REVIEW

Prolonged pregnancy: percentage of the population in whom pregnancy actually pro-

ceeds beyond 42 weeks varies widely in different clinical set-

balancing risks and tings, primarily as a result of differences in recommendations for

obstetric management of pregnancies in the 40e42 week range.

interventions for The incidence of prolonged pregnancy appears to be reducing

over time in well-resourced obstetric settings, as intervention to

post-term gestations deliver pregnancies that have proceeded beyond the due date is
increasingly recommended.
Aside from management recommendations, the other factor
Sara Latif that significantly influences the percentage of pregnancies clas-
Catherine Aiken sified as post-term is the accuracy of dating pregnancies. Routine
use of first trimester ultrasound tends to reduce the overall
incidence of post-term pregnancies compared to populations
where the due date is estimated from the last menstrual period.
Abstract
Accurate determination of gestational age, ideally via measure-
Pregnancy that continues beyond 42 weeks of gestation (post-term)
ment of the crown-rump length between 10 and 13 weeks, is
confers increased antepartum and intrapartum fetal risk. Maternal
essential to accurately identify pregnancies at risk of becoming
risk may also be associated with post-term pregnancy, for example
post-term and to allow timely initiation of appropriate manage-
increased likelihood of delivery via emergency Caesarean section.
ment discussions. Studies have suggested that a variety of
The increased likelihood of adverse perinatal outcomes associated
maternal factors increase the risk of post-term pregnancy
with post-term pregnancy derives mainly from increasing fetal size
(Table 1), but many of these are not well-evidenced.
and placental ageing. The key intervention currently available to
While it is widely accepted that post-term pregnancy is asso-
manage the risks associated with prolonged pregnancy is to offer
delivery. In the UK, induction of labour is routinely offered at
ciated with increased maternal and fetal risk compared to preg-
nancies that deliver prior to 42 weeks, there is considerable
41 weeks. Although offering induction of labour to manage post-
heterogeneity regarding the magnitude of these risks in the
term pregnancy is intended to minimize risk, women should feel
available literature. The risk of adverse perinatal outcomes in-
supported by healthcare professionals if they opt for expectant man-
creases incrementally from w40 weeks onwards, rather than
agement or decline induction of labour.
with a step-change at 42 weeks, as the definition of post-term
Keywords Expectant management; induction of labour; post-matu- pregnancy might imply. There are also potential risks associ-
rity; post-term; stillbirth
ated with the management strategies to avoid post-term preg-
nancy (for example induction of labour). Hence individualized
counselling is essential to determine the optimal management for
Introduction each pregnancy, with appropriate consideration not only of the
risk arising from the duration of pregnancy but also the back-
Terminology is important in obstetrics, in particular to achieve ground risk conferred by factors such as parity and maternal age.
shared understanding of the risk associated with pregnancy The specific risks associated with post-term pregnancy can be
complications. The terms ‘prolonged pregnancy’, ‘post-dates’, divided into those that apply to the mother, to the fetus, and to
and ‘post-term’ are often used interchangeably, although they the neonate (Table 2).
may also be understood to describe differing time-points. The
descriptor ‘post-term’ is the best defined, and is most widely used
for any pregnancy that has proceeded beyond 294 days of Maternal complications associated with prolonged
gestation. This definition is recognized by the Royal College of pregnancy
Obstetricians and Gynaecologists (RCOG), the American College Simply by virtue of remaining pregnant longer, women with
of Obstetricians, and Gynecologists (ACOG), the World Health post-term pregnancies are at higher risk of experiencing common
Organization (WHO), and the International Federation of Gyne- maternal complications of pregnancy, for example late-onset
cology and Obstetrics (FIGO). hypertensive disorders of pregnancy and anaemia.
The reported global frequency of post-term pregnancies is Studies also suggest that pregnancies continuing beyond
between 5 and 15%. Describing this proportion of the population 40 weeks are at addition risk of dysfunctional labour, including
as beyond the normal range is in keeping with the statistical delays in both the first and second stage. The aetiology of this risk
approach to defining thresholds for other obstetric risk factors, is likely to relate primarily to increased fetal size, in particular
such as small-for-gestational age fetuses. However, the reported relative cephalo-pelvic disproportion, but may also reflect issues
with synchronous and effective myometrial contractility. Cervical
ripening and syncytial myometrial contractions are essential for
Sara Latif MRCOG Locum Consultant Obstetrician, The Rosie spontaneous delivery, and prolonged labour will occur if these are
Hospital, Cambridge, UK. Conflicts of interest: none declared. not fully achieved. Hence if induction of labour is undertaken in
the context of post-term pregnancy, careful active management is
Catherine Aiken MRCOG MRCP PhD Associate Professor and Honorary
Consultant in Maternal and Fetal Medicine, University Department of required to avoid further delays in delivery.
Obstetrics and Gynaecology, University of Cambridge, UK. Conflicts If spontaneous delivery occurs, then the increased fetal size
of interest: none declared. associated with prolonged pregnancy confers a higher risk of

