and reflect, to acknowledge any fears or concerns you might have, to iron out the big stuff with your partner so you’re starting out on the same page, to prepare yourself not just for the birth, but for all that comes after. And an induction (when it’s not medically necessary) can rob you of this precious time.
“But — an induction means a faster, easier birth overall, right?”
In a word? Nope.
An induction changes the dynamic of the birth experience itself. Spontaneous labor might not be convenient from a scheduling standpoint, but you’ll actually get more sleep if you have no idea when labor’s going to start! You go to sleep thinking.”Maybe tonight?” and then wake up, just as pregnant as you were the day before.
But if you’re going to be induced, then you know exactly what day this whole thing is going down (unless, when you arrive for the induction, they bump you to the next day… it does happen sometimes) You’re unlikely to sleep very well — and that’s even if you get to start the induction in the morning hours, after spending the night before in your own bed.
Oftentimes, inductions start at night in the hospital. So, you spend the whole day running around taking care of all the last-minute things that HAVE to get done before the baby’s birth, and head into the hospital that evening exhausted. That’s when they’ll determine your body’s “readiness” so that the induction has a higher chance of being successful.
Because, you see, the most common medication used for induction is Pitocin, a synthetic form of Oxytocin. Oxytocin is the naturally occurring hormone in your body that causes your uterus to contract. The power of Oxytocin has been harnessed into an IV form of medication that will do exactly what it was created to do: make your uterus contract.
But if your cervix is not “ripened” first, despite contractions, it will not efface (thin out) and it will not dilate (open up). If we don’t do the prep work of ripening your cervix, you could have Pitocin contractions all day long and it won’t change the cervix at all.
So, at 39 weeks, you’ll most likely require some sort of cervical ripening agents to be administered prior to the start of Pitocin, in order to avoid what’s called a “failed induction.”
This could mean that you come into the hospital in the evening hours and they apply a gel, most likely Cervidil (a synthetic prostaglandin that can help to soften and ripen the cervix.) Fun Fact: Prostaglandins are found naturally in semen. You might have a free, cute and way more fun way of applying prostaglandins at home… if you get my meaning!
They might choose to use a medication called misoprostal, often branded as Cytotec. This tablet can be placed inside the cervix or given as an oral solution. (In some hospitals, Cytotec is replacing Cervidil, as it is cheaper and has been proven to be more effective.)
Your provider might also choose to manually dilate your cervix by inserting a catheter that has a balloon attached on one end. Filling the balloon with water can help to manually open the cervix.
They might also suggest over time, to augment the induction process (help speed things up) by sweeping the membranes (separating the amniotic membranes from the cervix) or performing an amniotomy (breaking the sac of amniotic fluid before it breaks on it’s own, through active labor or pushing).
Many of these things will end up being used in combination to jumpstart a labor that has not begun on it’s own.
I tell you ALL of this, so that you will let go of the expectation that an Induction will result in a faster, easier labor.
This is simply not true. Inductions that are not medically necessary can even mean much longer labors in the hospital overall. The cervix has to be ready for the Pitocin to take effect. And that process takes time. That’s why It’s NOT unusual for labor inductions to take 3-4 days in the hospital!
And this matters — a LOT. Because, despite their best efforts, hospitals are not known to be the most restful places on earth. Trying to get good sleep before labor kicks in the next day is challenging! Continuous electronic fetal monitoring is necessary when you’re being induced because some of these medications can lower your baby’s heart rate. You can still get up and move around, but now you’ve got a new dance partner: an IV pole.
An induction changes everything.
Sometimes, an induction is a necessary thing. You’ve been diagnosed with pre-eclampsia, for example (very high blood pressure that could lead to severe complications for the mother or baby or both if we don’t induce). When it’s medically necessary, you might not need as many of these interventions to nudge you into labor because your body, your baby, your uterus and placenta are all lined up saying, “Yep! Great idea! Let’s get this party started!”
But if there’s no medical indication for an induction of labor, your body, your baby your uterus and placenta are all thinking, “Wait, what? Why are we forcing this, when it’s best for the baby to stay inside and keep on cooking for a while longer?” A non-medically necessary induction could lead to a very long in-hospital labor process.
According to the ARRIVE Trial, an induction at 39 weeks might mean a small decrease in risk of Cesarean Birth. But, couldn’t it also lead to a number of other interventions that might have an impact on the baby’s heart rate? This might lead your provider to make the decision that Cesarean Birth is now necessary because they are concerned with the fetal heart rate pattern (that might not have been an issue at all, if we just let labor begin on it’s own in the first place).
Hmmmm… those are a lot of “mights.”
I didn’t write this piece to voice an opinion about induction at 39 weeks, good or bad. I wrote this piece for YOU! And here are a few other “mights” to consider…
If I were a pregnant woman, and I just skimmed the headlines and saw, “Induction at 39 Weeks Decreases Cesarean Birth” I might be inclined to shout from the rooftop: “Sign me up!” without understanding how and in what way an induction would affect my overall labor experience.
I might not consider that these last days and weeks (even if I’m really uncomfortable) are actually gifts, so that I can better prepare, mentally and emotionally, for my transition to motherhood.
I might not fully realize all that’s involved in an induction and therefore be shocked and disappointed in the process once it’s begun.
As always: Be informed. Look for current, evidence-based information. Ask lots and lots of questions, including questions that will help you determine your own risk assessment. Belly up to the BAR (Benefits, Alternatives, Risks) and do some research to help you make your best, and most informed decisions.
Lastly, make sure that you trust all the members of your birth team so that when the big day arrives (either spontaneously or in a very controlled and scheduled way) you feel prepared in all the ways that really matter for the start of your parenting journey.