Why is induction recommended over age 35?

What is induction?

Induction is using medical means to start a labor that hasn’t started on its own. (Learn more about methods of medical induction.)

Induction may be recommended if: the baby is not growing well or thriving in utero, the parent has an illness that is worsening (such as diabetes or hypertension), the baby is overdue, or the bag of water broke and labor hasn’t started on its own. There is also a category called elective induction, which is being induced for non-medical reasons, such as wanting to control the timing of the birth or being tired of being pregnant.

As with all medical interventions, induction has benefits and risks. If there is a clear medical indication that delivering the baby sooner rather than later would have more benefits than the risks of induction, then induction is recommended.

How Common is Induction

Induction rates rose steadily from 1990 to 2010 ((source for chart), then somewhat plateaued, following some active campaigns to reduce elective induction, such as AWHONN’s “Don’t Rush Me – Go the Full 40” about the physiologic benefits of full-term pregnancy, and an editorial in American Family Physician about stopping elective induction before 39 weeks to reduce unintended harms to babies not yet ready for birth.

In 2014, ACOG’s recommendation was to induce at 41 weeks.

That changed after the results of the ARRIVE trial were published in 2018. The ARRIVE trial was considered a high quality randomized controlled clinical study (although ACNM did caution against over-generalizing the results, this article addresses methodology concerns, and this infographic addresses how the results might not apply to all people.)

The results of that trial (and other trials) were that elective induction decreased the risk of cesarean. (Rates were 18.6% in the induction group versus 22.2% in those assigned to the wait for labor to begin group.) The induction group was also less likely to have gestational hypertension / preeclampsia (9% vs 14%).

ACOG (the American College of Obstetrics and Gynecology) issued guidance in response, and a joint statement from ACOG and SMFM (Society for Maternal Fetal Medicine) said ““ACOG and SMFM have … determined that it is reasonable for obstetric care providers to offer an induction of labor to … Women who are planning their first delivery, are healthy and have no medical or obstetrical complications… who are 39 weeks pregnant and had an ultrasound performed early in the pregnancy to confirm dating.”

In other words, elective induction at 39 weeks is back on the table as an option after 2018. In 2016, 24.5% of US births were induced. In 2021, 32% were.

There was not universal agreement with this recommendation: WHO says there’s insufficient evidence to recommend elective induction before 41 weeks and NICE says induction should be offered at 41 weeks. SOGC (Society of Obstetricians and Gynaecologists of Canada) said we shouldn’t recommend induction just to reduce cesarean risk, ACNM (American College of Nurse Midwives) said there are benefits of spontaneous labor and risks of induction and other effective ways to reduce the risk of cesarean (e.g. doulas, midwifery care, movement during labor)

Is induction recommended for parents over age 35?

In a 2022 consensus statement on Pregnancy after Age 35, ACOG made a more explicit move to recommend induction for older moms: “We recommend proceeding with delivery in well-dated pregnancies at 39 0/7–39 6/7 weeks of gestation for individuals with anticipated delivery at age 40 years or older due to increasing rates of neonatal morbidity and stillbirth beyond this gestational age.” A randomized trial of induction at 39 weeks for women over 35 also indicated no increased risk of cesarean and no short-term adverse effects on mothers or babies.

Stillbirth Risk

How high is the risk of stillbirth for mothers over age 35? How much higher is it if the pregnancy continues past 39 weeks?

This chart (source) compares the risk of stillbirth per 10,000 pregnancies during each week of pregnancy for pregnant people under age 35 vs. for people 35 years or older. It is clear that the risk does increase each week, and that it is much higher after age 35.

Weeks	<35 yrs	>35 years
39	3.9	5.0
40	6.8	10.0
41	8.5	15.4
42	28.2	32.5

[Note: if you’re a pregnant person reading this, I know that numbers like this can be frightening. Take a deep breath, and flip the numbers: even a rate like 32.5 per 10,000 means that 9,967 out of 10,000 will NOT have a stillbirth in week 42.]

Benefits and Risks of Induction

So, the research cited above indicates that inducing at week 39 may reduce the risk of stillbirth, possibly reduce the risk of cesarean, and can reduce the chance of hypertension or diabetes worsening.

What else does the research show us about the risks and benefits of induction? A Cochrane review, which mostly looked at induction at 41 weeks vs. continuing to the 42nd week, showed:

• fewer perinatal deaths / stillbirths
• better Apgar scores at birth, and fewer NICU admissions
• little to no difference for: perineal tears, postpartum hemorrhage, breastfeeding at discharge

But, induction is not innocuous. What are the risks or tradeoffs of induction?

