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KEY POINTS

Post-term pregnancy is defined as a singleton pregnancy


that has lasted until 42weeks or 294 days.
Complications include, for the baby, increased incidences
of meconium aspiration, intrauterine infection, oligo
hydramnios, macrosomia, non-reassuring fetal heart
testing (NRFHT), low umbilical artery pH, low 5minute Apgar score, dysmaturity syndrome, and perinatal
mortality; for the mother, increased risk of labor
dystocia, perineal injury, and cesarean delivery.
Pregnancies with risk factors such as maternal
(e.g. hypertension, diabetes, etc.) and fetal (growth
restriction, etc.) diseases necessitate special management,
as described in the pertinent guidelines.
Prevention of post-term pregnancy can be effectively
achieved with routine early pregnancy (< 20 weeks)
ultrasound and with stripping of membranes starting at
38 or 41 weeks.
There is insufficient evidence to assess the efficacy of
antepartum testing for pregnancies after their due date,
but twice-weekly fetal testing starting at 41 weeks with
the non-stress test (NST), or NST and amniotic fluid volume
(AFV), or biophysical profile (BPP) have been proposed.
At 41 weeks, even if the cervix is still unfavorable, routine
induction of labor reduces perinatal mortality,
mainly as a result of the decrease in fetal deaths. Routine
induction of labor is associated with a decrease in the
incidence of cesarean delivery in women who are nulliparous,
41 weeks, induced with prostaglandins, or
delivered in a center with a cesarean delivery rate >10%.
In women with a prior cesarean delivery, induction of
labor is associated with an increase in uterine rupture.

Diagnosis/definition
Post-term pregnancy is defined as a pregnancy that has
lasted until 42 weeks, or 294 days, or 14 days after
the due date (estimated date of confinement or EDC).1
Prolonged pregnancy can be defined as a pregnancy that
has lasted until 41 weeks, or 287 days, or 7 days after
the EDC.2 The term postdates can signify a pregnancy that
lasted until 40 weeks, or 280 days, but is often defined
differently in the literature and should be probably
avoided.1 All these definitions may have been differently
described in the literature, but it is important to be clear
when using these terms that everyone involved understands
their meaning. These definitions and this chapters guideline
pertain to singleton gestations. For multiple gestations,
please refer to Chapter 38 in MaternalFetal Evidence Based
Guidelines.

Epidemiology/incidence
The incidence of post-term pregnancy is about 7%.1

Etiology/basic pathophysiology
The most frequent cause of post-term pregnancy is an error
in dating.1 See Chapter 3 for accurate dating criteria and

ultrasound benefits, as well as below.

Risk factors/associations
Poor (wrong) dating; prior post-termpregnancy; nulliparity;
long (> 28 days) cycles without early ultrasound; placental
sulfatase deficiency; anencephaly; male fetus.

Complications
Perinatal
Meconium aspiration, intrauterine infection, oligohydramnios,
macrosomia, non-reassuring fetal heart testing
(NRFHT), low umbilical artery pH, and low 5-minute
Apgar score have all been associated with post-term pregnancy. Perinatal
mortality (fetal and neonatal deaths)
is twice as high at 42 weeks and 6 times as high at
43 weeks compared with 3940 weeks.1 Dysmaturity syndrome
is present in about 20% of neonates born post-term,
and has some of the characteristics above, as well as possibly
hypoglycemia, seizures, from uteroplacental insufficiency,
and unclear long-term outcome but increased risk of infant
death.1

Maternal
Women giving birth post-term are at increased risk of labor
dystocia, perineal injury, and cesarean delivery with their
complications.1

Pregnancy considerations
Every woman should be counseled early in pregnancy that
up to 50% of gestations, especially in nulliparous women,
last until past the due date (EDC). This is physiological, and
natural for humans. The incidence of fetal death is significantly
higher than that of neonatal death at 283 days
(40 weeks and 3 days).3 In large series, delivery at 38 weeks
is associated with the lowest risk of perinatal death, but the
risk of perinatal death is < 12/1000 up to 41 weeks and
6 days.4 It is important to identify risk factors such as
maternal (e.g. hypertension, diabetes, etc.) and fetal (growth
restriction, etc.) diseases that necessitate special management,
as described in the pertinent guidelines.

Management (Figure 23.1)


Preconception counseling
Women with prior post-term pregnancy are at increased
risk for recurrent post-term pregnancy. Prevention strategies
should be discussed.

Work-up
Early ultrasound < 20 weeks of gestation can prevent postterm
pregnancy, and therefore the need for induction.

Prevention
Routine early ultrasound to reduce
post-term pregnancies
Compared with no routine early ultrasound, routine early
pregnancy (< 20 weeks) ultrasound reduces by 3239%
the incidence of post-term pregnancy and of induction
for post-term pregnancy5,6 (see also Chapter 3). Accurate

assessment of gestational age is extremely important in


improving perinatal morbidity and mortality.

Stripping of membranes
Compared with no sweeping (stripping), sweeping of the
membranes, performed weekly as a general policy in women
at term (e.g. weekly starting at 38 weeks), is associated with
reduced duration of pregnancy and reduced frequency of
pregnancy continuing beyond 41 weeks and 42 weeks.2,7 To
avoid one formal induction of labor, sweeping of membranes
must be performed in 8 women. Risk of cesarean section and
maternal or neonatal infection is similar. Serial sweeping of
membranes starting at 41 weeks every 48 hours also
decreases the risk of post-term pregnancy from 41% to 23%,
with efficacy both in nulliparous and multiparous women.8
Discomfort during vaginal examination and other adverse
effects (bleeding, irregular contractions) are more frequently
reported by women allocated to sweeping, but are not associated
with complications (see also Chapter 17).

Breast and nipple stimulation to


reduce post-term pregnancies

Breast and nipple stimulation daily starting at 39 weeks has


not been sufficiently studied to ascertain safety, but it does
appear to reduce the incidence of post-term pregnancy by
48%.9,10

Antepartum testing

There are insufficient data to assess the best mode of fetal


monitoring after the EDC, as there are no trials to assess the
effect of antepartum testing on these pregnancies compared
with no testing. Since fetal death rates incrementally increase
after the EDC, it seems reasonable to test fetuses to assure
well-being, especially at 41 weeks.1,3,4 The most used
options include the non-stress test (NST) (also called
cardiography), biophysical profile (BPP), and modified BPP.
Modified BPP includes NST and ultrasound measurement
of maximum pool depth of amniotic fluid volume
(AFV). Other tests have been described, with even less
evidence for efficacy. Doppler ultrasound of any vessel,
including the umbilical artery, is not effective in the management
of post-term pregnancy. Compared with fetal monitoring
using NST and AFV, computerized cardiotocography,
amniotic fluid index, fetal breathing, fetal tone, and fetal
body movements were associated with increased incidence
of inductions and similar outcomes in a small trial in
women 42 weeks.11 At 41 weeks, twice-weekly testing is
recommended,1 but is not based on trials (see also Chapter
51 of MaternalFetal Evidence Based Guidelines).