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:5 127 Crown Copyright Ó 2024 Published by Elsevier Ltd. All rights reserved.
 REVIEW

Risk factors associated with post-term pregnancy

Risk factor Evidence/explanation

Dating error Naegle’s rule for estimating due date is error-prone due to assumptions about cycle length and regularity
Dating using CRL reduces inductions for post term pregnancies
Nulliparity Several studies suggest increased risk of post-term pregnancy in nulliparous women
Possibly related to necessity to form de novo myometrial gap junctions ahead of first labour, but mechanism
poorly evidenced
Previous prolonged pregnancy Increased risk of prolonged pregnancy following previous post-term pregnancy
Mechanism not well-defined, but some evidence of transgenerational effect (daughters of mother with
prolonged pregnancies have higher risk)
Obesity Recent studies suggest obesity is a risk factor for post-term pregnancy
Mechanism not well defined, but potentially modifiable risk factor
Cephalopelvic disproportion Larger fetus is generally considered to be consequence of post-term pregnancy, but in some cases may also
be causal
Potential mechanisms include less lower uterine segment distension, reduced physical pressure on cervix,
and reduced prostaglandin production due to unengaged head
Fetal anomaly Specific anomalies linked to post-term pregnancy include anencephaly, adrenal hypoplasia and placental
sulfatase deficiency
Potentially due to lack of oestrogen in sufficiently high concentrations
Male fetal sex Some evidence suggests increased risk of post-term induction of labour with a male fetus

Table 1

severe perineal trauma. Such trauma can include vaginal lacer- delivery is more likely to be unsuccessful in post-term pregnan-
ations leading to high blood loss and disruptions of the anal cies, because of larger fetal size, and may also be associated with
sphincter complex. Meticulous attention to repair of these in- increased vaginal trauma and blood loss. Emergency Caesarean
juries is essential to optimize outcome, and hence it is important section is associated with increased maternal morbidity
the obstetrician recognizes post-term pregnancy as a risk factor compared to other modes of delivery, including higher risks of
for perineal trauma. blood loss, infection, and venous thromboembolism.
Delay in the second stage is also more common in prolonged Pregnancies that continue to 42 weeks and beyond are also
pregnancy, and is associated with complications such as often accompanied by considerable maternal anxiety, for
maternal pyrexia and post-partum haemorrhage. If spontaneous example about the reasons that labour has not yet started or
delivery does not occur, then assisted vaginal delivery or emer- concerns for the well-being of the baby. Many mothers also ex-
gency Caesarean section must be performed. Assisted vaginal press feelings of frustration with waiting. These are important
psychological aspects of the pregnancy experience that are often
over-looked by healthcare professionals, and must be weighed
Complications of post-term pregnancy carefully when an individualized plan for management of post-
term pregnancy is made.
Maternal risks
Dysfunctional labour Fetal complications associated with prolonged pregnancy
Perineal trauma including injuries to anal sphincter complex
Emergency Caesarean section and instrumental deliveries Fetal complications associated with post-term pregnancy are
Post-partum haemorrhage related to both increased fetal size and an increased likelihood of
Pyrexia in labour placental dysfunction that accompanies placental ageing.
Psychological morbidity Increased fetal size is a complicating factor that can both
Fetal risks prolong labour and complicate delivery itself. Rates of macro-
Macrosomia (shoulder dystocia; orthopaedic and neurologic injury) somia are increased w2 fold in post-term babies, with associated
Oligohydramnios resulting in cord compression increased rates of shoulder dystocia and birth trauma. After
Hypoxic ischemic encephalopathy 40 weeks, babies are more likely to be born with low Apgar
Stillbirth scores, and the risk of hypoxic ischaemic encephalopathy in-
Neonatal risks creases by 20% with every week after the estimated due date.
Low Apgar score Placental ageing leading to post maturity syndrome is thought
Meconium Aspiration Syndrome to be due to reduced placental capacity and increased fetal de-
Acidaemia mands. Compensatory redistribution of fetal renal blood flow to
Unexpected admission to neonatal intensive care unit the brain may result in renal hypoperfusion and consequent
Neonatal encephalopathy oligohydramnios. Likewise oligohydramnios brings about cord
compression together with abnormal fetal heart rate patterns
Table 2 thus necessitating continuous FHR monitoring intrapartum.

