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Overdue Pregnancy

Posted by on Oct. 21, 2008 at 3:09 AM
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Postdates Pregnancies

Postdates, by themselves, are not associated with poor outcomes. A pregnancy that continues long after the due date or in conjunction with poor fetal growth or developmental abnormalities has an increased risk of stillbirth. If growth restriction and birth defects are not present, no statistical increase in risk is seen until a pregnancy reaches 42 weeks and no significant risk exists until past 43 weeks. The primary "evidence" of a sharp rise in stillbirth after 40 weeks—often misquoted as "double at 42 weeks and triple at 43 weeks"—seems to come from one study based on data collected in 1958.(1)

The first question one should ask is whether neonatal mortality statistics from the 1950s should be compared to modern statistics, since labor anesthetics and forceps rates were very different. Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks. Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten times the modern mortality rate. Either modern delivery methods are vastly different or something is wrong with the data collection. This study should be updated by research conducted at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1000).(2)

It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that in less than 10% of births at 43 weeks do babies suffer from postmaturity syndrome (more than 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks must be compared to the risks of interventions. Induction is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.

Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800 postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering "on time" (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56/1000 in the postterm and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery and low Apgar were actually lower in the postdate group than in the on-time group.(3)

When a group of researchers conducted a case-matched review of nearly 300 postdate pregnancies, they concluded that the increased rate of obstetric and neonatal interventions "does not appear to be a result of underlying pathology associated with postterm pregnancy." They suggest that "a lower threshold for clinical intervention in pregnancies perceived to be 'at risk' may be a significant contributing factor." In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy!(4)

— Gail Hart, excerpted from "A Timely Birth," Midwifery Today






Summary - Who Should Further Examine Their Due Dates?

If this is your first pregnancy, then your pregnancy will quite likely be longer. Usually, the first-time mom averages 8 days beyond her 40-week due date, if she is white and a private-care patient. (Women of color tend to have slightly shorter pregnancies, as do women not under private-insurance care, for whatever reason.) Your doctor will probably want to keep the traditional 40-week-from-LMP dating rather than change the date, but should be more flexible about not pressuring you into interventions before 42 weeks, assuming all is otherwise well. It is quite NORMAL for a first-time mom to go at least a week 'overdue' and pressure for interventions should probably not begin during that time! Try and sound out your health provider about when they think interventions should start to be considered; if they sound very interventionist you may wish to consider switching to a different care provider, depending on your philosophy. DON'T WAIT till you are 40 weeks along to consider the issue!

If your cycles are longer than 28 days, then your pregnancy may be longer. You may need to add another week or two onto your totals. Some doctors are quite good about taking this into account, but unless you can document that you KNOW when you ovulate or when you conceived, many doctors will still arbitrarily set your date according to the 28-day cycle, possibly setting you up for early interventions, a difficult labor and perhaps even a C-section (worst-case scenario). It is in your best interest to dialogue with your physician about this concern; you may be able to come up with a compromise date or use ultrasound to confirm dating. However, if your physician seem overly rigid in dating, it may be time to seek an alternate provider. Charting before future pregnancies is an excellent idea for you to consider.

If your cycle is quite irregular, you may have great difficulty dating your pregnancy. If you have records showing when you ovulate (either by charting or by ovulation predictor kits), then these can be used to help determine a more accurate due date. If you do not have any idea of when you typically ovulate or if it varies significantly from month to month, then your doctor will probably need to use multiple ultrasounds during the pregnancy to date your pregnancy via measurements of the fetus. These are most accurate before about 20 weeks or so. You will also probably need more testing at term to confirm whether baby is doing OK, due to the possibility that dating may be off. If you are not already pregnant, it is an excellent idea to start charting your temperature and mucus to avoid this difficult problem. If you are already pregnant, you will need to rely on your doctor's expertise and ultrasound testing to help you set a reliable due date.





How DARE Mother Nature question SCIENCE! ~Mike Tymeson

The impossible is often the untried. ~Jim Goodwin

Women's bodies have their own wisdom, and a system of birth refined over 100,000 generations is not so easily overpowered. ~Sarah Buckley

by on Oct. 21, 2008 at 3:09 AM
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