Who should be induced?

When you’re feeling huge and rolling over in bed requires the help of your husband, booking an induction like a hair appointment can seem like a fabulous idea. But there’s a lot to consider before you decide to go that route, especially the fact that experts agree on the large role failed inductions are playing in the ever-increasing Caesarean section rate.

A 2005 study by the American College of Obstetricians and Gynaecologists (ACOG) determined that inducing first-time mothers was directly associated with an increased risk for C-section. The rate was 12 percent for spontaneous labour, 23.4 percent for medically indicated inductions and 23.8 percent for elective inductions.

Other complications can stem from the fact that due dates are notoriously inaccurate. The same is true for predicting a baby’s size: inducing for a suspected large baby actually increases C-section risk. What’s more, a foetus’s lungs are among the last organs to develop; scheduling an induction before 39 weeks may result in the delivery of a newborn who needs to spend time in the neonatal intensive care unit (NICU).

So who should be induced?
Sometimes, inducing labour is the safest thing to do. If a baby is showing signs of poor growth or distress, or is more than a week or two overdue, he may be healthier if delivered quickly. For mothers with high blood pressure, pre-eclampsia, uncontrolled diabetes or certain other health conditions, a medically indicated induction may mean the difference between a healthy delivery and a catastrophe.

“Inductions are getting a bad rap because we’re doing too many for no reason, but many times they’re an appropriate medical tool,” says Dr Kim Gregory. Elective inductions, on the other hand, are scheduled for convenience – to eliminate messy schedules, middle-of-the-night deliveries and late-pregnancy discomforts. Many experts speculate that up to 50 percent of inductions are elective.

Your body must be ready
Delivering a healthy newborn vaginally depends on having a cervix – as well as a baby – that’s ready. The cervix is assessed by a Bishop Score – a point system of 0 to 3 on five factors, including how far open and thinned out it is. The higher the score, the greater the chance of a vaginal delivery, while totals under five are the biggest risk factor for a C-section. Inductions also can cause medical complications for the mom and baby as well as interfere with the natural labour process.

Pitocin (a drug that stimulates contractions) requires almost continuous foetal monitoring, which decreases a mother’s mobility. Evidence suggests moving around can speed labour. If labour progresses slowly, her amniotic sac may be ruptured to accelerate the process, increasing the risk of maternal and foetal infection. Women who experience powerful, painful contractions caused by Pitocin often request an epidural, which, in turn, may affect blood pressure and circulation to the placenta.

Weigh risks vs rewards
Although many doctors schedule inductions at 38 weeks, the increase in failed inductions, maternal and newborn infections that result from the membranes being ruptured prematurely, C-sections, and NICU admissions have all led to stricter guidelines. In the US, the ACOG states that elective inductions shouldn’t happen before 39 weeks unless the baby’s lung maturity is determined by amniocentesis. Regardless, elective inductions often happen earlier. Making the decision to induce requires thoughtful consideration. Sometimes, it’s just not worth taking a shortcut. “If there’s a medical indication, that’s a no-brainer,” says midwife Karen Parker-Linn.

“The benefit outweighs the risk. But if a woman’s not ready, I won’t induce. I’ll ask, ‘If your baby’s in the NICU and they’re poking him with yet another IV, was your discomfort more important than preventing that?’”

Did you know?
Inducing labour if the pregnancy goes 42 weeks or longer, rather than waiting for labour to start, is safer for mom and baby and reduces the C-section risk.

Want a shorter labour and a healthier baby?
Let nature run its course. Babies delivered before 39 weeks have more complications. So in 2001, US-based Intermountain Healthcare, whose 21 hospitals handle 30,000 births a year, began to eliminate elective inductions for first-time mothers before 39 weeks.

They found that those with a low (0 to 2) Bishop Score (a measure of how “ripe” the cervix is), even at 39 weeks, had labours that averaged 21 hours and C-section rates of almost 50 percent. With a score of 10, labour lasted 91⁄2 hours and C-sections dropped to eight percent. The result: inappropriate elective inductions declined by more than 50 percent.

