With Delivery Times, Defer to Mother Nature

“Let nature take its course.” Over the years, I’ve found this saying particularly applies to the process of giving birth. My personal experience as an ob-gyn and reams of scientific research demonstrate that Mother Nature knows best when a child is ready to be born. The start of natural labor is the main sign, but we’re not always patient enough to wait for it.

Today, one in three babies in the US are born by cesarean—the delivery of a baby through an incision in the mother’s abdomen and uterus. The rate of labor induction is also at an all-time high. Unfortunately, many of these births occur before the pregnancy is considered “term” at 39 weeks. These upward trends have long been a source of concern in the medical community, especially considering the increased risks to a baby who may not be fully developed at delivery.

Among cesarean deliveries, an estimated 2.5% (more than 100,000 births each year) are scheduled on a designated date by the mother and her doctor. Some women cite reasons such as a lower risk of future incontinence, better sexual functioning after childbirth, and fear of pain as motivations to schedule cesareans. Inevitably, some cesareans (and labor inductions, too) are scheduled before a pregnancy is full term, increasing the risk of negative outcomes for the newborn, including respiratory problems and time spent in the neonatal intensive care unit. The fact remains that due dates are estimates, and you can never be sure that the infant will have reached optimal maturity at the time of a scheduled delivery.

Women should keep in mind that cesarean delivery is no walk in the park. While it’s a safe option, cesarean delivery is a major surgery and comes with a number of risks, such as placental complications in future pregnancies, problems with anesthesia, infection, and longer recovery times.

Certain urgent situations—such as preeclampsia, eclampsia, multiple fetuses, fetal growth restriction, and poorly controlled diabetes—may make it necessary to deliver the baby before the onset of natural labor. However, newly issued guidelines from ACOG remind women and ob-gyns that in uncomplicated pregnancies, a vaginal birth that occurs after the natural onset of labor is ideal. Additional new ACOG guidelines reaffirm that cesareans and labor inductions should only be performed when medically-necessary.

Delaying delivery until labor starts naturally may not make ob-gyns too popular with a patient who’s uncomfortable and near the end of her pregnancy, but it’s a decision that will pay dividends by giving the baby the extra time it needs to face the world.

22 thoughts on “With Delivery Times, Defer to Mother Nature

  1. There are a number of issues being discussed here in regards to early delivery by cesarean, and all are part of the whole picture. I have been monitoring current literature and discussion and have seen the same elements discussed and expressed. I also have personal experience with this as an L&D nurse. I agree, and it seems evidence supports that early, elective cesarean section does not carry the benefits the women who seek it think it does, and actually increases risk to both mother and newborn. But, as mentioned in comments above, it is not always the mother who seeks this route of delivery. There is far too much impatience with the process of pregnancy, labor and delivery, on the part of obstetricians and pregnant women, whatever their reasons are, often leading to interventions to make it faster which always add risk to the process. Whether the reasons for electing cesarean are fear (of the process of vaginal birth and its possible lasting effects,) disgust, mistrust of the process, impatience, convenience, desire to avoid conflict between mother and physician, the desire by the physician to increase his/her income, unwillingness or mistrust to allow midwifery care, and desire to avoid lawsuit or higher cost malpractice insurance by allowing VBAC, the bottom line is that vaginal birth is still more clinically desirable than cesarean unless there is a valid medical reason for it.
    What will need to happen for the trend toward elective and early cesarean delivery is for physicians to educate their patients about this and resist pressure on their patients’ part to persuade them to perform early cesarean, and to allow vaginal birth after cesarean when other risk factors do not interfere with offering that option. Repeat cesarean is not absolutely necessary and we all know there have been many, many successful VBACs. I am aware that the risks in VBAC are higher than vaginal birth without prior cesarean delivery, and that when adverse events occur, that they can potentially be devastating, but that is the nature of childbirth, and in this case, offering VBAC may be no more risk-prone than doing elective cesareans.
    It is also true that some of our traditional practices in assisting women in labor are more to protect us from lawsuit or inconvenience than to help the process along and let the baby come out. Electronic fetal heart rate monitoring has contributed to confining women to bed for their labors as well as increased the rate of cesarean for perceived fetal distress and fear of lawsuit, as has the extreme popularity of epidural anesthesia. While I doubt that the majority of women would want to go back to completely “natural childbirth” when they know they can be numb for the process of giving birth, and some nurses and doctors prefer managing numb women in labor, encouraging “walking” epidurals, spending time coaching the patient in labor to breathe, relax, walk, rock, shower, sit in a tub in order to aid the process could help to reduce the need for cesarean. Allowing positions for delivery other than lithotomy position could also help decrease second stage time. Some of the most satisfying and joyful births I have had the privilege of witnessing and participating in saw the mother in whatever position she chose to deliver. There are no “rules” in that regard, only tradition and preferences on the part of the birth attendants.
    The final outcome we all hope to achieve for our patients and ourselves as birth attendants is safe, satisfying birth. As evidence is telling us, we ALL need to change our attitudes and practices to acheive this end.

