SOGC

CLINICAL PRACTKE GUIDELINES

COMMITTEE OPINION
POST-TERM PREGNANCY
This Committee opinion supersedes the minion published inifialy in the Apfl 1994 issue of the Journal SCGC.

No. 15, Mamh 1907

This Committee Opinion has been prepared by the Maternal-Fetal Medicine Committee of the Society of obstetricians and Gynaecoiogists of Canada and i4ppmved by its Council.

Maternal-Fetal Medicine Committee:

Karen Ash, MD, FRCSC Gregory Connors, MD, FRCSC Philip Hall, MD, FRCSC Line Leduc, MD, FRCSC Robert Liston, (Chair), MD, FRCSC Douglas McMillan, MD, FRCSC Frank Sanderson, MD, FRCSC Ottawa, Ont. Calgary, Alta. Winnipeg, Man. Montreal, Que. Halifax, N.S. Calgary, Alta. St-John, N.B.

Principal author: Dr. Mary Hannah, University of Toronto

Committee Opinions: This OpimOn raftects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dktating an exclusivg course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented I modified at the local level. To enquire about ordering addiial wples, ptease contact the SCGC information and documentation centre. None of the cantents may be reproduced in any form wdhout prior written pennisslon of SOGC.

DEFINITION OF POST-TERM PREGNANCY

A pregnancy has traditionally been considered post-term at 42 completed weeks of gestation or 294 days from the last menstrual period (LMP) (280 days from the date of conception) as it was at this gestational age that risk of adverse fetal and neonatal outcome, and in particular the risk of perinatal death, increased. It is now believed that the risk of adverse perinatal outcome may increase as early as 41 completed weeks.3 Accurate dating of the pregnancy is essential. This should avoid unnecessary and perhaps harmful intervention if the pregnancy is not truly post-term, and will allow for the provision of effective care if the pregnancy is indeed post-term. An ultrasound examination prior to 20 weeks gestation, as per SOGC policy, is an excellent method of confirming or establishing the true gestational age of the fetus. This is particularly important when the first day of the last menstrual period is uncertain, the cycles are irregular, or birth control pills were taken prior to the last menstrual period. Randomized controlled trials of routine versus indicated ultrasound have shown a decreased rate of induction of labour for post-term pregnancy among women having routine ultrasound scans.
INCJDENCE OF POST-TERM PREGNANCY

The incidence of pregnancies completing 41 weeks of gestation may be as high as 27 percent.5 The incidence of pregnancies completing 42 weeks varies from four percent to 14 percent, and for those completing 43 weeks, from two percent to seven percent. Studies undertaken within the last 10 years indicate that the incidence of post-term pregnancy has decreased, probably due to the increased use of ultrasound to date pregnancies! This decreasing incidence may also have an effect on the risk of perinatal mortality and morbidity. For example, higher rates of induced delivery at term for perinatal complications, so that only very low risk pregnancies are allowed to continue beyond 41 weeks gestation, may result in a decrease in risk of adverse perinatal outcome for a given gestational age. On the other hand, more frequent use of early ultrasound, and thus more accurate dating of pregnancies, may increase the risk of adverse perinatal outcome for a given gestational age after 40 weeks, due to the exclusion of pregnancies which are truly younger. The incidence of post-term pregnancy will vary depending on many factors: the population studied, the frequency of preterm birth, the frequency with which labour is induced, the frequency of elective Caesarean section, the use of ultrasound for confirming or determining gestational age, and the definition of post-term pregnancy (41 versus 42 completed weeks). Specifically, the incidence of post-term pregnancy will be lower if the frequency of preterm birth is higher, if the rate of induction of labour and elective Caesarean section are higher, and if ultrasound is used more frequently to confirm or determine gestational age.
ADVERSE PERINATAL OUTCOME ASSOCIATED WITH PREGNANCY

Post-term pregnancies are at a higher risk than term pregnancies, of perinatal death (antepartum, intrapartum, and post-parturn) due to anomalies (eg. anencephaly), intra-uterine infection, and asphyxia with and without meconium. Post-term pregnancies are also at a higher risk of neonatal morbidity (eg. macrosomia, shoulder dystocia, meconium aspiration syndrome, admission to the neonatal intensive care unit, treatment with positive pressure oxygen, endotracheal intubation, respiratory distress, persistent fetal circulation, pneumonia, and seizures).2*E7 Post-term pregnancies are more likely to have a higher rate of induced labour, fetal distress in labour, meconium staining of the amniotic fluid, and operative delivery than term pregnancies.

