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Post-term pregnancy
1 Introduction
2 Risks in post-term pregnancy
3 Prevention of post-term pregnancy
4 Routine induction of labor
4.1 Perinatal death
4.2 Perinatal morbidity
4.3 Effects on the mother
5 Surveillance
6 Conclusions
1 Introduction
The reported frequency of post-term pregnancy (defined as pregnancy
lasting 42 completed weeks or more), varies from 4 to 14%, depending
on the nature of the population surveyed, the criteria used for assess-
ment of gestational age, and the proportion of women who undergo
elective delivery. The more accurate determination of gestational age
made possible by routine early pregnancy ultrasound reduces the
number of women who receive induction of labor for apparently post-
term pregnancy.
Contradictory findings and conclusions about the risks associated
with post-term pregnancy have led to opposing views on the most
effective form of care. A variety of policies for care of a woman with a
post-term pregnancy have evolved, ranging from routine induction of
labor at or around 40 weeks, 41 weeks, or 42 weeks gestation, through
selective induction of labor based on abnormalities detected by ante-
natal fetal surveillance, to an intention to await spontaneous labor.
Semantic problems have also contributed to the confusion in under-
standing of post-term pregnancy. The words post-term, prolonged,
post-dates, and post-mature are all used as synonyms but are laden
with different evaluative overtones. The name post-maturity has also
been given to a clinical syndrome in the infant with a hierarchy of
features ranging from loss of subcutaneous fat and dry cracked skin,
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SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000
through meconium staining and birth asphyxia, to respiratory distress,
convulsions, and fetal death. Confusion is bound to arise when a
clearly pathological syndrome is described by a word that is used
as well to make a simple statement about the chronological duration
of a pregnancy.
2 Risks in post-term pregnancy
Post-term pregnancy is associated with an increase in perinatal
mortality. Part of this increase is due to congenital malformations,
which are more frequent among post-term births than among births
at term. The other main cause of death is asphyxia.
The risk of perinatal death with post-term pregnancy increases with
the onset of labor. It occurs mainly during the intrapartum and
neonatal period, rather than during the pregnancy. Meconium-stained
amniotic fluid is a common feature among the intrapartum and
asphyxial neonatal deaths.
The incidence of early neonatal seizures, a marker of perinatal
asphyxia, is between two and five times higher in infants born after
41 weeks.
3 Prevention of post-term pregnancy
Stripping or sweeping of membranes (digital separation of the fetal
membranes from the lower pole of the uterus) in pregnancies at or
beyond term reduces both the incidence of formal induction of labor
and the frequency of the pregnancy continuing beyond 42 weeks. It
does not appear to have any effect on the mode of delivery or on the
risk of infection. Women have reported increased discomfort during
vaginal examination with sweeping, as well as other side effects of
bleeding and irregular contractions (see Chapter 40).
Advice advocating breast stimulation for women from 39 weeks until
the onset of labor has been compared with avoiding breast stimulation
in two small trials. One of these suggested a decrease in the number of
women who remained undelivered at 42 weeks, the other showed no
difference. Neither trial showed a difference in any other outcome. For
the present, breast and nipple stimulation cannot be recommended to
prevent post-term pregnancy. It should not be implemented without
further trials to assess the efficacy and acceptability to women.
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4 Routine induction of labor
Obstetricians have, for many years, expressed irreconcilably different
opinions on the role of induction of labor for post-term pregnancy.
The results of even large observational studies shed little light on the
question, because of inherent selection biases and the influence of both
duration of pregnancy and other aspects of care on outcome. The best
evidence supporting a policy of routine induction at 41 weeks or
beyond, versus a selective induction of labor, comes from randomized
trials. Fortunately, the results of a number of trials are now available.
Some trials have examined the effects of induction at or about
40 weeks, other trials have dealt with induction during or after the 41st
week.
4.1 Perinatal death
A policy of routine induction of labor reduces the risk of perinatal
death in normally formed babies. This is due to a reduction in peri-
natal mortality in pregnancies with induced labor after 41 weeks.
Although none of the trials individually was large enough to show a
statistically significant difference, the combined results of the 19
randomized trials that have assessed this outcome show a clear picture.
There was one such death among more than 4000 women allocated to
elective delivery, compared to nine among the similar number of
women in the surveillance arm of the trials; that is, one perinatal death
was prevented for each 500 inductions performed. This difference is
both clinically important and statistically significant. There is no
evidence of a beneficial effect of induction at less than 41 completed
weeks gestation.