  2. I see many new moms on our Postpartum floor who were sectioned for ‘failure to progress’ when they are complete and pushing for a couple hours, after having been induced for post dates. Of course, the pushing is done on their backs and they aren’t allowed to ambulate freely to labor down and let gravity help the baby descend. There are many nights when, out of three or four couplets, all my moms are recovering from sections. C-sections can inhibit the establishment of breastfeeding, as some moms are in too much pain to really engage with their babies, and many get frustrated and put their babies in the nursery with formula until they feel better. I can’t help but wonder if their deliveries would have been different if they had waited for natural labor to begin. My message to the OB docs who don’t want to be ‘inconvenienced’ – change your specialty to podiatry or dermatology. You are less likely to be wakened in the night by emergencies.

  3. Very interesting article, I sincerely hope that it reaches many obsstetricians, midwives and parents to be so as to decrease medicalisatikn of childbirth.

  4. yes doctors have been pushing inductions for years but the women need to be more informed when it comes to childbirth to oppose an induction that is not medically necessary. So we cannot have the accuse that the doctor “made” me. Yes sometimes doctors push but sometimes women need to research what to say no to! This article is well written!

  5. Yes i do believe medicine could be good in moderation but i feel like for the benefit of some of …. And to get something out of it other than a good birth abuse medicine comes in to the picture and there i were one of the problem start when i start to hear more of the good true stories it would be a good blessing

  6. Just be aware that the data used is retrospective and not adjusting for different risk groups. Also certain statistics do not show statistical validity. I would be curious to know what this doctor’s CS rate is? The average in the country is over 32% and the use of induction is being restricted. This doctor is referencing less than 3% as non-indicated elective inductions, what about the other 30% of deliveries resulting in CS? Were they allowing nature to “take its course”? The current standard of care is not preventing CS. There are health risks and birth protocol that are not being effectively treated by our medical community. I agree that informed mothers and family members need to be allowed to make the decision to give birth in a supportive and trusted environment. Much can be learned from the midwife community. (Remember, many midwives use practices to get labor started). Understanding the high C-Section rate and the correlation to induction needs to be studied with best scientific standards of research. ACOG has offered very few RCT (randomized control studies) in most areas of birth outcome research. NON are referenced by this doctor. Why is he not advocating for (and referencing) RTCs to study the correlation between elective preventive induction and birth outcomes? This would provide for the highest level of research standards in an area that is so important to the health of our mothers and babies. This is essential for making accurate and informed policies.

  7. As an OB/GYN, allow me to assure you all that the blame is shared. Just as there are no doubt docs out there who want inductions scheduled for their convenience, I have had many mothers demand I deliver their baby NOW, for no reason, because they are uncomfortable. And there are plenty of them that are happy to turn around and sue me if I decline and then something unforseeable happens. All parties have a hand in this.