• Medicalization: An induced birth is inherently more medicalized than waiting for labor to begin spontaneously – continuous fetal monitoring is required, IV fluids are common – these two factors can also reduce the birthing parent’s ability to move around and use natural coping techniques. Plus they may not be allowed to eat solid foods. ACNM summarizes this as “Based on US practices, induction may not be a desirable option for those persons who prioritize a… low-intervention birth experience.”
• Not waiting for baby to trigger labor: In the final weeks of pregnancy, babies are gaining immunities, gaining weight, increasing their brain development and maturing their lungs. When the baby’s lungs are mature, that triggers hormones that trigger labor. If we induce labor before that happens, there is a chance that baby is not as ready for birth as they would be if labor started spontaneously. At 39 weeks, many babies are totally ready to go, but not all.
• Longer labor / hospital stay: In late pregnancy, prostaglandins cause the cervix to ripen and thin. If we jumpstart labor, the body may not have made these preparations for labor. So, with an induction, it can take a while to get labor started. It might take 12 – 24 hours, or longer if cervical ripening is needed. If an induction takes too long, cesarean may be recommended.
• Changes to the hormonal dance of labor. Typically, in late pregnancy, the uterus becomes more sensitive to the oxytocin hormone which causes labor contractions. During labor, as the cervix stretches, pain receptors in your brain release endorphins, a natural painkiller more effective than morphine. When labor is induced with Pitocin (synthetic oxytocin), your body does not produce as much natural oxytocin and does not produce as much endorphins, so you miss out on that natural pain relief. (Learn more about the hormonal differences.)
• More Pain? I have not been able to find any research comparing average pain levels in an induced labor versus a spontaneous labor. (Nor much on maternal satisfaction, although it seems to me that both of these things are important factors that we should be researching.) Anecdotally, many people seem to experience more pain in an induced labor. That may be partially due to the fact that a natural labor builds intensity gradually, allowing you to adapt and find coping techniques thar work for you. With a Pitocin induced labor you jump straight into long, strong contractions. (3 – 4 contractions in ten minutes, each lasting 40 – 60 seconds.)
• Induction can cause variations in the baby’s heart rate, which can lead to additional interventions.

Questions to Ask

If your care provider has offered induction at 39 weeks, here are some questions you can ask yourself or them to decide if it’s right for you:

• Are there other ways to reduce risk of stillbirth or monitor for other problems with my baby?
  • Learn about fetal movement tracking – paying attention to your baby’s kicks can reassure you that all is well.
  • Ask about tests to monitor baby’s well-being, such as the non-stress test, biophysical profile
• Are there other ways to reduce the chance of cesarean birth? There are: having continuous labor support (especially from a doula), upright positions and movement during labor and birth, choosing a midwife rather than an OB as your care provider and waiting until 6 cm dilation before being admitted to the hospital are just a few. (Learn more.)
• Are there non-medical ways to get labor started? Possibly sexual intercourse, definitely breast / nipple stimulation, possibly acupuncture, herbs, or castor oil. If the need to start labor is urgent, your care provider may tell you these aren’t effective enough. But, if you have some time, they may say these are options you could try.
• How likely is induction to be successful? If you’re almost ready to go into labor on your own, induction will be faster and more effective than if you’re not. So, learn about the Bishop score which measures ripening and effacement of the cervix and ask your caregiver what your score is. Starting Pitocin only when you have a Bishop score of 4 increases the chance of cesarean. Waiting for your cervix to get ready naturally, or using cervical ripening methods to get your Bishop score up to 8 or higher (if it’s your first baby, 6 or higher if you’ve given birth before) will increase the chance of a successful induction. (Learn more about this and other factors here.)

How to have the best possible induction?

If you do decide that induction is the best answer for you, here’s how to increase your satisfaction:

• Ask your care provider what method(s) will be used, and learn more about them.
• Be prepared for a long process. Pack some entertainment options and plenty of patience. Consider having an extra support person so they can swap off or take breaks.
• Eat before your induction begins, as you may not be able to eat after it begins.
• Create an environment that is as calm and soothing as possible: perhaps dim light, music playing, favorite items to wear or look at or hold.
• Try to be as mobile as possible (this helps baby rotate and descend which helps labor to progress.) For example, try sitting on a birth ball or in a rocking chair rather than lying in bed.

Learn more about interventions in maternity care and making informed choices in episode 8 of the Transition to Parenthood Podcast, or by reading Pregnancy, Childbirth, and the Newborn: The Complete Guide.

