How late is really late?

There is only one answer to this: a very precise, one-in-365 date, the date at which it has been decided that you are exactly 40 weeks pregnant. On your notes, and in your head, that magical date becomes etched. Of course you know very well that almost no babies actually arrive on their due date, but it still becomes the focus of all forward planning in this pregnancy.

Then the date comes, and the chances are you’re still pregnant – 42% of women are still pregnant on their due date. You go to bed that night – still pregnant. You wake up in the morning – you’re still pregnant. Only now you are overdue. And if you have the temerity to be one of the 26% of women who carry on being still pregnant for another seven days, you are plunged into the conundrum of whether or not to accept the induction that’s urged on the vast majority of post-date women.

Only, hang on a sec.

The World Health Organization defines term pregnancy as 37 to 42 weeks after the last monthly period, so could it be that you’re not overdue at all?

That anything up to 42 weeks is perfectly normal and nothing to worry about? How does that sit with the cries of alarm that might now begin – your baby is in trouble, your placenta is failing and you are doubling your chance of a stillbirth by choosing to continue the pregnancy?

This is where the can of worms is well and truly opened. In 2001 the National Institute for Clinical Excellence (NICE) published its guidelines on induction of labour. Based on the available evidence, these stated that a woman should be offered induction beyond 41 weeks pregnant, and that, if she declined such an offer, she should be offered increased monitoring and have the levels of her amniotic fluid checked after 42 weeks.

The research upon which the guidelines was based has since been called into question; in 2002 Menticoglou and Hall stated in the British Journal of Obstetrics and Gynaecology that, ‘the higher risk that routine induction at 41 weeks aims to reduce is dubious, if it exists at all.’

<>The argument rumbles on; in October 2006 another report published online at www.cochrane.org reiterated NICE’s suggestion that induction at 41 weeks was associated with fewer deaths.

When it comes to post-date pregnancy, the key sources of information are contradictory and confusing. Let’s take a look into pregnancy at 41 weeks in more detail.

• Research suggests that a woman who is 41 weeks pregnant has a 60% chance that she will labour spontaneously within the next three days, and a 90% chance that she will do so within the next seven days.
• A baby is at slightly higher risk of stillbirth at 41 weeks than 40 weeks, but the data is not clear on this. A baby at 43 weeks has double the chance of stillbirth of a baby at 40 weeks, although the risk is small: 0.4% compared with 0.2%. Some studies suggest that the risk is around 0.3% at 42 weeks, but we don’t know how the rates increase over the three weeks from 40 to 43 weeks.
• If a baby is small for a full-term baby, the risks of stillbirth become higher. Some studies suggest that where a baby is of normal size, the increased risks up to 42 weeks are almost negligible.
• Many studies suggest that induction at 41 weeks does not affect the rate of caesarean; some go further and suggest that neither does it affect the rate of assisted delivery (use of forceps or ventouse) or epidural.
• Instinctively, however, many people dispute this: if an induced labour may be longer and more painful, they argue, how can it not affect the rate of interventions?

Many women may end up with varying estimates of their due date, which can be based on the first day of their last period or, more accurately, on an estimate from an early scan. NICE recommends a dating scan in order to avoid this problem arising. The average discrepancy between the two dates is three days, and researchers in Sweden have therefore suggested that if the due date was considered to be 40+3 rather than 40+0, the early scan would no longer be necessary.

So, let’s imagine that you’re 41 weeks – the stage at which most NHS hospitals start suggesting induction (although the specific date varies according to the hospital, and the circumstances of the woman and the labour ward). You have two options: to go for the induction, or to decline it. Mary Newburn, Head of Policy Research for the NCT, says, ‘Women can decline if they don’t want the treatment. There’s no need to make an immediate decision – they can review every few days if that’s what they want to do.’

Prior to considering a medical induction of labour with synthetic hormones, NICE say that women should be offered a stretch and sweep, where a midwife or doctor inserts a finger into the vagina to feel the cervix (neck of the womb), and, having stretched the cervix slightly open, sweeps the membranes (amniotic sac). This can result in the woman releasing a flood of hormones that can be enough, if you’re lucky, to start labour off with no further intervention. Studies suggest that three sweeps on consecutive days is the most effective course of action. Some women report that sweeps are slightly uncomfortable. After a sweep you can go home and carry on as normal.

<>The next option is to insert a pessary of prostaglandin, one of the hormones associated with the onset of labour, into the vagina. Again, sometimes this is enough to start labour and can be repeated at a 6-8 hour interval. Generally you will be advised to stay in hospital once an induction with a pessary has begun, although increasing numbers of women are sent home once the mother’s and baby’s well being has been checked.

If neither the sweep nor the pessary has had an effect, the next step may be to rupture the membranes or to set up a drip of artificial hormones. The step taken varies from unit to unit and even from woman to woman. From here on, there’s no turning back – you are finally in labour and your baby is on its way! However, it may not be plain sailing, and once you are induced with a drip of artificial hormones, continuous monitoring is strongly recommended (which in turn is believed to increase the rate of caesarean). Hertfordshire midwife Lynn Walcott says, ‘I think that an induced labour may well be more painful than a spontaneous one, particularly if the woman was not ‘ready’. But not necessarily, if the body was about to labour anyway – and in that case it’ll often take very little intervention to get labour started.’