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 REVIEW

The risk of antenatal stillbirth is the most commonly cited additional morbidity for mother or baby. The ARRIVE trial
reason to recommend delivery in a post-term pregnancy. Despite showed a reduction in the rate of Caesarean delivery in low-risk
a low absolute risk, the relative risk of antepartum stillbirth in- women assigned to elective induction of labour at 39 weeks,
creases steadily up to 42 weeks of gestation. Beyond 42 weeks, with 28 inductions needed to prevent 1 primary Caesarean sec-
there are few high quality epidemiological studies from which to tion. Moreover there was no increase in the rate of adverse
calculate the ongoing risk of expectant management, however perinatal or delivery outcomes in the induction of labour group,
based on available evidence this is likely to continue to rise. The and a decrease in maternal hypertensive disorders. On the basis
likely aetiology of the increase in antenatal stillbirth is the of this trial, ACOG now endorses elective induction at 39 weeks as
increasing likelihood of placental dysfunction as pregnancies a reasonable option to be offered to all women in the absence of
continue beyond the estimated date of delivery. In addition to other risk factors. A further recent multicentre non-inferiority trial
antepartum stillbirth, placental dysfunction in post-term preg- (INDEX) in the Netherlands specifically examined the question of
nancies is associated with late-onset fetal growth restriction and inducing labour at 41 weeks versus expectant management. This
perinatal death. study concluded that induction reduced adverse perinatal out-
comes with no increase in maternal or fetal risks compared to
Neonatal complications associated with prolonged expectant management, although both strategies carried low ab-
pregnancy solute risk in an otherwise healthy population. The SWEPIS trial
(a multi-centre, randomized, superiority trial conducted in Swe-
Neonatal complications associated with post-term pregnancy
den) was halted early due to a significantly higher rate of peri-
include unplanned admission to the neonatal intensive care unit
natal mortality in pregnancies randomized to expectant
and acidaemia at delivery. Some evidence suggests that rates of
management until 42 weeks. There was no difference in adverse
sudden infant death syndrome are higher in babies born beyond
maternal outcome between the group randomized to induction at
42 weeks of pregnancy.
41 weeks versus expectant management until 42 weeks. These
Babies that remain in utero at 41e42 weeks are also significantly
valuable sources of evidence should inform our management of
more likely to have passed meconium by the time labour begins
pregnancies that remain undelivered beyond the estimated due
and thus have higher rates of meconium aspiration. The finding of
date, and increase our confidence in recommending induction of
meconium in post-term labour can be normal and not an indicator
labour to avoid adverse perinatal outcomes (Table 3).
of fetal distress, but the presence of meconium-stained liquor
The National Institute for Health and Care Excellence (NICE)
makes reassurance about fetal well-being more difficult.
issued a 2021 update to the ‘Inducing labour’ guideline (NG207).
‘Post-maturity’ is a complication of post-term pregnancy, and
The earlier 2008 version recommended that routine post-dates
is not applicable to all babies born beyond 42 weeks of gestation.
induction be offered between 41 and 42 weeks, with consider-
It is used to describe babies born >42 weeks with distinctive
ation for women’s preferences and local scenarios. The 2021
features such as dry skin, minimal subcutaneous fat deposition,
update places a stronger emphasis on discussing the option of
visible creases on palms and soles, or skin coloration from
induction at 41 weeks to mitigate risks while continuing to
meconium staining. These features are variously explained by
consider the impact of induction on birth experience. This
the loss of vernix or by placental dysfunction. Post-maturity
guideline revision was heavily influenced by the finding in the
syndrome complicates up to 20% of post-term pregnancies.
SWEPIS study of perinatal deaths occurring between 41 þ 2 and
42 þ 0 weeks in the group randomized to expectant manage-
Management of post-term pregnancies
ment. While not powered for this outcome, it was considered
In view of the continuous spectrum of increasing risk of both significant that a large RCT needed to be halted on these ethical
antepartum stillbirth and intrapartum complications beyond 39 grounds. The review of evidence that under-pinned the NICE
e40 weeks, there is significant debate about the optimal man- guideline revision also illuminated the need for more data on
agement of pregnancies that remain undelivered beyond the week-to-week comparisons and for groups potentially at higher
estimated date of delivery. In various high-income obstetric set- risk of adverse outcomes, including black, Asian, and other mi-
tings globally, delivery is routinely offered at various times be- nority ethnic groups, women with a BMI of 30 or higher, those
tween 40 and 42 weeks. The WHO recommends routine offer of aged 35 years and older, and women who conceived through
induction of labour at 42 weeks, noting that both expectant artificial reproductive technology.
management and planned delivery carry risks to mother and baby. It is also important to consider whether implementation of
Observational studies examining expectant management trial recommendations in a non-research context has the inten-
versus induction of labour often conclude that induction of labour ded effects and whether the effects of interventions that are
is associated with an increase in adverse outcomes, for example beneficial within trials are also beneficial ‘in real life’. An
increased rates of instrumental delivery. However interpretation observational analysis of population-level data in the US
of such studies is complicated by unobserved variation in the comparing obstetric outcomes before v. after the publication of
complexity of patients allocated to each group on clinical the ARRIVE study demonstrates some reduction in Caesarean
grounds, with higher risk cases usually assigned to induction. section rates (as the trial data would have predicted), but also
More recent evidence on this very important question comes from potential small increases in other adverse outcomes, for example
several large randomized controlled trials, which avoid the diffi- the need for blood transfusion. While a causal association with
culties inherent in clinical assignment of treatment group. The ARRIVE and its recommendations cannot be shown by this type
35/39 trial showed that induction of labour versus expectant of analysis, it is worth considering a note of caution about the
management in women over the age of 35 did not result in real-world implementation of trial data.

