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Are you past your delivery date?

Overdue pregnancyUma was very excited about the coming baby. It was her first pregnancy after all! She was eating healthy, exercising regularly, and was having a trouble free pregnancy. All was well. Then the due date came and went. But there was no sign of the baby. Close to 42 weeks and she still hadn't delivered. Now what?

Uma was having, what is technically called, post term pregnancy where a pregnancy lasts more than 42 weeks, that is, 294 days since the first day of the last menstrual period. Generally, women deliver between 37 and 42 weeks of pregnancy. But statistics show that only 5 percent of babies are delivered on the exact due date. And the reported post term pregnancy is anywhere between 3 to 12 percent.

Although you don't have to be too alarmed if you are past your delivery date, prolonged pregnancy does have certain risks for the baby and the mother.

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Post term pregnancy risk for the mother

  • Babies born past due date are usually bigger as they keep growing inside the mother thus causing perineal injury (injury to the tissue located between the vagina and the anus) to the mother. Common consequences of perineal injury are pain and incontinence (involuntary passing of urine), which affect the quality of life of healthy women, as well as negative emotional and psychological effects on overall well-being of the mother.
  • Similarly, sphincter injuries or tears of the anus because of the big baby. This can cause faecal incontinence (involuntary passing of stools), painful fissures and discomfort for years to the mother.
  • Foetal distress during labour is common in post term pregnancy, so C-section delivery is twice as likely.
  • Longer labours and operative delivery such as forceps or vacuum assisted birth is also common.
  • Risk for infection and wound complications, and post-partum (after birth) haemorrhage also increases in post term pregnancy.

Post term pregnancy risk for the baby

The baby might be born absolutely healthy in most cases, but in some cases

  • There are chances of still birth and infant death.
  • The foetus may stop gaining or even lose weight because the amniotic fluid decreases.
  • Nutrients and oxygen supply from the mother to the child through the placenta reduces (reduced placental perfusion) leading to placental insufficiency so the baby does not get adequate nourishment.
  • The amniotic fluid in the mother decreases with prolonged pregnancy (termed oligohydramnios) causing complications like compression of the umbilical cord, musculo-skeletal abnormalities (facial distortion, clubfoot, etc.), incomplete development of the lungs and growth restriction of the baby inside the uterus.
  • The newborn may be at risk for meconium aspiration (the yet-to-be-born baby may breath in meconium (the first fecal discharge that is sometimes passed while the baby is still in the womb) along with the amniotic fluid, resulting in breathing difficulty.
  • Low blood sugar can also occur because the baby has too little glucose-producing stores.
  • Prolonged pregnancy may cause neurological or developmental disturbance at around 5 years of age in about 13 per cent of post term children, according to a Swedish study. According to another Dutch study, it has been revealed that such children were prone to emotional and behavioural problems at both 18 and 36 months after birth.

Causes of post term pregnancy

Medical fraternity is not very sure why post term pregnancies occur. In most cases, it is attributed to miscalculation in the due date. Normally, the last menstrual period (LMP) is used to calculate the estimated due date (EDD). Inaccuracies occur in women who

  • Have irregular cycles, for example, a 35-day cycle instead of 28 days;
  • Use hormonal birth control; or
  • Experience first trimester bleeding.

However, ultrasonographic dating done early in pregnancy can improve the reliability of the EDD (estimated due date).

Another cause of post term pregnancy could be your genes. A Danish study published in the American Journal of Obstetrics & Gynecology suggested that 'genetic factors account for 23% to 30% of the liability to prolonged gestation' and it is the maternal but not paternal genetic factors that influenced the rate of post term pregnancies.

Research also indicates obesity to be one of the causes of post term pregnancy that progress beyond 41 or 42 weeks of gestation. 'Obese women have 69% higher adjusted odds of reaching 42 weeks' gestation, compared with women of normal pre-pregnancy BMI,' says Dr. Stotland from the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco.

Management of post term pregnancy

Once you have crossed the 39 week mark, your doctor will monitor you closely and recommend specific management for post-term pregnancy based on your overall health and medical history, your tolerance for specific medications or therapies, and your opinion, expectations or preferences.

Maternal and foetal tests will be performed to monitor for signs of problems. Some of these tests are:

  • Foetal movement counting to keep track of foetal kicks and movements. A change in the number or frequency may mean the foetus is under stress.
  • Non-stress testing to check the foetal heart rate for increases with foetal movements, a sign of foetal well-being.
  • Ultrasound, a diagnostic imaging technique to view internal organs as they function, and to assess blood flow through various vessels, to check the foetal growth.
  • Biophysical profile or a non-stress test with an ultrasound to evaluate foetal well-being.
  • Doppler flow studies, a type of ultrasound which uses sound waves to measure blood flow.

If a foetal problem shows up in testing or it is more than two weeks past your due date (equal to or less than 42 weeks), it is time to deliver.

Your doctor will 'induce labour' if it doesn't start on its own. One of the minimally invasive interventions is inducing labour by a technique called 'sweeping the foetal membrane'. Stripping or sweeping of the membranes means digital separation of the membranes from the wall of the cervix and lower uterine segment. Your doctor will gently separate the bag of water from the side of the uterus near the cervix. This procedure will release prostaglandins (hormones) from the cervix and prepare the uterus to contract. Once the contractions start, the cervix will open (dilate).

Using a Foley catheter or using IV infusion of oxytocin are other methods of ripening the cervix and inducing labour.

Various studies have shown that unprotected sexual intercourse and acupuncture can also induce labour. Unprotected coitus is very similar that of stripping of the membranes in its action as it causes uterine contractions through the action of prostaglandins in semen and potential release of endogenous prostaglandins from the cervix. However, the studies show conflicting data, so its efficacy cannot be assessed. So is the case with acupuncture. Since there is lack of large studies regarding induction of labour with acupuncture, this too requires further trials to confirm its efficacy.

Management of post term pregnancy is a complex issue. And the decision to induce labor is a difficult one and has its own set of risks. You and your doctor need to work together to come up with a solution that works best for you.

Reference:

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=p02487

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hrpregnant/postterm.html

https://www.ncbi.nlm.nih.gov/pubmed/16278984?dopt=Abstract

https://reference.medscape.com/medline/abstract/17904967

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