Around weeks 34 to 36 of pregnancy, many of my patients begin to suffer from an ailment that health care providers affectionately term “TOP,” or “tired of pregnancy.” At this point the novelty and excitement starts to wear off, and the aches and pains begin to become overwhelming for many pregnant women.
TOP continues to get worse for some women as the weeks progress. They are anxious to meet the baby and ready to be done with swollen feet, backaches, and the need to urinate every 2 hours. These patients and their families often start asking when we will decide that enough is enough and just induce labor.
Our practice has a fairly strict policy against elective labor induction before 39 weeks of pregnancy. At 39 weeks, if the cervix has a favorable Bishop score — a measurement of cervical position, effacement, dilatation and consistency — we can begin to discuss induction, but true elective labor induction is not permitted until 41 weeks.
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This rule is based on evidence that shows an increased risk for neonatal complications in babies born before 39 weeks gestation. There is also an increased chance of cesarean delivery with a Bishop score of less than six.
Medical complications of pregnancy sometimes necessitate induction of labor earlier during the pregnancy, but the risks and benefits of continuing a pregnancy are always considered in these cases.
A pregnancy is at term at 37 weeks gestation, but even some babies born between 37 and 39 weeks have some initial difficulty breathing on their own due to lung immaturity. These babies often require NICU care for a few days to a few weeks.
Pregnancy is not considered post-dates until 42 weeks gestation. Many women, particularly those who suffer from TOP, are shocked that we would allow them to continue past their due date. Truthfully, only a small percentage of women give birth on their due date.
It is very difficult to convince a heavily pregnant and uncomfortable woman that inducing labor could lead to an unnecessary cesarean section or a NICU admission for her baby. However, the more health care providers intervene unnecessarily, the more complications tend to arise.
Interventions lead to more interventions, but the client suffering from TOP often cannot see beyond the immediate desire to be done with pregnancy. The pregnancy aches and pains are real to her at the moment, but the pain from cesarean section or stress from having a sick newborn are vague unknowns.
It is up to the provider to set firm guidelines for elective induction of labor. Discussing comfort measures during the final weeks of pregnancy and suggesting some natural ways to stimulate labor, such as sex, nipple stimulation, or acupuncture can be helpful to the TOP client. In normal healthy pregnancies, it is best to let the baby decide when it is time to arrive.
