These days women in South Africa have become a lot more clued up on the high c-section rate and the benefits of opting for a natural birth. Studies done internationally have shown that the saying "Too posh to push" may have been somewhat of a myth and that many women were instead being pressured by their care provider to opt for a c-section, rather than choosing it themselves from the outset. Certainly in South Africa, women have become much more informed on the subject and will be choosing to "try for a natural birth" with many finding their doctor to be supportive, in the early part of pregnancy at least.

While women have become more vocal in their wishes to have a natural birth and the media has drawn attention to the pressure they come under by doctors to choose a c-section, this seems to have started a new trend of the 38 week induction. Instead of doctors urging the women to have a c-section, they instead compromise by offering an induction at 38 weeks so that the mother still feels that she is being given the option to try for a natural birth, but often she doesn't know that for most women the chance of the induction failing is almost certain - leaving her with no choice but to have a c-section.

With everything we do there is a risk, and it is up to us what risks we are the most comfortable with for any given choice. There are obviously risks involved with induction of labour at any stage of pregnancy (whether pre- or post- due date) and it's up to the individual to decide of the risks associated with induction outweigh the risks of continuing to be pregnant.
 
1. The risk of the induction resulting in a c-section be required is significant

research study by Ehrenthal et al. (2010) found an increased c-section rate of 20% for women being induced with their first baby. They concluded that: “Labor induction is significantly associated with a cesarean delivery among nulliparous women at term… reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population.” Another study by Selo-Ojeme et al (2010) found induction increased the chance of a c-section by 3 for first time mothers. 


2. The need for medical pain relief is higher

Induced labour is not the same as going into labour naturally and studies have shown that it can be much more painful than a natural labour. The drugs used in an induction of labour do not trigger the same responses in the brain that cause a rush of pain-relieving hormones to be released into the blood stream. In a natural labour, a womans own endorphins are released in response to pain. Endorphins as a painkiller are much more powerful than morphine. Twenty different types of endorphins have been discovered in the nervous system. One of the endorphins, beta-endorphin, is 18-50 times more effective than morphine , while another, called dynorphin, is over 500 times stronger. 

This means that a first time mother is up to 3 times more likely to request an epidural for pain relief. The risks of epidural then also apply meaning she is more likely to need an assisted delivery - such as forceps, vacuum or a c-section.

3. The risk of Fetal Distress is higher

The drugs used for an induction of labour are much more powerful than those in a natural labour. The hormones of labour also moderate each other, for example, if the mother is feeling a huge amount of pain then more endorphins will be released - or if the baby is not in the correct position, this lack of correct stimulation will cause the contractions not to get stronger until the position is changed. With an induction, the drugs are blindly forcing the body to labour and the drip can not react to any messages the baby or other hormones in the mothers system may be trying to communicate. The first time a problem will be picked up is when the baby goes into distress. This is also why babies born from an induced labour are also more likely to need resuscitation, NICU care and have lower APGAR scores.

A baby who is being born at 38 weeks also has the risk that the due date may have been incorrect and is therefore younger than 38 weeks. A baby born before 38 weeks will be more likely to have comprimised breathing and need special care in NICU.

4. The risk of major maternal complications is higher

When a Pitocin drip is used to induce labour it increases the chance of hyperstimulation of the uterus. This means that the muscles of the uterus are being over-worked and once the baby is born there is a much higher risk of Post-Partum Hemorrhage (excessive bleeding after birth). If the uterus has become overstimulated it will be very tired and unable to adequately contract, thereby sealing off the open blood vessels at the site where the placenta was attached. After a non-induced labour, if such bleeding occurred an injection of a similar drug would be given to assist in contracting the uterus. If Pitocin has already being used then other stronger drugs may be required, or in an absolute worst case senario a hysterectomy would be done or the bleeding could result in the death of the mother.


 Perspective


While these risks are present for any induction, it's important to look at the reason why it may be necessary. If a mother is sure of her due date and the baby is most definitely overdue and showing signs of less movement or dips in heart rate, then an induction would by far outweigh the risks of continuing to wait for labour to occur naturally.

The best thing to do if you are being pressured to have an induction at 38 weeks is to ask for more information about what your Bishop Score is. This will help you to know if there is any chance that the induction will be successful or if it will be more beneficial to wait until your body is more ready to go into labour.

The Bishop Score

  Bishop score is a pre-labour scoring system to assist in predicting whether induction of labour will be required. The total score is achieved by assessing the following five components on vaginal examination: The Bishop score grades patients who would be most likely to achieve a successful induction. The duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth.
Bishop score
Parameter\Score0123Description
PositionPosteriorIntermediateAnterior-The position of the cervix varies between individual women. As the anatomical location of the vagina is actually downward facing, anterior and posteriorlocations relatively describe the upper and lower borders of the vagina. The anterior position is better aligned with the uterus, and therefore there is an increased likelihood of spontaneous delivery.
ConsistencyFirmIntermediateSoft-In primigravid women the cervix is typically tougher and resistant to stretching, much like a balloon that has not been previously inflated. Furthermore, in young women the cervix is more resilient than in older women. With subsequent vaginal deliveries the cervix becomes less rigid and allows for easier dilation at term.
Effacement0-30%31-50%51-80%>80%Effacement is a measure of stretch already present in the cervix. It is analogous to stretching a rubber band; as the rubber band is stretched further, it becomes thinner. This is affected by individual variation and previous surgery such as loop excision for cervical dysplasia or cancer.
Dilation0 cm1–2 cm3–4 cm>5 cmDilation is a measure of the diameter of the stretched cervix. It complements effacement, and is usually the most important indicator of progression through the first stage of labour.
Fetal station-3-2-1, 0+1, +2Fetal station describes the position in of the fetus' head in relation to the distance from the ischial spines, which can be palpated deep inside the posterior vagina (approximately 8–10 cm) as a bony protrusion. Negative numbers indicate that the head is further inside, above the ischial spines.


If your Bishop Score is lower than 8 then it is unlikely that induction will be successful.