Childbirth: Should it start on its own or with a planned induction? A midwife answers – Proto Thema

While we often hear about the high rates of cesarean sections in Greece, the practice of planning and inducing labor is equally concerning.
When a baby is born before 37 weeks of gestation, it is premature, while when it is born after 42 weeks of gestation, it is considered postterm. The normal duration of pregnancy is defined internationally as between 37-42 weeks, while only about 51% of births would occur exactly on the expected due date (Gestational age, i.e. at 40 completed weeks), if labor started spontaneously. Gestational age is calculated at the beginning of pregnancy based on the last period and ultrasound measurements.

Why is it important for labor to start on its own?;

• When labor begins on its own, the body has created ideal conditions for both mother and baby and the chance of a normal birth is high.
• The fetus's vital organs, especially its lungs, mature until the very last moment. When labor begins on its own, there are fewer complications during its adaptation to extrauterine life.
• Better fixation of the baby: In the last few days before the spontaneous onset of labor, the baby "takes position" and adjusts for birth through the mother's birth canal.
• Hormone secretion: The secretion of natural oxytocin during the spontaneous onset of labor creates contractions and contributes to the strong bond between mother and child and should not be disrupted.

Birth planning is a medical intervention that induces uterine contractions before the spontaneous onset of labor.

When is there an indication to induce labor?;

• When there are confirmed medical reasons, such as gestational diabetes mellitus or high blood pressure in the mother, or when residual intrauterine growth of the fetus is diagnosed.
• When there is extension of pregnancy beyond 42 weeks, as there is an increased risk of complications and stillbirth.
• When the potential benefits of inducing labor outweigh the potential risks of inducing labor, following an assessment of the specific case.

Personal risk factors (if any) and the potential benefits of induction of labor should always be discussed with your pregnancy care provider. Gestational age or date alone is not a reason to induce labor, as mothers and newborns may face a number of risks.

The possible risks of inducing labor are:

• Uterine hyperstimulation: Artificially inducing labor can cause more frequent and stronger contractions than normal. This reduces blood flow to the placenta and leads to fetal distress.
• Fetal distress: The fetus is burdened by the artificial contractions and its heartbeat is altered.
• Increased rates of cesarean sections due to fetal distress and cervical immaturity. Cervical maturity and dilation are assessed through vaginal examinations.
• Risk of infection: Due to the increased rate of vaginal examinations, there is an increased risk of infection, especially if artificial rupture of the membranes (the so-called "breaking of the waters") is performed as a method of accelerating labor.
• Due to the unnatural and continuous strain on the uterus, induction of labor is associated with a lot of high rates of bleeding after childbirth.
• The artificial pains is more painful and are often accompanied by nausea, vomiting and other side effects from the drug challenge.

Medical induction of labor is performed with a vaginal suppository and/or intravenous administration of saline, which necessitates continuous fetal heart monitoring using a cardiotocograph. The use of a cardiotocograph is not associated with better perinatal outcomes, but is associated with increased rates of interventions and cesarean sections.

Regarding the most recent available evidence on the long-term effects of induced labor, research from 2021 and 2023 shows a significant association of autism spectrum disorders and lower school performance in children born after induced labor.

In Greece, there are many high rates of medical interventions, induced labor (>30%) and cesarean sections (>60%). The degree of medicalization of a health system is influenced by many factors.

A very key factor is that all personnel involved in childbirth (obstetricians, gynecologists, midwives, obstetricians) are trained in the current medicalized regime, which is thus perpetuated.

A very important role is also played by defensive medicine. To avoid legal consequences, more interventions are made that limit the normal, usually uncontrollable or predictable, natural progression of childbirth.

The financial and personal motivations of health professionals cannot be overlooked either: Appointment births are shorter and can be better planned. It is no coincidence that in Greece most births occur during the morning shift and on weekdays, while very few births occur on holidays.

Systemic reasons also include attachment to «our doctor.» As long as there is an expectation that «our doctor» will support us in childbirth, who also maintains a practice with other gynecological cases and has additional scheduled surgeries, it is easy to understand that the schedule comes out more easily when the deliveries are scheduled and a time limit is imposed. The alternative would be for deliveries to be completed on time with the obstetric staff on shift, as is done in most countries abroad.