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RISK FACTORS FOR ADVERSE OUTCOME AMONG PREGNANCIES

Hypertension or pre-eclampsia, diabetes, abruptio placentae, and intra-uterine growth restriction are factors which increase the risk of adverse perinatal outcome in post-term pregnancy.*~B
MANAGEMENT STRATEGIES Fetal Surveillance

We now have available to us many forms of testing to follow the wellbeing of the post-term fetus while still in utem. There is still considerable uncertainty, however, as to how well these tests measure fetal compromise and how effective treatment is when we use these tests in our management. Whatever form of testing is chosen, it is important to remember that the condition of the fetus can change quickly and, thus, monitoring should be at frequent intervals, and that none of the tests are immune from false positives, and false negatives.o
Induction of Labour

Induction of labour has seemed, to many physicians, an obvious approach to the post-term pregnancy, with the standard method being amniotomy with or without intravenous oxytocin. Inducing labour, however, is not always easy or uneventful when the cervix is unfavourable. There is growing research evidence that the use of prostaglandin E, gels for cervical ripening in this situation, prior to planned induction, is slightly less likely to result in delivery by Caesarean section.2o2 Other approaches which have been investigated but need further evaluation include nipple stimulation, stripping or sweeping of the membranes, and use of mechanical methods such as the Foley catheter.224
EFFECllVENESS OF INDUCTION OF LABOUR COMPARED TO EXPECTANT MANAGEMENT WITH SERIAL FETAL SURVEILLANCE

There have now been at least 11 randomized or quasi randomized controlled trials which have compared a policy of induction of labour in pregnant women at 41 or more weeks gestation with a policy of expectant management with serial fetal surveillance.o The largest of these trials was carried out from 1985 to 1990 in 22 Canadian hospitals.20 Overviews (or meta-analyses) have been undertaken to allow the combination of results from all these tfials.025 Between 20 percent and 38 percent of women managed expectantly, either had labour induced or had a Caesarean section prior to the onset of labour. Thus, expectant management did not necessarily mean that labour began spontaneously. Inducing labour at 41 or more weeks resulted in a significantly lower Caesarean section rate (Typical odds ratio (95 percent Confidence Interval]: 0.85 [0.74 to 0.971) compared with expectant management. This reduction was seen in both nulliparous women and multiparous women. Inducing labour at 41 or more weeks resulted in a lower rate of non reassuring fetal heart changes as defined by the different authors, a lower rate of meconium staining of the amniotic fluid, and a lower rate of macrosomia (usually defined as birth weight > 4000 gms) compared with expectant management. Inducing labour at 41 or more weeks resulted in a lower rate of fetal or neonatal death (excluding lethal/major congenital anomalies) compared to expectant management (Typical odds ratio (95 percent Confidence 3

interval]: 0.23 [0.06 to 0.90]), and this reduction was largely due to a reduction in the rate of stillbirths. Most of the deaths in these trials wereassociated with asphyxia and/or meconium aspiration.
SUMMARY

In summary, post-term pregnancies are at higher risk of adverse maternal, fetal and neonatal outcomes than pregnancies that end spontaneously at term, and when perinatal deaths do occur, they are frequently associated with asphyxia and meconium aspiration. There is a multitude of methods available for fetal surveillance in post-term pregnancy, but the effectiveness of these methods is still uncertain. The overview or meta-analysis of randomized controlled trials comparing elective induction of labour with serial antenatal surveillance at 41 or more weeks gestation reveals that the induction of labour groups are less likely to have non reassuring fetal heart changes, meconium stained amniotic fluid, macrosomic babies, and babies who die during the perinatal period. Despite the fact that five of the 11 trials specifically restricted entry to women with unripe cervices, all available evidence suggests that a routine policy of inducing labour at 41 to 42 weeks gestation is less likely to result in delivery by Caesarean section than a policy of expectant management with close fetal surveillance. Women who reach 41 weeks gestation should be counselled appropriately regarding the higher risks to themselves and to their babies if they should pursue a policy of expectant management. These results suggest that a policy of induction is, in general, to be preferred.