Real life stories

Induction ‘success’: Kirsten Alberts, 36, mother of Cara, six, and Ben, five

After my first labour, which was long and traumatic and took place in the UK at 39 weeks, I decided that a 39 week pregnancy was in fact "just fine" second time round.

Besides, I had a dilemma. We had moved back to Johannesburg from London and I didn’t know many people. My sister-in-law, who was prepared to babysit my daughter any time of day or night in the event of a wild dash to hospital at 3am, was going to be on holiday on my due date. My mom, who lives in Port Elizabeth and was on her way back from Namibia, would only be available a week earlier. As I desperately wanted support this time round, I asked my gynae if we could schedule an induction at 39 weeks. Of course, I hoped that my baby would decide on his own that “it was time”, but no amount of “willing him” to emerge did the trick.

The important thing to me was that, even though the Pitocin drip took a while to work and my waters had to be broken manually, it felt like everything was under control (compared to being left alone to 'tough it out till my toes curled' in the UK); my daughter was being looked after by her granny and I was able to relax and concentrate on my breathing, making the most of the birthing experience.

This time, the pain felt more manageable and I was able to spend time sitting on my birthing-ball and move around, confident that things would proceed steadily and safely. It took a while for me to dilate (I think it’s a family thing, all my cousins have had 30-hour-plus labours), and the drip had to be increased. I had an epidural but there were no complications and my sweet little Ben was born after “only” 12 hours, perfect in every way.

Induction ‘disaster’: Yvette Samaai, mother of Leah, age 3

After a seemingly long and wearisome pregnancy, I simply couldn’t wait any longer to go into labour naturally, particularly as I’d experienced a lot of water retention, had gestational diabetes, and my doctor seemed sure that I would most likely have to have a C-section. I was determined to have a natural birth and I didn’t want to have to wait until the following Tuesday for the gynae’s “Caesarean day”.

I was booked in for an induction early in the morning a few days before my due date and was induced before 8am. Eventually, the contractions began, and by the late afternoon they were so bad I couldn’t bear the pain. I had so badly wanted to have a natural birth but, after 10 hours of labour, I felt like I had reached the limit.

By the evening, my feelings of anxiety and excitement had been replaced by unbearable pain and all I wanted was for it to be over. Around 6pm, my gynae examined me and proclaimed that the induction hadn’t worked and that I needed to go in for surgery before my baby went into distress. All those hours of pain that I had endured were for nothing!

I had no choice but to agree to a C-section. My baby girl, Leah, was a good weight (2.9kg) and all was well in the end, but I would never advise anyone to have an elective induction as it was most painful and simply didn’t work for me.

‘Why won’t it work?’ Liesl Lennox, age 32, mother of Callum, age 4

I decided I would like an induction on my due date, if my baby hadn’t already “arrived” by then. I was sure that by 40 weeks he would naturally be “ready” and there wouldn’t be any risk. I really didn’t like the idea of being heavy and “overdue”. Although I didn’t want a Caesar, I felt like I couldn’t wait any longer, especially as I was having such trouble sleeping. So, in order to be able to plan (I am a bit of a control freak), I arranged with my gynae for an induction.

I was given a drip and, after some time, my waters were broken manually. My contractions became much, much stronger; so much so that I was struggling to feel “in control” and I was worried I would pass out. I decided to have an epidural. But I just wasn’t dilating and eventually, after almost 12 hours, my gynae insisted that I go in for a Caesar. As they had given me an epidural, they assumed I wouldn’t need further anaesthetic and did an experimental cut, at which point I threatened to strangle someone if they did it again. I’ve never experienced such uncontrollable pain; thank goodness for epidurals.

I was terribly disappointed that my body didn’t respond the way it was “supposed” to but the most important thing is that my gorgeous boy was finally delivered safely into my arms. I’ve never been more relieved and happy than at that moment.