When Birth Doesn’t Go as Planned

The Complex Reality of Induction, C-Sections, and Baby Safety

Dear readers,

I apologize in advance to my subscribers who want to read something inspiring about motherhood, some description of the various roles we play, and/or a discussion about all the factors that lead so many of us to burnout. This will be a different sort of post, however, because I need to vent.

Recently, I have been following Elena Bridgers’ popular Substack, “Motherhood Until Yesterday.” She typically provides an interesting perspective by assessing our current motherhood situations and issues in the context of our evolutionary history as mammals and hunter-gatherers. I enjoy reading her discussions on how we evolved into these, our most challenging modern times.

However, I found her recent series about births – home births, inductions of labor, and more, to be triggering for me both personally and professionally. For example, I felt so many different emotions reading her accounts of home births, hospital births gone wrong, birthing centers, fetal head size mismatch to maternal pelvic width, scheduled inductions, and C-section rates.

How can I explain my emotional reactions to you? Simply put, all the birthing situations she discussed over the past month were my life. As a mother of three, I had one premature baby born by C-section at 36 weeks (after premature labor onset at 25 weeks), one full term repeat C-section, and one large for gestational age baby (10 lbs 2 oz) at 40 years of age, clearly advanced maternal age. The middle child born full-term had prior lung maturity studies done at 38 weeks - because I wanted to be delivered, nothing more - and she was found to be immature! My high-risk OB sent me home, unhappy, and said to come back when I was 40 weeks or in labor.

Despite my personal complicated obstetrical history, the clinical cases that I have seen and cared for in my professional life (as a neonatologist of 34 years) have been far more complex than my own.

What the pregnant mother wants (you may know this as a “birth plan”) is important yet often neglects the circumstances of what is best or necessary for mother and her baby. Here are some examples that impressed me greatly over the years:

• The home birth in which the mom developed severe post-partum hemorrhage and had to be transferred to a hospital for blood transfusions.

• The mother who arranged to have a tub birth in a well-staffed, popular birthing center, yet her baby ended up 95 degrees and moribund (close to death) with cold stress.

• The mother whose specific birth plan required that “nothing-but-breastmilk” be given to her baby after birth, however born at 37 weeks gestation, her early-term baby developed severe hypoglycemia (low blood sugar) unresponsive to oral glucose and required IV dextrose in the NICU.

• The RN mother who convinced her OB (also her actual employer) to perform a repeat C-section at 38 weeks gestation, and subsequently her baby boy required NICU care for six weeks for the most severe case of respiratory distress syndrome (due to her infant’s prematurity) we had seen in a decade.

This latter case prompted our hospital to review elective inductions and elective C-sections prior to 39 weeks gestation in 2008, and to discover that, as a result, there had been seventy-five babies admitted to our NICU for respiratory distress in one year (a high number among our 8,000 total deliveries). Our data describing iatrogenic respiratory distress syndrome contributed to a ground swell of concern among neonatologists in the U.S. that many (actual) premature babies were being delivered electively prior to 39 weeks gestation (many for the convenience of the mother or her doctor).

The 39-week rule.

That was the year preceding ACOG’s adoption of the “39-week rule,” in 2009. That “rule” has come under great scrutiny since then with many obstetrical researchers studying its effects on neonatal morbidity (generally down), neonatal mortality (generally the same) and stillbirths (maybe increased slightly). The “rule” does not fit well for babies with intrauterine growth restriction (small for gestational age) who often must be delivered earlier.

In her recent article on elective induction at 39 weeks actually decreasing the C-section rate, Elena Bridgers sites the ARRIVE study published in 2018 which found that when 3,062 women with their first pregnancy were randomly assigned to be induced at 39 weeks, there was a lower 4.3% rate of fetal death or severe neonatal complication, and a lower 18.6% C-section rate. In that study, first time moms who were randomized to expectant management had a higher, 22% C-section rate, and their babies a higher 5.4% rate of fetal death or severe neonatal complication. Many thought that this study proved that elective induction at 39 weeks was safe and effective.

Based on this one randomized trial, Eleana Bridgers concluded that “if it’s your first birth, outcomes are actually slightly better if you induce at 39 weeks.” The ARRIVE study was conducted by the NICHD and 18 academic medical centers, which probably explains the very low C-section rates.

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A subsequent study published in 2019 compiled data from 6 large observational studies and found similarly a lower C-section rate of 26% and a low peripartum infection rate of 2.8% among 66,000 women induced at 39 weeks. The 584,000 women delivered with expectant management had a higher 29% C-section rate and a high peripartum infection rate of 5.2%. In the induction group, neonatal rates of respiratory morbidity and NICU admission were lower. Moreover, the perinatal mortality (death) rates were lower 0.04% (vs. 0.2%) in the induction group. These data are from non-academic centers, mostly private practices, so the higher 29% C-section rate is more typical of the U.S. in general.