1.

f+ablishing gestational age

The management of post-term pregnancy is difficult if there is uncertainty as to the gestational age of the fetus. All pregnant women should have a careful assessment of the gestational age of the fetus at their first prenatal visit. This visit should take place as early as possible in the pregnancy. During this visit, a careful menstrual history should be taken, noting the first day of the last normal menstrual period, the regularity and length of cycles, and any history of oral contraceptive use in the three months preceding the last menstrual period. For some women, the exact day of conception may be known, and if so, this should be the basis for determining gestational age. A physical examination should be undertaken to assess the size of the uterus and to determine that the size is consistent with the gestational age of the fetus as determined by the menstrual history. If there is uncertainty as to the timing of the last menstrual period, if the cycles have been irregular, if there has been a history of oral contraceptive use prior to the last menstrual period, or if the physical examination is inconsistent with the dates of the pregnancy as determined by the menstrual history, an obstetrical ultrasound examination should be requested to confirm or determine the gestational age of the fetus. The ultrasound examination is more accurate the earlier it is performed. However, as an ultrasound examination performed at 16 to 20 weeks of gestation may also, with some confidence, assess the physical status of the fetus (including the presence or absence of more than one fetus), it is reasonable and appropriate for most women to delay an ultrasound examination for determination of gestational age until that point.

2.

Management at 39 to 40 M Weeks

For the uncomplicated pregnancy, there is no evidence to support elective induction of labour or the commencement of serial antenatal monitoring. However, if there are other risk factors including hypertension, diabetes mellitus, intra-uterine growth restriction, macrosomia, hydramnios, or multiple pregnancy, strong consideration should be given to either serial fetal surveillance or elective delivery.

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Management at 41 to 42 Weeks

Women who reach 41 to 42 weeks gestation, with an uncomplicated pregnancy, should be offered elective delivery. If there is a contra-indication to vaginal delivery, a Caesarean section should be undertaken. If vaginal delivery is not contra-indicated, labour should be induced. If the cervix is unfavourable, the cervix should be ripened using any of the accepted methods available (example: prostaglandin gel or mechanical methods). As long as the fetus and mother are not in distress, there is no need for this process to be undertaken rapidly. If the cervix is favourable, and the presenting part of the fetus is engaged and well applied to the cervix, labour may be most easily induced either by amniotomy with or without intravenous oxytocin. or with vaginal prostaglandin E, gel. The decision as to which method to pursue will be influenced by physician and patient preferences and relative costs.
4. Exceptions (Expectant management)

There are exceptions to the above recommendations. The decision regarding care during childbirth should be made in conjunction with the mother and her partner. Some women, despite the slightly lower risks of perinatal mortality, neonatal morbidity, and Caesarean section, with elective delivery, may perceive that induced labour is sufficiently unpteasant that they may prefer a wait and see approach. If so, they should be offered serial fetal surveillance. Serial fetal surveillance should consist (as a minimum) of an ultrasound assessment of amniotic fluid volume twice weekly. If the volume of fluid appears decreased, consideration should be given to immediate delivery. Other forms of monitoring of the fetus may be added to this (example: fetal movement counts, biophysical profile, nonstress test).
The MatemaCFetal Medicine Committee has reviewed this opinion in the light of an inaeasing indufion rate in many Canadian maternity centres. The followihg additional recommendations are appended for cladfiiion.

1.

In an uncomplicated pregnancy, there is no evidence to support the initiation of either the induction of labour or serial antenatal monitoring prior to 41 completed weeks. Indeed, such an approach may lead to increased operative intervention, particularly in nulligravida where, overall, the likelihood of Caesarean section may be twice as great when labour is induced as comparedto spontaneous. After 41 completed weeks (by good dating parameters), women should be offered elective delivery. If the cervix is unfavourable, ripening should be undertaken. As long as the fetus and mother are healthy, there is no need for this ripening process to be undertaken rapidly. Ripening before 41 completed weeks, is not indicated in an uncomplicated pregnancy. If after 41 completed weeks expectant management is elected, ongoing assessment of fetal health should be initiated.

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REFERENCES

1.

Maternal-Fetal Medicine Committee, The Society of Obstetricians and Gynaecologists of Canada, Management of post-term pregnancy, Committee Opinion, J Sot Obstet Gynaecol Can 1994;16(4):1581-6.

2.