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 REVIEW

Summary of key trials on labor induction and expectant management in prolonged pregnancies
Study name Study type Study location and Sample size Intervention Key findings
dates

35/39 Trial Randomized control United Kingdom Randomized N ¼ 619 Comparing CS rates in In older mothers,
trial August 2012 and Analysed N ¼ 618 nulliparous women inducing labor at
March 2015 aged 35 or older, 39 weeks did not
induced at 39 þ 0e39 significantly change
þ 6weeks versus those caesarean rates or
under expectant cause short term
management neonatal or maternal
harm compared to
expectant management
ARRIVE Trial Randomized control USA Randomized Randomly assigned low Inducing labour at
trial March 2014 to N ¼ 6106 risk nulliparous women 39 weeks in nulliparous
August 2017 Analysed ¼ 6096 at 38 þ 0e 38 þ women did not
6weeks to either labor significantly reduce
induction at 39 weeks adverse perinatal
or expectant outcomes but did
management. Primary reduce caesarean
outcome of perinatal deliveries
death or severe
neonatal complications,
with caesarean delivery
as a secondary outcome
INDEX Trial Randomized control Amsterdam Randomized 41 þ 0-41 þ 1weeks Both strategies had low
trial May 2012 to March N ¼ 1815; analysed women were scheduled overall risks in healthy
2016 N ¼ 1801 for IOL, 42 weeks women, but IOL showed
awaited spontaneous decreased perinatal
onset of labour with adverse outcomes
standard monitoring, without raising fetal or
both groups IOL if maternal risks
concerns compared to expectant
management
SWEPIS Trial Randomized control Sweden May 2016 to N ¼ 2762, Power IOL within 24 hours No significant difference
trial October 2018 calculation based on after randomization at in primary adverse
n ¼ 5019 per group, 41 weeks in the perinatal outcomes
but study terminated induction group, and between labor induction
early due to high between 42 þ 0-42 þ at 41 weeks and
perinatal death rate 1weeks in the expectant expectant management,
in expectant management group however decrease in
management group perinatal mortality with
IOL at 41 weeks. The
results suggest that
offering IOL no later
then 41 weeks could
help reduce stillbirth
rate
Timing of induction Systematic review March 2020 search 509 records after de- Updating the systematic Supports offering
of labor in the and meta-analysis and September 2021 duplication review for the ‘Inducing induction at 41 þ
prevention of search Labor’ guideline by 0weeks compared to 42
prolonged NICE, with new data and þ 0weeks to reduce
pregnancy analyses adverse perinatal and
obstetric outcomes

