CHAPTER 53
Postdates Pregnancy
PATHOPHYSIOLOGY
Postdates or postterm pregnancy is defined as a pregnancy
that extends to or beyond 42 weeks of gestation (294 days
or estimated date of delivery [EDD] plus 14 days). A nor-
mal pregnancy lasts approximately 40 weeks from the start
of a woman’s last menstrual period, but any pregnancy
that lasts between 37 and 42 weeks is considered normal.
Approximately 4%–7% of all singleton pregnancies extend
to 42 weeks or 14 days beyond the EDD.1
Postterm pregnancy is associated with a higher peri-
natal mortality rate (stillbirth and newborn death within
the first week) and a higher risk for complications during
delivery, such as an emergency cesarean delivery, shoulder
dystocia, postpartum hemorrhage, birth asphyxia, meco-
nium aspiration syndrome, and neonatal birth injury.2
Current research suggests that the lowest infant mortality
rate is achieved when pregnant women have completed
at least 41 weeks of gestation before labor is induced and
when induction occurs before or at 42 weeks of gestation,
although the absolute risk for problems from delivering
beyond 42 weeks is low.2 The overall risk for perinatal
death is estimated at 0.4% in women who deliver beyond
42 weeks of gestation and 0.3% for women who deliver
between 37 and 42 weeks of gestation.3
Because of this small increase in perinatal mortality, the
induction of labor is widely practiced at or before 42 weeks
of gestation, and postterm pregnancy has become the
most common reason for induction.4 Unfortunately, labor
induction itself is not without risks. Obstetric problems
associated with induction of labor in postterm pregnancy
include cesarean section, prolonged labor, postpartum
hemorrhage, and traumatic birth. These problems are
more likely to result from induction when the uterus and
cervix are not ready for labor.2 Furthermore, induction of
labor brings with it increased risks of uterine rupture, uter-
ine hyperstimulation, fetal distress, and instrumentation.5
Very few studies have considered women’s experiences
and opinions when it comes to the timing of inducing
labor, and for women seeking a natural, unmedicated labor
and birth, induction poses many philosophical challenges.
Accurate dating is obviously important for reducing the
need of induction, and studies have shown that early ultra-
sound is associated with a reduced incidence of pregnancies
misclassified as postterm.6 When women have accurate
pregnancy dating and are approaching 41 weeks of gesta-
tion, many may seek nonpharmaceutical measures of cer-
vical ripening and labor induction. One small study of 50
women showed that many were opposed to medical induc-
tion of labor, yet they used self-help measures to stimulate
labor at home.7 More research is needed in the realm of
nonpharmaceutical cervical ripening and labor induction
options for women who have postdate pregnancies.
D. Jill Mallory, MD
INTEGRATIVE THERAPY
Nutrition
Pineapple
Pineapple (Ananas comosus), which contains the com-
pound bromelain, has historical medicinal use both as
a whole food and in extract form. Bromelain has been
proposed as the active ingredient, and it is present only
in the fresh fruit because the canning process destroys it.
Bromelain has been used to elicit uterine contractions
as a means of shortening labor. Some animal model
research suggests that instead of increasing cervical
prostaglandins, bromelain may actually inhibit them.8
No research is available on the possible effectiveness of
bromelain for induction of human uterine contractions,
although this use is widely suggested in lay pregnancy
resources. Some investigators suggest that pineapple’s
effects on labor may result from gastrointestinal stimula-
tion by fiber and sugar, thus affecting local neural path-
ways.9 No known risks are associated with pineapple use
in pregnancy.
Supplements
Castor Oil
Castor oil, derived from the bean of the castor plant (Ric-
inus communis), has a very rich history of use for labor
stimulation that dates back to ancient Egypt. One sur-
vey completed in 1999 found that 93% of U.S. midwives
reported using castor oil to induce labor.10 Despite this
prevalence, research into the use of castor oil has been
limited. A recent study in mice found that the castor oil
metabolite ricinoleic acid activated intestinal and uter-
ine smooth muscle cells via prostaglandin E2 recep-
tor 3 (EP3) prostanoid receptors.11 This may explain
its mechanism of action in humans. Three trials were
included in a recent Cochrane review looking at castor
oil for labor induction.12 It included 233 women at term
and compared ingestion of castor oil with no treatment/
placebo. Outcomes evaluated included cesarean section
rate, meconium staining of amniotic fluid, instrumental
delivery, and Apgar scores. All women who ingested cas-
tor oil had nausea; otherwise, outcomes were not signifi-
cantly different from those in women who did not ingest
castor oil. A retrospective observational study done in
Thailand of 612 women looked at the timing of delivery,
fetal distress, meconium-stained amniotic fluid, tachy-
systole of the uterus, uterine rupture, abnormal mater-
nal blood pressure during labor, Apgar scores, neonatal
resuscitation, stillbirth, postpartum hemorrhage, severe
diarrhea, and maternal death.13 No differences were seen
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