Perusing Pub Med, the NLM and NIH database where all published biomedical and health literature are indexed, I found many other large studies and/or meta-analyses (studies of multiple large studies), looking at the “39-week rule” which found additional concerning outcomes.

The 39 week rule: neonatal and fetal outcomes.

The ARRIVE study that Elena wrote about is not the final answer. In 2016 a retrospective study of all U.S. births from 45 states and D.C, comparing time periods 2007-2009 to 2011-2013, it was determined that the 39-week rule did, in fact, decrease deliveries at 37 and 38 weeks gestation, and increased those at 39-40 weeks. However, the stillbirth rate increased from 0.110% to 0.1170% during those time periods.

In 2017, a study examining 55% of births in the U.S. (from 23 states) during the period 2010-2014 examined the effect of the 39-week rule on high-risk pregnancy deliveries. The new 39-week rule, as expected, decreased deliveries at 38 weeks gestation by 2.5% and increased those at 39 weeks gestation by 2.3% among low-risk pregnancies and had a similar effect among high-risk pregnancies. For the high-risk population, NICU admissions increased from 5.4 to 6.3% in 2014 and assisted ventilation rates declined from 3.8 to 2.9%. This study found no increase in the rate of stillbirth (0.23% in 2010 and 0.23% in 2014).

A large study from Australia published in 2023 examined 948,000 pregnancies and birth outcomes between 2000-2018 and sought to answer whether the 39-week rule affected rates of neonatal mortality and severe neonatal morbidity for babies born 37 to 39 weeks gestation. They found increased neonatal mortality and morbidity for intrauterine growth restricted (IUGR) fetuses (those with weight below the 10%ile and those below the 3%ile for growth). Rates of stillbirth increased with gestational age, with the highest rate observed in infants with birthweight below the 3%ile. Neonatal mortality was highest at the lowest centiles of growth, and at 37 weeks gestation, so for these groups the 39-week rule may not apply.

My review of medical literature reassured me that the picture of when and how to deliver the first-time pregnant mom is complex. Maternal complications happen; fetuses do not grow well for any number of reasons. Childbirth is a complex medical issue, one that requires an obstetrician and/or a certified nurse midwife to manage. It is not as simple as elective induction at 39 weeks is best.

The Pitt series highlights maternal wishes for a “free birth.”

I loved the finale of The Pitt’s second season since the pregnant woman who came in with preeclampsia progressing to eclampsia wanted a “free birth,” i.e. no medical care. But for the ED staff performing an emergency C-section, she and her baby would have died after she began having a prolonged seizure. The moral of that story – one that I have witnessed thousands of times in my clinical practice - is that what the mother wants is not always in the best interest of having a healthy baby.

Women do not get pregnant to be pregnant. They get pregnant to have a baby, and this is the problem with saying that mothers are entitled to a stress-free, perfect vaginal delivery. (I have never had one, but I have attended hundreds.) More often, however, I attended births that were planned to occur a certain, perfect way and some complication arose – either with the mother (hypertension, gestational diabetes, pre-eclampsia, abruption, chorioamnionitis, HEELP syndrome, etc.) or the baby – usually significant fetal distress.

The delivering physician or mid-wife is making decisions based on the welfare of both patients. The mother is a big girl - and the baby is helpless - in their ability to deal with these changing circumstances.

I am advocating for mothers to recognize the need to surrender to what their body needs and deal with a C-section or assisted vaginal delivery, if necessary. Moreover, I am advocating for pregnant women to think about the possibility of delivering a dead baby when they do not access proper medical care.

Five Key Takeaways

1. Childbirth is medically complex - not ideological

Labor and delivery decisions cannot be reduced to slogans about “natural birth,” avoiding interventions, or rigid birth plans. Obstetric care requires constant reassessment of risks to both mother and baby.

2. The “39-week rule” improved some outcomes but is not universally applicable

Delaying elective deliveries until 39 weeks reduced neonatal respiratory distress and NICU admissions in many healthy pregnancies, but newer studies suggest the rule may not fit high-risk pregnancies, especially fetuses with intrauterine growth restriction (IUGR).

3. The ARRIVE trial is influential - but not the final word

Oversimplified interpretations of the 2018 ARRIVE trial are incomplete - while induction at 39 weeks lowered C-section rates in that study, later observational research revealed more nuanced outcomes involving stillbirth risk, NICU admissions, and maternal complications.

4. Birth plans can conflict with medical realities

Rigid expectations about home birth, “nothing but breastmilk,” or avoiding intervention sometimes leads to severe complications for mothers and babies. A central argument is that flexibility and medical judgment are essential during labor.

5. The ultimate goal of pregnancy is a healthy mother and baby

Childbirth is not a performance or idealized experience - it is a high-stakes medical event. Sometimes interventions like induction, assisted delivery, or C-section are necessary to prevent tragedy.