PROLONGED PREGNANCY

by D E Tucker MRCOG

How long pregnancy lasts varies somewhat between women. The due date toward which you have been working is based on pregnancy lasting 40 weeks or 280 days from the date of the last menstrual period. Ovulation will have taken place roughly 2 weeks after this, so in effect pregnancy is about 38 weeks long. This is just an average, and it is considered normal to deliver anywhere between 37 weeks and 42 weeks from LMP.

How accurate is dating by LMP and scan?

When your dates are calculated from the LMP, this presumes that fertilisation occurs 2 weeks later. In many women, an ultrasound scan may shift their expected date of delivery (EDD), which comes as a surprise. No-one doubts that you know when your last period was. What may have happened is that in the particular cycle that you conceived, you ovulated later (or earlier) than usual, which is not at all uncommon. Sometimes the difference comes when a bleed which was thought to be the last period was in fact some bleeding in early pregnancy and you are one month further on than initially expected.

Pregnancy length when dated by LMP has a median length of 281 days, and by scan 278 days. If we look at how many women end up going 2 weeks over their due date, it is 9.5% according to dating by LMP but only 1.5% when dated by scan. This suggests that the dating of pregnancy by LMP tends to overestimate the gestation. Therefore if scan information is available, it is preferable to use this for dating a pregnancy (presuming it was carried out during the first half of pregnancy, when dating is most accurate).

The above information is taken from a study which reviewed the computerised database of about 25,000 women delivering at Queen's Medical Centre, Nottingham between 1988 and 1995.

Why do we want to induce labour?

Many studies have been done looking at the outcome of pregnancies when the baby delivered at various gestations. After 42-43 weeks, there seems to be a consensus that there is more chance of problems for the baby. One of the indicators of how well a population's babies do is perinatal mortality. This is the ratio of stillbirths and early neonatal deaths per total livebirths and stillbirths. It is expressed 'per 1000 births'. In the UK the overall perinatal mortality rate (PNMR) is about 8 per 1000. Considering infants weighing 1.5-2.0 kg (3lb 4oz - 4lb 7oz) the PNMR of this group is about 75 per 1000.

After 42 weeks the PNMR doubles and after 43 weeks it has tripled. Many studies have looked into how we can monitor women after this time to try & pick out those that really do warrant induction, leaving the others to labour naturally. This has included surveillance techniques such as: kick charts, fetal heart monitoring, ultrasound scans to check for liquor volume, and 'doppler' assessment of blood flow in the cord. In summary none of these is perfect, and even with intensive monitoring, such as a scan at 42 weeks, then twice weekly fetal heart monitoring, 1 baby in 1000 will die before it is born. The underlying problem here is that the placenta starts to show signs of 'ageing' as pregnancy progresses, and eventually doesn't work as well as it did previously.

These are the reasons why, in general, we recommend induction of labour around 42 weeks. Inducing labour before 41 weeks can lead to problems in labour. The cervix may not be ready to dilate and earlier induction does carry an increased risk of caesarean section for slow labour or 'failed' induction. After 41 weeks it is unlikely that induction of labour will alter the final mode of delivery.

What are my chances of going into labour naturally after 40 weeks?

Actually, very good! The above-mentioned study in Nottingham found that of women at 40 weeks, 65% labour spontaneously within the next week. Of those at 10 days over their dates, 60% will enter spontaneous labour within the next 3 days.

So it is worth trying to get induction as close as possible to 42 weeks, giving you every chance to labour spontaneously. Most Obstetricians would not find this an unreasonable request, if you find yourself in the antenatal clinic at 41 weeks!