Table 3

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 REVIEW

Routinely offering mothers the option of delivery to avoid post- rate tends be lower in post-term pregnancy. Mild oligohydramnios
term pregnancy leads to the question of whether induction of is also a common finding in post-term pregnancy, and the reduced
labour, elective Caesarean section, or either should be offered. As liquor volume increases the risk of variable decelerations due to
induction of labour at gestations beyond 39 weeks does not cord compression. These features can be difficult to distinguish
appear to lead to an increased risk of emergency Caesarean sec- from evidence of fetal hypoxia when interpreting CTG tracings.
tion, for low-risk women induction of labour would appear to be With this in mind, some women, particularly those who have
the choice associated with the lowest risk of adverse outcomes. chosen to wait for spontaneous labour, may decline continuous
However, other factors, such as previous mode of delivery, may fetal monitoring post-term.
tip the balance in favour of Caesarean delivery. In other cases Post-term labour is also associated with longer duration of
women may choose to accept the offer of delivery to avoid the both the first and second stage, and thus close attention should
risks associated with post-term pregnancy, but refuse induction of be paid to maternal pain relief, hydration, and rest. As with all
labour. In this case, the best available evidence suggests that post- labouring women, there should be extensive support to ensure
term elective Caesarean section should be offered to minimize comfort and mobility, with prompt response to requests for
perinatal risk at a gestation acceptable to the woman. There is no analgesia or additional support. IV access may be considered,
high quality evidence available to suggest that elective Caesarean given that the risk of post-partum haemorrhage is increased by
section carries additional maternal morbidity when performed at both higher birthweight and prolonged labour.
42 weeks or beyond compared to 37e42 weeks.
Expectant management of post-term pregnancy may be
Counselling in the context of post-term pregnancy
requested by women. In this scenario, careful individualized
understanding of risk factors and counselling is the key to shared Women must be given adequate time and counselling to come to
decision-making. It is important that respect for the autonomy of a decision about the management of their pregnancy, with the
every individual to take decisions for themselves and their baby discussion covering the major risks and benefits of each possible
is kept paramount, while ensuring that they have as much in- strategy (Table 4). Regardless of the decision that a woman
formation as they desire on which to base their decisions. In the comes to regarding management of her post-term pregnancy, she
UK, guidelines recommend that women who decline induction of should be supported in her decision. It is common for women to
labour beyond 42 weeks should be offered monitoring with CTG feel not listened to when their preferences diverge from the
(minimum twice weekly, but often in practice performed more recommendations of their care-givers or when their personal
often) and ultrasound scans to assess the liquor volume. decisions do not align with evidence regarding risk.
Observational studies suggest that the decline in liquor volume All conversations regarding management of prolonged preg-
observed from w35 weeks to 40 weeks is physiological, but it is nancy should begin by eliciting the ideas, concerns, and expec-
less clear whether the higher rates of oligohydramnios observed tations of the pregnant woman. She should be encouraged to
after 40 weeks are associated with increased fetal risk. It has express both her preferences and her feelings about alternative
been suggested that liquor volume may decline after 40 weeks courses of action. Although informed decision-making involves
because of redistribution of fluid towards the fetal circulation, explaining the increased fetal and maternal risks associated with
but this is not supported by high-quality evidence. Women are prolonging pregnancy beyond 42 weeks, caregivers should be
also often offered Doppler ultrasound estimations of the umbili- aware that while the relative risks are increased, the absolute
cal artery pulsatility index and are advised to be aware of fetal risks remain low. It is therefore important to avoid being alarmist
movements. However women choosing to await spontaneous in explanations about risk.
labour should be informed of the limitations of fetal surveillance, While many women are frustrated by a post-term pregnancy
in particular that monitoring reflects only the current well-being and are happy to accept delivery, there are also many women
of the baby. There is a lack of any high-quality evidence sug- whose strong preference is to avoid any intervention, including
gesting that the surveillance currently available can prevent induction of labour. In this case, it is important to explore a
adverse outcomes. It is important to keep an open dialogue with shared understanding of what induction of labour actually in-
women who chose this option, in particular not to alienate them volves and the associated risks. Women may perceive any inter-
or make them feel dismissed. A crucial aspect of the management vention as adding potential risk for themselves or their baby, and
of post-term pregnancy is to encourage women to attend if any may be surprised by recent evidence that induction after 39 weeks
complications (e.g. reduced fetal movements) do occur and to confers lower risk of Caesarean section than expectant manage-
give them the opportunity to re-discuss or revise their decisions ment. It may also be useful to explore perspectives of other people
at any stage. This is much less likely to happen if there has been a whose opinions may strongly influence the decision-making
breakdown in communication between the obstetrician and process, for example partners, although the final decision
pregnant woman. regarding care must always rest with the mother herself.
For labour in the context of post-term pregnancy, whether For women who prefer not to have intervention in the context
induced or spontaneous, intra-partum care should be adapted to of post-term pregnancy, it may be helpful to explore what they
minimize the associated risks. Continuous electronic fetal moni- would feel able to accept, rather than to focus on what is
toring is usually advised, despite its known limitations. During declined. This may include agreeing on a point at which delivery
labour, there are more likely to be concerns regarding the fetal would be acceptable if spontaneous labour did not occur. This
heart rate, which can lead to increased concerns about fetal focus can often bring into perspective the increased time at risk
distress and higher rates of intervention. Due to increasing of adverse antenatal outcomes, and be reassuring to both
maturity of the autonomic nervous system, the baseline fetal heart women and their caregivers. Women may also decline induction