Finally, the social perception of risk and safety plays a decisive role in the medicalization of the health system in Greece. As long as we see childbirth as something potentially dangerous for the mother and child, from which they must be protected, it is natural that every effort should be made to plan and control.

Why do some gynecologists recommend scheduled delivery at 39 weeks?;

In 2018, the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) study was published, which caused great controversy in the scientific community. The study aimed to compare perinatal outcomes between 3062 deliveries induced without medical indication at 39 weeks and 3044 deliveries induced spontaneously in primiparous women with low-risk pregnancies.

The study, which was conducted in the US, showed lower rates of cesarean sections in women who were induced at 39 weeks. There were no differences in neonatal parameters, while fewer cases of hypertension were observed in pregnant women who were induced at 39 weeks.

The results of this small study cannot be transferred to the general population and their interpretation requires special caution.

The majority of pregnant women (72%) declined to participate in the study, possibly to avoid random assignment to one of the two groups. The average age of the women participating in the study was 24 years. The rates of cesarean sections in the study were extremely low (19% and 22%) compared to the US average (32%), which raises further questions about the representativeness of the study.

The publication of the ARRIVE study has significant shortcomings in its methodology and design, and led to a global increase in induction rates. However, the expected reduction in cesarean section rates or gestational hypertension was not observed.

Inducing labor without a medical indication, there is a high probability that the risks of induction outweigh the potential benefits. It is safe to expect spontaneous onset of labor in healthy and uncomplicated pregnancies up to 42 weeks, while assessing clinical parameters.

Data from a systematic meta-analysis including 15 million (15,000,000) low-risk pregnancies showed that while the stillbirth rate increases after PHT, the absolute rate remains extremely low. Specifically, there are 0.1 perinatal deaths per 1000 pregnancies at 38+0 weeks and 0.88 perinatal deaths per 1000 pregnancies at 42+0 weeks of gestation.

On the contrary, Inducing labor in low-risk pregnancies appears to significantly increase the chances of a cesarean section. The following data comes from a study from the USA that included over sixteen thousand (16,000) births:

• At 39 weeks of gestation, the cesarean section rates were 17.9% in spontaneous labor and 33.8% after induction of labor.
• At 40 weeks of gestation, the cesarean section rates were 18.9% in spontaneous labor and 35.8% after induction of labor.
• At 41 weeks of gestation, the cesarean section rates were 25.2% in spontaneous labor and 38.7% after induction of labor.

It is unreasonable to perform a dangerous and costly intervention without a clinical indication to avoid another intervention (e.g., cesarean section).

In the ARRIVE study from 2018, induction of labor was associated with a 161% reduction in cesarean sections, while less invasive approaches lead to a much greater reduction in cesarean sections. Intermittent fetal heart rate monitoring, for example, is associated with a 391% reduction in cesarean sections, while continuous midwifery support during labor leads to a reduction in cesarean sections of at least 301%. Practices that have been shown to improve perinatal outcomes at a national level include:

• the establishment of a review and control of perinatal mortality cases and perinatal statistics in general
• the emphasis on prevention, health promotion, smoking cessation and alcohol avoidance
• strengthening the role of midwives and promoting the autonomy of the midwifery profession
• the establishment of scientifically documented guidelines for all obstetric practices

Must the each pregnancy should be evaluated individually, with comprehensive, scientifically documented and personalized information provided and to take into account women's personal preferences, so that they can make appropriate decisions about childbirth and their health.

Common myths and misconceptions about childbirth:

Myth: Natural childbirth is dangerous.
Truth: Natural childbirth, when supported by appropriately trained medical personnel (midwives, gynecologists) is very safe when it comes to low-risk pregnancies. Scientific literature supports the safety of natural childbirth and the avoidance of unnecessary interventions.

Myth: Cesarean section is easier and simpler than vaginal birth
Truth: A cesarean section is a major surgery, which requires a longer recovery period and carries more risks than a normal birth.

Myth: Natural childbirth is only for "special cases" of women.
Truth: Natural childbirth is a personal choice and a human right regardless of social or economic background, age or medical history. Every woman should have access to information and support to make informed decisions about her personal birth preferences.

Myth: Once a cesarean, always a cesarean
Truth: Many women give birth vaginally after a cesarean (VBAC). When well supported, vaginal birth after a cesarean is a safe and reasonable option for many women.

*Written by Mrs. Dimitra Koutoumanou, Freelance Midwife, B.Sc in Midwifery (Germany)