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Stages of Labor and the 3R’s

An overview of the stages of labor and comfort techniques for the first stage of labor: Early labor, as the cervix moves from 0 to 5 cm dilated is the longest phase of labor, but also the least intense. The focus is on Relaxation, so techniques like slow deep breathing visualization, massages and baths all help. In active labor as the cervix goes from 5 to 8 cm, contractions are longer, stronger, and closer together and take more work to cope with. The focus is on Rhythm, so rhythmic breathing helps, as does movement such as walking, slow dancing, or rocking on a birth ball or in a rocking chair. In transition, as the cervix dilates to 10 cm, contractions are coming hard and fast and it can be very overwhelming. So, the focus is Ritual – find something that works to reduce pain, and just keep doing it on every contraction to help feel like there’s some control over the process. [Transcript of podcast episode 3 at: https://transitiontoparenthood.wordpress.com/for-parents/labor-and-birth/]

Medical Mindset Tool

When making choices about medical care, are you a maximalist or a minimalist? A maximalist may use lots of tools to prevent and treat problems. A minimalist may try to use as few tools as possible, letting things run their natural course. What kinds of medical tools do you use? Natural remedies and self-help techniques or medicine and technology? A maximalist naturalist might prepare for birth by attending prenatal yoga, drinking raspberry leaf tea, and frequent love-making to get her oxytocin flowing. A minimalist technologist might choose a hospital birth with an OB, but ask for as few interventions as possible.

Helping your students or clients understand their medical mindset may help them in choosing care providers and birth places, and may also help them explain their decision making in labor to their partners and care givers. There are a few tools you can use to learn more and help your clients to understand this idea.

Jerome Groopman has written a book on Your Medical Mind: How to Decide What is Right for You. (He also wrote How Doctors Think and some other great books.) You can read an article which summarizes it here: http://news.harvard.edu/gazette/story/2012/02/%E2%80%98your-medical-mind%E2%80%99-explored/ or watch a video here that presents the idea to medical professionals: http://practicalbioethics.tv/2012/06/11/jerome-groopman-pamela-hartzband/when-experts-disagree.html

Kim James and Laurie Levy discuss this in their childbirth classes and with doula clients. They designed a worksheet you can find here: http://kimjames.net/Data/Sites/3/groopmanspectrumsforlamaze2012landscape9.24.12.pdf

I liked their idea, but found the worksheet complicated and a little dense on information for my client population, so I made a simplified version of the worksheet. Click here for the PDF. If I were using this in a class, I might give one copy to the pregnant parent, and one to the support person to fill out separately, then compare and discuss.

[Added on 7/28/15: a 2-page version of the handout that looks at more factors that affect decision-making. Find it here.]

Research Summary on Effectiveness of Non-Drug Coping Techniques

There have been several literature reviews of available research on the available non-pharmacological techniques for coping with labor pain. Each of these reviews acknowledges the limitations of the research that they compile: primarily the studies are small sample sizes, and are not properly randomized control trials. (Women are typically allowed to choose which coping techniques to use with their labor.) So, all conclusions come with the caveat that “more research is needed.”

This chart summarizes those reviews. (Note: the birth ball results are based on a single study rather than a review.) Pain coping techniques are compared to “usual care.”

The chart compares the following factors that might be desired outcomes coping measures: less pain intensity, less likelihood that the laboring mother will turn to pain medications (unless that was her goal), higher satisfaction with pain relief, shorter labor, higher chance of spontaneous vaginal delivery (vs. instrumental delivery or cesarean), and less use of Pitocin to augment a slow labor.

Source	Less pain?	Less pain meds?	More satisfaction	Shorter labor	Spontan. vaginal	Less pitocin
Acupressure	yes *
Acupuncture		yes				yes
Acupuncture	yes	yes *	yes *		yes *
Aromatherapy	NSD
Aromatherapy	NSD	NSD		NSD	NSD
Birth Ball	yes *			NSD
Continuous Support		yes	yes	yes	yes	yes
Epidural & Pain Meds	yes	N/A	yes	no	no	no
Hypnosis	yes *	NSD	NSD	yes *	NSD
Hypnosis		yes	yes		yes	yes
Immersion in Water		yes			NSD
Massage	yes
Music / audio	NSD	NSD			NSD
Positions & Movement		yes		yes	yes
Relaxation	yes		yes		yes
Sterile Water Inj.	yes				NSD
Sterile Water Inj.	yes				yes
TENS	yes *				NSD
Yoga	yes		yes	yes

* means limited data; NSD means there may have been a difference, but it wasn’t statistically significant

(Note: In a 2014 review by Chaillet, et al, these techniques were pooled into 3 categories, which helped to increase the statistical significance of the findings. Learn more. Also check out more articles about coping with labor pain.)