Crowley P. Post-term pregnancy: induction or surveillance? In: Chalmers I, Enkin M, Keirse MJNC (Eds). Effective care in pregnancy and childbirth. Oxford, England: Oxford University Press 1989:776-91. Feldman GB. Prospective risk of stillbirth. Obstet Gynecol 1992;79:547-53. Neilson JP. Routine ultrasonography in early pregnancy. In: Chalmers I (Ed). Oxford database of Perinatal Trials. Version 1.3, Disk issue 7, Spring 1992, Record 3872. Beischer NA, Evans JH, Townsend L. Studies in prolonged pregnancy I. The incidence of prolonged pregnancy. Am J Obstet Gynecol 1969;103:476-82. Goldenberg RL, Davis RO, Cutter GR, Hoffman HJ, Brumfield CG, Foster JM. Prematurity, postdates and growth retardation: the influence of use of ultrasonography on reported gestational age. Am J Gbstet Gynecol 1989;160:462-70. Bakketeig L, Bergjso P. Post-term pregnancy: magnitude of the problem. In: Chalmers I, Enkin M, Keirse MJNC (Eds). Effective care in pregnancy and childbirth. Oxford, England: Oxford University Press 1989:765-75. Ballantyne JW, Browne FJ. The problems of fetal postmaturity and prolongation of pregnancy. J Obstet Gynaecol Brit Emp 1922;29:177-237. McClure Browne JC. Postmaturity. Am J Obstet Gynecol 1963;85:573-82. Hannah M. Post-term pregnancy: should all women have labour induced? A review of the literature. Fetal and Maternal Medicine Review 1993;5:3-1. Naeye R. Causes of perinatal mortality excess in prolonged gestations. Am J Epidemiol 1978;108:429-33. Lucas WE, Anctil AO, Callagan DA. The problem of post-term pregnancy. Am J Obstet Gynecol 1965;91:241-50. Clifford S. Postmaturity - with placental dysfunction: clinical syndrome and pathologic findings: J Pediatr 1954;44:1-13. Curtis PD, Matthews TG, Clarke TA, Darling M, Crowley P, Griffin E, OConnell P, Gorman W, OBrien N, OHerlihy C, ORegan M. Neonatal Seizures: the Dublin collaborative study. Arch Dis Child 1988;63:1065-8. Saunders N, Paterson C. Effect of gestational age on obstetric performance: when is term over? Lancet 1991;338:1190-2. McLean FH, Boyd ME, Usher RH, Kramer MS. Post-term infants: too big or too small? Am J Obstet Gynecol 1991 ;164:619-24.

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Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol 1985;66:762-8. Shime J, Gare DJ, Andrews J, Bertrand M, Salgado J, Whillans G. Prolonged pregnancy: surveillance of the fetus and the neonate and the course of labor and delivery. Am J Obstet Gynecol 1984;148:547-52. Eden RD, Seifert LS, Winegar A, Spellacy Wn. Maternal risk status and postdate pregnancy outcome. J Reprod Med. 1988;33:53-7. Hannah ME, Hannah WJ, Hellmann J, Hewson S, Milner R, Willan A, and the Canadian Multicentre Post-term Pregnancy Trial Group. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. N Engl J Med 1992;326:1587-92. Keirse MJNC, Van Oppen ACA. Preparing the cervix for induction of labour. In: Chalmers I, Enkin M, Keirse MJNC, (Eds). Effective care in pregnancy and childbirth. Oxford, England: Oxford University Press 1989:988-l 056. Crowley P. Breast stimulation for the management of post-term pregnancy. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP (Eds). Pregnancy and Childbirth Module Cochrane Database of Systematic Reviews: Review No. 06860,2 April 1992. Published through Cochrane Updates on Disk, Oxford: Update Software, Spring 1993. Keirse MJNC. Stripping/sweeping membranes at term for induction of labour. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP (Eds), Pregnancy and Childbirth Module Cochrane Database of Systematic Reviews: Review No. 05090,3 April 1992. Published through Cochrane Updates on Disk, Oxford: Update Software, Spring 1993. Keirse MJNC. Mechanical methods for cervical ripening. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP (Eds).Pregnancy and Childbirth Module Cochrane Database of Systematic Reviews: Review No. 03863,3 April 1992. Published through Cochrane Updates on Disk, Oxford: Update Software, Spring 1993. Crowley P. Induction of labour at 41+ weeks. In Chalmers I (Ed). Oxford Database of Perinatal Trials. Version 1.3, Disk Issue 7, Spring 1992. Record 4142.

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SOGC File: post.ter