4.2 Perinatal morbidity
Routine induction of labor reduces the risk of meconium-stained fluid
but the risk of meconium-aspiration syndrome and neonatal seizures
is not affected. No consistent effect of elective induction on the inci-
dence of neonatal jaundice has been demonstrated in the available
trials. There is no evidence that routine induction of labor influences
the rate of fetal heart-rate abnormalities during labor.
During the 1970s, there were several reports of an association
between elective induction of labor and unintended preterm birth,
followed by respiratory distress and other neonatal morbidity. By the
1980s, this had become less of a problem, because of greater awareness
of the dangers of elective induction of labor without firm grounds for
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being certain about the duration of gestation. No cases of iatrogenic
respiratory distress syndrome are reported in the randomized trials
of routine induction of labor, but it must be realized that well-
documented fetal maturity was an entry criteria for most of them.
4.3 Effects on the mother
In the one trial that assessed maternal satisfaction, this was not found
to be affected by induction of labor. Policies of active induction of labor
do not show any effect on the use of opiate or epidural analgesia.
Routine induction of labor is not associated with an increased use of
cesarean birth; indeed, the trials of induction after 41 weeks show a
small, but statistically significant decrease in the frequency of cesarean
section for women in whom labor is induced. Subgroup analysis
shows this to be true regardless of parity, state of the cervix, method
of induction or overall cesarean section rates in the trials. Subgroup
analyses also show a significant decrease in the use of cesarean section
for primigravid women in whom labor is induced, when prosta-
glandins are used for induction, and when the overall cesarean section
rates in the trial was 10% or more. This challenges a widely held belief
that there is an inherent association between induction post-term and
an increased risk of cesarean section.
5 Surveillance
In all randomized trials of routine induction of labor at 41+ weeks,
some form of fetal surveillance was used in the conservatively managed
arm of the trial. This surveillance usually involved consultations
at 23-day intervals after 41+ weeks, and varied from the mildly
intrusive use of ultrasound or cardiotocography, to the highly invasive
procedures of amnioscopy or amniocentesis. There is some evidence
that these tests can detect pregnancies in which there is something
wrong, but less evidence that their use improves outcome, or can elim-
inate the additional risk of post-term pregnancy. The only controlled
trial shows no advantages of complex fetal monitoring with comput-
erized cardiotocography, amniotic fluid index, assessment of fetal
breathing tone, and gross body movements over simple monitoring
with standard cardiotocography and ultrasound measurement using
maximum amniotic fluid pool depth.
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6 Conclusions
Post-term pregnancy, in most cases, probably represents a variant of
normal, and is associated with a good outcome, regardless of the form
of care given. In a minority of cases there is an increased risk of peri-
natal death and early neonatal convulsions.
Where reliable early pregnancy ultrasound is available at an accept-
able cost this should be offered routinely to confirm expected date of
delivery and avoid unnecessary induction of labor for a mistaken diag-
nosis of post-term pregnancy.
A policy of induction of labor after 41+ weeks gestation slightly
reduces the risk of perinatal death, in the range of one death saved for
each 500 inductions. It also reduces the rate of meconium staining of
the amniotic fluid, and is not associated with any major disadvantage.
Provided that appropriate induction methods are used, there is a small
reduction in the risk of cesarean section for women with a post-term
pregnancy.
Induction of labor before 41 weeks gestation is not associated with
any advantage apart from a small reduction in meconium staining of
the amniotic fluid. The reduction in perinatal death associated with
induction of labor appears to be confined to pregnancies of 41+ weeks
duration. A policy of routine induction at 4041 weeks in normal preg-
nancies cannot be justified in the light of this evidence from controlled
trials, and is unacceptable to many mothers.
Obstetricians, midwives, and women should be aware of the poor
quality of the evidence available to support the use of all methods of
fetal surveillance commonly offered to women with prolonged preg-
nancies. The best policy is to provide women with the most accurate
information available, including the small reduction in risk in perinatal
mortality with induction. Once the duration of pregnancy has with
certainty attained 41 completed weeks, women who choose to be
induced should be offered induction of labor by the best available
method.
Sources
Effective care in pregnancy and childbirth
Bakketeig, L.S. and Bergsjo, P., Post-term pregnancy: magnitude of the
problem.
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Crowley, P. Post-term pregnancy: induction or surveillance?
Cochrane Library
Alfirevic, Z. and Neilson, J.P., Biophysical profile for fetal assessment
in high risk pregnancies.
Boulvain, M. and Irion, O., Stripping/sweeping the membranes for
inducing labour or preventing post-term pregnancy.
Chambers, H.M. and Chan, F.Y., Support for women/families after
perinatal death.
Crowley, P., Interventions for prevention or improving the outcome of
delivery at or beyond term.
Neilson, J.P., Ultrasound for fetal assessment in early pregnancy.
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