There are a lot of public plays albeit via media outlets, advocacy groups or the like, positioning childbirth as a debate. Associating divisive “too many” or “too few” to the notion of vaginal delivery and surgically-assisted forms as is the case with C-sections. Words like “normal” or “natural” seem to have lost their objectively descriptive roles and transitioned into ideological brands. Unfortunately, we have lost sight in the narrative of the main goal of such a uniquely dynamic physiological process: healthy mother and healthy baby.
The consideration throughout the entire perinatal experience is always, from a medical perspective, preserving the short- and long-term optimal health and well-being of the two patients involved who for much of the time are interconnected. Hence, when a new study comes out making any assessment of the aggregate population and the impact of delivery mode, it can certainly be used to inform but rarely can it be used to dictate what is in the best interest of both mother and newborn under such changing conditions.
In the latest work published in Ultrasound In Obstetrics & Gynecology, researchers performed a meta-analysis of five studies to pursue this objective:
“The rate of maternal and perinatal complications increases after 39 weeks in both unselected and complicated pregnancies. The aim of this study was to synthesize quantitatively the evidence on the effect of elective induction of labor at term on the risk of Cesarean section, and maternal and perinatal outcome.”
Like many things in life, perfect timing contributes to the most optimal results. However, in maternal-fetal considerations a delicate dance is requisite and integrated into a complex series of decisions that cause a chain reaction of events - good, bad or indifferent. When a baby is delivered too prematurely, issues arise. When too late, the same can hold true. The difference with birth and a lot of other aspects we manage navigating the world is that the stakes are much higher when falling short of achieving the previously stated goal of a healthy mother and child. Complications can occur when beyond a certain point in gestation - and, this is variable for patients and the unique nature of clinical history, status and compounding scenarios. For example, the baby can grow larger thereby imperiling delivery and restricting movement, for instance, while the amniotic fluid diminishes as does placental reserve prompting other problems.
So, knowing when to give a nudge like an induction or make the choice to step toward C-section or complex vaginal birth has consequences and determining the less risky path requires expertise and complete understanding of the clinical course at hand. When situations are extreme, even with a perfect decision, there can be long-term disability or death. Thankfully, most births are happy endings. But, taking the wrong road that makes you miss your movie in the theater is nowhere near the result when a labor turns highly risky and rapid interventions become essential as circumstances quickly become unpredictable.
Understanding the impact of electively employing medical induction, as opposed to expectant management, at the 39 week mark (greater than or equal to 37 weeks is technically term) to an uncomplicated low-risk singleton pregnancy of a nulliparous (never given birth) woman is very important. The authors conclude from their review:
“There is moderate quality evidence that elective induction of labor in uncomplicated singleton pregnancies from 39 weeks may be associated with reduced risk of cesarean section, maternal hypertension and need for respiratory support in the neonate. Unresolved issues, should systematic induction be adopted, involve logistics, cost, the preferences of women and possibly the long-term neurodevelopmental outcome of the offspring.”
This is good information, but its applicability or capacity to be abstracted for implementation in any and all pregnancies is not its purpose or point. For medical decision-making, the determinations in this study must be weighed and measured through the lens of a person current in the field of obstetrics and gynecology who can place it into context, not simply overall in the field and population but also, and most importantly, for his particular patient. And adapt such guidance based on the clinical status of the pregnancy at hand. Appreciating the limitations that exist in this systematic review is imperative to fully informing patients on the topic so that the best shared decision-making takes place.
Adding to the conversation the notion elective induction at 39 weeks might just be the sweet spot in terms of timing, under a set standard of conditions for mother and neonate, that is necessary to avoid the cascade of untoward events that can be precipitated from delay is very worthwhile. But, for the many reasons described, it is a mere guide, a piece of a complicated puzzle that can be quite volatile in real time. Which brings me back to the original question of how a baby should be born given the consistent public refrain of “too much” medical intervention in delivery or “too many” C-sections.
In the end, it is just the wrong question altogether. Despite that, since the landscape has become so misguided and binary of “pro” and “anti” no matter the topic, the right answer is a baby should be born in the mode and manner that respects the largest stakeholders, mother and infant, in a way that optimally promotes their short- and long-term health and well-being. Due to the extreme variability in confounding factors, how that looks will be distinct for the individuals involved. And, this and other studies to come, can only help to inform on such design and, hopefully, will continue to chisel away at any unnecessary shaming attributed to whatever the manner.
After all, it wasn't that long ago when every birth carried tremendous risks for mother and child, modern medical advances have prevented a lot of harm and continued research should only improve the picture.