  8. You know its a start its a nice one but if hospitals could get on the same boat and everybody worked together would be a work of art magic . For the vbacrs its even more nice to feel as comfortable as possible that means even in a “hospital ” i would love to have another baby but if the emergency wasn’t needed but i felt the need to go to the hospital I DON’T WANT TO FEEL LIKE IM GOING TO END UP IN A C SEC .I WANT TO FEEL just like i was at home imagine you go to a restaurant and as soon as you go in you feel the warm inviting feeling and your not rushed and when you leave you leave with the thought of reminding everyone to ho back to that one place you will never regret its kinda like that i will love to hear more nicetbibirth vbac story on tv not a baby story all the time imagine ….

  9. Yes, please let nature take its course. As a mother who was pressured into scheduling a c-section by my ob 10 days before my “due” date so that I wouldn’t go into labor at an “inconvenient” time for their practice, I want to echo the comments that doctors need to be held accountable. While I applaud the sentiment in this posting, I am disturbed that the language used places the blame solely on mothers. The manipulation doctors use to scare women into scheduling cesareans and the lack of support for vbac among many hospitals and doctors are significant contributing factors to the high c-section rates. We also need better ways of educating women and doctors so that there is not so much ignorance about and fear surrounding natural childbirth.

  10. As a woman who has had a c-section after a failed (at 41 weeks 4 days) induction, I am well aware of the downfalls of cesarean childbirth, and applaud ACOG for coming out and issuing a statement, of the what ought to be obvious but unfortunately for both many women and obstetricians has not been, that spontaneous vaginal birth is the ideal end to pregnancy for both mother and baby. Knowing that ACOG’s position is that VBACs are a viable option for most women with a prior cesarean, I hope that this will encourage more OBs and hospitals to offer and support VBACs since, I believe, the most common reason for non-medically indicated elective c-sections are a prior c-section. Imagine how much better US c-section rates would be if all women eligible for a VBAC were encouraged to plan a spontaneous vaginal delivery instead of a scheduled c-section.

  11. Why is this article focused on women as the cause of this trend toward inductions and cesareans? Doctors and the medical establishment have been behind this trend, and are the main cause of the US having the worst birth outcomes in the industrialized world. These doctors need to be held accountable for the harm they’re doing to their patients.

  12. Why don’t they advocate midwifery as main attendants in hospitals with OBGYN’s as back up for real emergencies? Oh, yea, I guess that would take away their business……

  13. Quick question: is there any way you would be willing to issue a statement against augmenting labor without medical inidication? I have heard far too many birth stories when the mom said labor was going great, she was progressing and was not needing drugs, then they hook her up to Pitocin to “speed things up”. And that is when a host of problems happen in her labor. Which is unfortunate, because as you well know, if the provider had left well enough alone, she would have had a successful vaginal birth without the added risks of epidurals, IV medcines and drips, or pushing on her back for being numb.

  14. Yes, yes, yes. Wait for Mother Nature-
    And yes, I agree, most of the aggressive “active management” philosophy, elective inductions for no clear medical indication, overuse of Pitocin, and climbing C-section rates have been spearheaded by doctors, not mothers! I’m happy that ACOG leadership wants to change this!

  15. I do agree with Jennifer Barron Fishman. I am studying to become a doula and I participate in a lot of advocacy work. If I had a dime for every time a provider did not follow the ACOG guidelines for suspected fetal macrosomia ALONE I would be writing this comment from a beautiful beach somewhere! Providers need to be held accountable for the ACOG guidelines on a multitude of topics. Many providers are not reading these guidelines or are willfully ignoring them!

  16. Thank you so much! As an advocate for informed birthing, I try and tell women the risks and benefits of the options available to them. Thank you for taking such a strong stand in support of the spontaneous onset of labor over elective inductions!

  17. Please be careful with the continued use of language that suggests all of these early inductions and cesareans are due to women suggesting them for convenience. Please recognize that Docs have been behind this trend more so then mothers.

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