New Ways to Talk about Labor Pain V: Research on Effectiveness of 3 Mechanisms

In 2012, a new Cochrane review of pain management for women in labor was released. Although it had positive things to say about the non-pharmacological techniques, it also said that research into their efficacy was unclear due to limited evidence…

“WHAT WORKS: Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. … WHAT MAY WORK: There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. …INSUFFICIENT EVIDENCE: There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo… Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.”

A 2014 review by Chaillet, et al (Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801) is a significant addition to the research about non-drug approaches.

Chaillet, et al pooled techniques into three categories. If you’ve read my posts from the past few days, you’ll be familiar with these concepts. Also, see the chart at the top of this post for more information.

• Gate Control mechanism = apply non-painful stimuli on the painful area. Methods included massage, bath, positions, walking, and birth ball. The theory is that this will block some of the intensity of the pain.
• Diffuse Noxious Inhibitory Control (counter-irritant) = create pain or discomfort anywhere on the body. Methods included acupressure, acupuncture, TENS, sterile water injections. The theory is that this discomfort causes the body to release endorphins which reduce pain intensity. (Birth combs also fit in this category although they were not included in the research.)
• Central Nervous System Control (cognitive/support techniques). Methods included  attention focus, education, relaxation, hypnosis, continuous labor support.

By pooling studies together, you get larger sample sizes which increases the statistical significance of the results. Note, all techniques were compared to “usual care” which might have ranged broadly depending on the preparation of the laboring family and the support they were given by caregivers. It is possible that some in the “usual care” groups were also using a variety of coping techniques. So, the true difference between people who use some coping techniques and those who use none may be even greater than these results indicate.

The results of this review were:

• Gate Control mechanism. Those who used these techniques had lower pain intensity (as predicted), were less likely to use epidural, and needed less Pitocin.
• Diffuse Noxious Inhibitory Control (counter-irritant). Those who used these techniques had lower pain intensity, were less likely to use epidural, and more satisfied with birth. (Two trials found women felt safer, more relaxed, and more in control.)
• Central Nervous System Control (cognitive/support techniques) Those who used these techniques were less likely to use epidural, Pitocin, less likely to need instrumental delivery or cesarean, and had a higher satisfaction with birth. The CNSC did not reduce the intensity of the pain so much as they reduced the unpleasantness of the pain. (See more on intensity and unpleasantness here.) So, although labor still hurt a lot, women felt better able to cope – more like they were working with labor pain.

The most effective technique overall was continuous labor support, such as that offered by a doula. The effectiveness of support was already demonstrated in a Cochrane review by Hodnett et al, (Hodnett E, Gates S, et al.. Continuous support for women during in childbirth. Cochrane Database Syst Rev. 2013. CD003766)

The best results in pain coping were from combining the labor support and education which reduce the unpleasantness of pain with gate control or DNIC techniques that reduce the intensity of the pain.

Recommended: be sure to also check out Henci Goer’s discussion of this study on Science and Sensibility.

New Ways to Talk about Labor Pain, IV: Bonapace Method

The Bonapace Method for reducing pain during childbirth can be used instead of, or in conjunction with, a traditional childbirth education class.

This method does not just teach pain coping techniques, but also teaches about the role of labor pain, how pain messages are transmitted in the body, and three mechanisms that help moderate the perception of pain. Those mechanisms are:

Cognitive structuring / central nervous system control (CNSC). Understanding labor pain and progression – what’s happening and why – enhances a sense of self-control. Focusing on something positive (like a self-affirmation) helps with labor pain.

Gate ControlTheory. Non-painful stimulation blocks part of the pain message transmitted by the spinal cord. Note: Bonapace interprets this differently than I have see elsewhere, saying specifically that it is pleasant sensation applied where the pain is located. The description on their website says “To activate this mechanism during childbirth, the fingers must be run lightly over the painful area, particularly during contractions.”

Diffuse Noxious Inhibitory Control (DNIC). (I call this counter-irritation) Creating a second pain elsewhere on the body (i.e. not where you’re already hurting). The brain wants to reduce the pain’s effect on the body as a whole, so releases endorphins to do so. But the sensations near the second pain are still felt because the body is assessing them. (So, under this theory, holding a birth comb tightly causes a release of endorphins which helps with the labor pain, but the user is still aware of the pressure points from the comb on their palm.) In the Bonapace method, sensitive points on the body (trigger areas) are massaged by the partner, causing pain.