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 REVIEW

of labour, but be open to discussion of Caesarean section or less

Reasonable option if associated risk factors (maternal age, previous Caesarean) or declining induction of labour
invasive options such as membrane sweeping. A recent
Cochrane review concluded that membrane sweeping may be
effective in inducing spontaneous labour and avoiding induc-
tion, although the evidence in general regarding this is of low
quality. Nevertheless it is a low risk intervention that may be
offered in order to reduce the interval to spontaneous onset of
labour, and which is acceptable to many women. The NICE
guideline update in 2021 makes specific reference to ‘giving
women with uncomplicated pregnancies every opportunity to go
into spontaneous labour’.

No increased risk of maternal or fetal morbidity associated with procedure

Neonatal considerations
Although the risks of unplanned admission to the neonatal
intensive care unit are increased, care of the baby born in good
Reduced risk of adverse perinatal outcomes (including stillbirth)

Reduced risk of adverse perinatal outcomes (including stillbirth)

condition beyond 42 weeks does not differ from other term ba-
bies. There is a 2-fold increased risk of macrosomia, which may
require careful attention to early feeding and blood sugar levels.
Babies with post-maturity syndrome should be treated on
Absolute risk of adverse outcome post-term is low

symptomatic grounds and do not necessarily require specific

Reduced risk of maternal hypertensive disorders
Reduced risk of emergency Caesarean section

treatment with respect to this.

May reduce interval to spontaneous delivery

Economic considerations
A significant concern regarding elective induction of labour at
Meeting maternal expectations

term is that it would be associated with escalating healthcare

Acceptable to most women

costs, and be unsustainable for many healthcare services.

However cost-effectiveness modelling based on the results of the
Low risk intervention

ARRIVE trial implies that while elective induction at 39 weeks

would be associated with increased costs, it is cost-effective in
terms of reducing complications for both mothers (particularly
hypertensive disease) and babies (particularly stillbirth at term).
Benefits

A further study based on a subset of the ARRIVE trial concluded

that elective induction at 39 weeks is cost neutral because of
the reduction in complications and prolonged admissions asso-
Counselling women on the management of post-term pregnancy

ciated with post-term pregnancy. Based on this modelling, it

Placental morbidity in future pregnancies

follows that induction of labour versus expectant management

Low quality evidence to suggest benefit

at later gestational ages (41 weeks and beyond) would be cost-

Does not reduce rate of assisted or

Increased length of stay in hospital

effective and likely to result in decreased rather than increased

Precludes use of birth centre/pool
Limitations of fetal surveillance

health service use. A cost-effectiveness analysis was also con-

ducted in conjunction with SWEPIS, aiming to evaluate the
financial ramifications of initiating labour induction (IOL)
May be uncomfortable

at 41 weeks of gestation versus an expectant management

Antepartum stillbirth

operative delivery

approach until 42 weeks. This analysis concluded that induction

Visceral injury

at 41 weeks offers better health outcomes without significant

cost increases and is thus cost-effective by standard life year/
Bleeding
Infection