The other option is to wait and see what happens. The NICE guidelines suggest that where women decline induction beyond 41 weeks, daily monitoring is offered from 42 weeks, although many hospitals will begin monitoring earlier than this. Again, it is your choice whether or not you agree to daily monitoring. Later, a scan might be offered to assess the level of fluid that remains around your baby. There might also be the option of a Doppler Scan, which tests the functioning of the umbilical artery.

There is some suggestion that the position of your baby, particularly one that is posterior, where the baby faces forwards with its spine close to the mother’s spine, is likely to stay inside longer than a baby in the more usual anterior position, where the baby faces back with its spine at the front of the mother’s bump. The neat solution to avoiding an unwanted induction here is to practice optimal fetal positioning (OFP). Imagine that your uterus acts like a hammock, and the baby will lie on her back in that hammock. You want to make the hammock the front of your body, not the back – and to do that you need to lean forwards as much as possible, and avoid reclining positions. It’s not always that straightforward. ‘A posterior baby is more likely to go post-date,’ says Lynn Walcott. ‘I am, however, not convinced of the benefits or effectiveness of OFP. I am concerned at women blaming themselves if their baby does not get into the ‘right’ position. Also, frankly, we do not always get it right on palpation! I believe that should a pregnancy go way beyond ‘dates’ owing to a posterior position, all the same ‘rules’ apply with regard to ‘is it ok?’ – that is, closer surveillance of the pregnancy.’

There is no simple, straightforward answer then in terms of whether and when to agree to an induction of labour, but you do have options and the right to say no if you want to. As with all decisions about pregnancy and parenthood, if you don’t feel you have enough information about why something is being recommended, ask more questions; and if you feel under pressure you can always say that you need more time to decide. Lynn Walcott explains: ‘If there was one intervention I would like to see ended, it’s induction of labour for post-dates. Independent midwives have an induction rate of around two per cent, versus a UK rate of over 20 per cent… what does that say to you? Choosing the best option is not dependent on risk or outcome, but, I believe, philosophy – individual circumstances and those of the people the woman surrounds herself with. This is especially true of induction.’

‘I declined induction at 10 days over 40 weeks – I felt that at that stage the risks outweighed the benefits. But I didn’t really want to be pregnant beyond 42 weeks, so after discussion with the registrar we booked induction for then. That said, I was thinking about the options of monitoring instead of induction then, but didn’t want a huge battle. Fortunately Jamie had other plans and arrived at 41 weeks and five days… and the birth was great.’

Jemimah E, York branch

‘I kept refusing induction – at 10 days over, 12 days over, and instead I went in for daily monitoring. At 42+1 I decided to be induced, having talked through the options with my NCT teacher and the hospital.

‘Labour started and there were some scary ‘pull-the-emergency-cord’ heartbeat dips on four occasions, but a clever midwife got me to move position and that solved the problem. At that point though I was put on a drip to speed things up – ouch! – but I still did second stage on my knees and Hayden was born at 42+2.

‘With my second pregnancy I again began daily monitoring at 41+5, with an appointment to discuss induction at 42 weeks. But this time a sweep got me going, and I had a lovely natural birth. Maya was born bang on 42 weeks – just at the time I was supposed to be in my appointment to discuss induction!

‘I was very impressed that the hospital’s policy was not to do anything until 41+5, and delighted that they were so accepting of my refusal to induce.’

Sarah E, East Cheshire branch

‘My first labour was a classic ‘horrible induction story’ at 41 weeks – Daniel and I were both thoroughly traumatised by the experience. So I resolved that I would wait and see what happened when I was pregnant for the second time, and was not keen to accept another induction without compelling reasons. Things started spontaneously at exactly 42 weeks, and although I had another long, hard labour, I felt pleased that my body had done it without any intervention and that the choice of labour had been all mine.’

Charlotte M, Bicester branch

Why might you go beyond 40 weeks

There are a few indications that may mean your pregnancy is likely to last more than 40 weeks – but none of these are hard-and-fast rules.

• Your family history: if all the women you’re closely related to have longer pregnancies
• Your own obstetric history: women who have had a longer first pregnancy are more likely to go beyond 40 weeks in subsequent pregnancies
• Your ethnicity: Asian babies tend to be born earlier than white ones; black ones are in the middle.
• Your baby’s position: there is some evidence to suggest that a posterior baby is more likely to go beyond 40 weeks
• Your baby’s gender: baby boys tend to stay inside for longer than girls
• Your height: the taller you are, the longer you are likely to stay pregnant – one study reckoned each additional centimetre above average equated to another 0.13 days’ gestation

Talk about your experience

If you are experiencing a post-date pregnancy or would like to talk to someone about your experience of being induced, call the NCT Pregnancy& Birth Line for information and support on 0870 444 8709