In a journal article (“Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth”, J Pain Res 6: 653-661 at http://www.dovepress.com/articles.php?article_id=14256), Bonapace et al, compare the results of a “traditional childbirth training program” (TCTP) with the Bonapace method. Study participants chose which class to take from these options.

The TCTP was a 4 week class, with a total of 8 hours of class time, started around the 23rd week of pregnancy. It covered A&P of childbirth, exercises, stages of labor, variations, pain meds and newborn care. Relaxation, visualization, massage, and labor positions were not taught. Only breathing techniques were practiced.

The Bonapace class was 4 weeks, 8 hours, starting in the 30th week. The entire program was dedicated to pain management and partner participation. It covered 1) CNSC through breathing, relaxation, and cognitive understanding of labor pain and endorphins, 2) Gate control – non-painful stimuli such as walking and light back massage between contractions, and 3) DNIC where the partner did painful massage of acupuncture triggers points in the lower back, hands, and buttocks.

39 women participated in the full study. In labor, every 15 minutes, participants were asked to rate their pain on two scales: intensity and unpleasantness. (If pain medications were given, they stopped assessing pain after the medication. If that participant had pain scores for two phases of labor, they were kept in the study, if not, they were dropped.

Those who had learned the Bonapace method had an average of 45% less pain intensity and 47% less unpleasantness than those who had received the “traditional” childbirth education. No difference was found in the use of pain medication.

The reduction in intensity of pain was consistent for nulliparous and multiparous parents. On the “unpleasant” ratings, there was a larger reduction in scores for nulliparous than multiparous. This is likely due to anxiety… a nulliparous woman with no birth experience and no training / childbirth preparation is likely to be anxious about labor pain (and, of course, anxiety increases pain). With the TCTP, her anxiety may have been somewhat reduced and thus her pain unpleasantness would be reduced, but with the Bonapace method, her anxiety and thus unpleasantness were much more reduced.

This study indicates that being given information about the physiology of pain, and plenty of education in clear, simple techniques to manage it, has a significant impact on pain intensity and pain coping.

Prolonged Labor: New definitions

A 2010 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US, and a 2014 consensus statement from ACOG and Society for Maternal Fetal Medicine argue for a re-definition of what should be considered prolonged labor, and when intervention should happen.Here is a brief summary:

Phase	Definition	Friedman / standard practice	Consortium on Safe Labor / ACOG & SMFM
Latent	When mother perceives regular contractions	Prolonged if over 20 hr in nullips, and 14 in multips	A prolonged latent phase (e.g. over 20 hours) is not an indication for cesarean. If it is not treated, women may stop contracting or may eventually reach active labor. If treated with AROM and Pitocin, most will enter active labor.
Active	When rate of dilation significantly increases. Protracted = slow. Arrest = progress has stopped.	Protracted if < 1.2 cm/hr for nullips and < 1.5 for multips.	Typical dilation ranged from .5 cm/hr to .7 for nullips, and from .5 to 1.3 for multips. From 4-6 cm, dilation is slower than historically described. After 6 cm, progress speeds up. Protracted labor should not be diagnosed before 6 cm. After 6 cm, protracted labor is not an indication for cesarean as long as there is progress, even if it’s slow.
		Arrest if no change in 2 hours (after 4 cm and with adequate contractions)	Cesarean for arrest should only be for women who are beyond 6 cm with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity or, for those with inadequate contractions, at least 6 hours on Pitocin.
Second Stage	When cervix is fully dilated through delivery. (Note: some researchers argue we should define it as when the mother develops the urge to push)	Typical practice has been to limit nullips to three hours, and multips to two, even with epidural. (ACOG)	Parity, delayed pushing, use of epidural analgesia, mom’s BMI, birth weight, and OP position affect length of pushing. (e.g. pushing is one hour longer on average with epidural). No absolute maximum length of pushing has been defined. Arrest should not be diagnosed until after 3 hours pushing for a nullip, and 2 for multip – longer if she has an epidural or diagnosed malposition. In case of prolonged second stage or arrest of descent, vacuum, forceps, and manual rotation of the fetus should be considered prior to cesarean.

In an induced labor, latent phase may go 24 hours or longer. It should not be considered a “failed induction” until Pitocin has been administered for at least 12 – 18 hours after AROM.