QALY thresholds.
Risks

VTE

Conclusions
In the contemporary obstetric landscape, the management of
Planned Caesarean section

prolonged pregnancies has evolved into a domain where

Expectant management

Membrane sweeping

evidence-based recommendations and individualized patient

Induction of labour

care converge. A growing body of evidence supports offering

induction of labor at 41 weeks as a strategy to mitigate adverse
perinatal and obstetric outcomes. However, each case demands
Strategy

a bespoke approach that meticulously considers individual pa-

Table 4

tient circumstances and preferences. As such, personalized

counselling emerges as a pivotal aspect, empowering women to

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 REVIEW

make informed decisions about their care. Ultimately, the man- National Institute for Clinical Excellence. Clinical guideline NG207
agement of prolonged pregnancies is characterized as a delicately ‘Inducing labour’ published. November 2021, https://www.nice.
balanced interplay of evolving evidence, clinical guidelines, and org.uk/guidance/ng207/evidence/c-induction-of-labour-for-
patient-centred care. A prevention-of-prolonged-pregnancy-pdf-9266825056.
Walker KF, Bugg GJ, Macpherson M, et al. Randomized trial of labor
induction in women 35 years of age or older. N Engl J Med 2016;
FURTHER READING
374: 813e22. https://doi.org/10.1056/nejmoa1509117.
Alkmark M, Wennerholm U-B, Saltvedt S, et al. Induction of labour at
Wennerholm U-B, Saltvedt S, Wessberg A, et al. Induction of labour at
41 weeks of gestation versus expectant management and induc-
41 weeks versus expectant management and induction of labour at
tion of labour at 42 weeks of gestation: a cost-effectiveness
42 weeks (Swedish Post-term Induction Study, SWEPIS): multi-
analysis. BJOG An Int J Obstet Gynaecol 2022; 129: 2157e65.
centre, open label, randomised, superiority trial. BMJ 2019; 367:
https://doi.org/10.1111/1471-0528.16929.
l6131. https://doi.org/10.1136/bmj.l6131. Clinical Research Ed.
Geneen LJ, Gilbert J, Reeves T, et al. Timing of induction of labour in
the prevention of prolonged pregnancy: systematic review with
meta-analysis. Reproductive, Female Child Health 2022; 1: 69e79.
https://doi.org/10.1002/rfc2.6.
Gilroy LC, Al-Kouatly HB, Minkoff HL, et al. Changes in obstetrical Practice points
practices and pregnancy outcomes following the ARRIVE trial. Am C Post-term pregnancy carries additional antepartum and intra-
J Obstet Gynecol 2022; 226: 716.e1e71612. https://doi.org/10.
partum risk to both mothers and babies, conferred mainly by
1016/j.ajog.2022.02.003.
increased fetal growth coupled with advanced placental ageing
Grobman WA, Rice MM, Reddy UM, et al. Labor induction versus C Although the relative risk of adverse perinatal outcome is
expectant management in low-risk nulliparous women. N Engl J
increased in post-term pregnancy, the additional absolute risk is
Med 2018; 379: 513e23. https://doi.org/10.1056/nejmoa1800566.
low
Keulen JKJ, Bruinsma A, Kortekaas JC, et al. Induction of labour at 41 C Delivery is recommended to reduce the risk of antepartum still-
weeks versus expectant management until 42 weeks (INDEX):
birth, although international guidelines vary about when induc-
multicentre, randomised non-inferiority trial. BMJ 2019; 364: l344.
tion of labour should be routinely offered in low-risk women
https://doi.org/10.1136/bmj.l344. Clinical Research Ed. C Women can be reassured that recent evidence implies that in-
Middleton P, Shepherd E, Crowther CA. Induction of labour for
duction of labour versus expectant management after 39 weeks
improving birth outcomes for women at or beyond term. The
does not confer increased risk of adverse perinatal outcomes, and
Cochrane Library, 2018. https://doi.org/10.1002/14651858.
may reduce the risk of delivery by Caesarean section
cd004945.pub4. C Women who decline delivery in the context of post-term preg-
Muglu J, Rather H, Arroyo-Manzano D, et al. Risks of stillbirth and
nancy should be offered information about risk, but supported in
neonatal death with advancing gestation at term: a systematic re-
their decision-making. They should be offered antenatal moni-
view and meta-analysis of cohort studies of 15 million pregnancies.
toring until delivery occurs, but with the caveat that monitoring
PLoS Med 2019; 16: e1002838. https://doi.org/10.1371/journal.
has not been shown to prevent adverse outcomes in this context
pmed.1002838.

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